Pakistani origin, Bissell et al.(2004) found that some patients felt they could not
discuss emotional, familial and financial factors that undermined their attempts to follow
a diet appropriate to their condition. Being unable to discuss key barriers to adher -
ence meant that doctors did not have the opportunity to offer advice on how to most
closely approximate the recommended diets within everyday social constraints. Thus
health care professionals need to consider real-world challenges the patient may face
in following an agreed plan and allow time for such discussion and negotiation in
consultations.
Patient-centredness and concordance are important because studies show that the
relationship between health care professionals and their patients predicts patient
satisfaction and adherence. This relationship is often been referred to as the ‘working
alliance’ or ‘therapeutic alliance’ and Fuertus et al.(2007) found that patients’ ratings
of the working alliance and their self-efficacy predicted adherence and also satisfaction.
Similarly, in a meta-analysis of 48 studies Arbuthnott and Sharpe (2009) found that
better physician–patient collaboration is associated with better patient adherence and
that this association was evident for paediatric and adult patient populations, for those
with chronic and acute conditions and for family doctors (or general practitioners) and
medical specialists. Similar findings have been reported for psychiatric consultations
(McCabe and Priebe, 2004). Thus, across the board, sharing of views and establishing
concordance within a therapeutic alliance appears to promote adherence.
In a related meta-analysis of studies of doctor–patient communication, Haskard
Zolnierek and DiMatteo (2009) found a 19 per cent higher risk of non-adherence
among patients whose doctor communicated poorly compared to patients whose
doctor communicated well. They also found that training doctors in communication
skills resulted in improvements in patient adherence. The odds of patient adherence
were 1.62 times higher for patients whose doctor had received communication
training compared to those whose doctor had not received such training. More
generally a systematic review of 43 trials of interventions designed to promote ‘patient-
centred care’, including shared control of the consultation and consideration of the
person as a whole, found that such training is effective in transferring patient-centred
skills to health care professionals. However, the effects of such training on patient
satisfaction, patients’ health behaviour and health varied across trials. Complex
interventions directed at professionals and patients including condition-specific
educational materials seemed to have greater effects on health behaviour and health
status but the authors concluded that further trials were needed to confirm this latter
conclusion (Dwamena et al., 2012). Nonetheless, these findings strongly suggest that
training health care professionals to communicate well and to build therapeutic
alliances (or collaborations) with their patients could improve the effectiveness and cost-
effectiveness of health services. Training is important because concordance may
involve patients in sharing uncertainties about treatment outcomes (Elwyn et al., 1999)
and (as we have seen above) this needs to be managed in a positive manner by doctors
and health care professionals to order to optimise adherence.
These findings suggest that the presenting problem (or illness) does not moderate
the effectiveness of consultation styles. Yet a study by Savage and Armstrong (1990)
suggests that it does. In this experimental study 200 patients were randomly allocated
to two different consulting styles and followed up one week later. The styles were
referred to as ‘sharing’ (‘Why do you think this has happened?’; ‘What do you think
RELATING TO PATIENTS 241