INTRODUCTION

Clinical audit is the process used to improve the overall quality of health care for patients. It involves the systematic and critical analysis of the quality of the procedures used for diagnosis and treatment, the use of resources, the resulting outcome, and the quality of life of the patients.¹ Clinical audit provides a tool for the evaluation of the efficiency and effectiveness of total care. It also helps to set standards of care and guidelines for “best practice.”² There are a number of areas of clinical practice that can be subjected to audit, but one area that is seldom audited is the quality of communication with patients about their understanding of disease status, treatment options, as well as the prognosis, and the style of communication by the physician.

In Developing countries, communication has been studied less but is probably more difficult compared with Developed countries because of the lack of medical training, inappropriate staffing and layout of medical facilities, and the increased emphasis on paternalism by physicians when communicating with patients and their families.^3,4

Common problems of communication include simple errors like faults in common courtesy or failure to listen and to acknowledge patients’ needs.⁵ Many clinicians feel uncomfortable communicating sensitive news to cancer patients because of a lack of basic skills in nonverbal communication. Good training for physicians in verbal and nonverbal communication skills facilitates patient compliance and overall satisfaction.

In Developed countries, physicians have a trend to underestimate the willingness of patients to be informed and make decisions regarding their care.^6-9

Most communication research and clinical tools have been Developed and implemented in the Developed world. However, similar work has not been reproduced in the Developing world. The existing tools and the audit systems utilized by Western countries are frequently unsuitable for the population in the Developing countries due to high levels of illiteracy and different realities of health care systems and expectations. As palliative care programs emerge in these regions, appropriate audit studies are needed to guide improvements in practice.⁸ We undertook a study, which involved a clinical audit of cancer patients’ perceptions of physicians’ communication, and measured the outcomes before and after implementation of a communication strategy in a regional cancer center (RCC) in Cuttack, India.

METHODS

The palliative care group of the RCC decided to conduct a survey of patients’ perceptions of the quality of communication, based on the anecdotal evidence of patients’ complaints about the poor standard of information shared during the interview process in the hospital. The team reviewed previous audits on similar subjects done in the Developed world. The process of audit was done in three steps: Step I, assessment of perception of communication; Step II, analysis of the data and adaptation of communication strategy; Step III, reassessment of perception of communication 12 weeks after the new strategy was adopted. The ethics committee of the RCC approved the protocol. All patients gave written consent to participate in the study.

RESULTS

A total of 400 patients were able to participate in the Step I study. Patient characteristics of both Steps I and III are listed in Table 2. All of the physicians, irrespective of their specialty, had agreed to participate in Step I, Step II for implementation of the communication strategy, and Step III for a follow-up outcome study. They accepted to abide by the rules regarding communication skills, learned from attending the weekly seminars, reading the review materials provided, and attending the scientific meetings outside the institution.

The analysis of the data from Step I showed that the majority of patients were not satisfied with the overall communication process (348 [87%] of 400 patients; Table 3). The responses to the questions pertaining to doctor’s attitude towards clarification of issues, allowing sufficient time for the patient and families, use of ambiguous language, as well as providing a conducive atmosphere for the interview, revealed equally discouraging results (Table 3).

After the policy change was adopted by the institution, a total of 400 patients were entered onto the Step III study.

In Step III, there was a significant improvement in satisfaction in all eight questions (Table 3). Satisfaction with privacy revealed a dramatic improvement (70%, compared with 5% in Step I; Table 3). The main source of interruptions/disturbance during the interview process was found to be the telephone, other patients or relatives, and other hospital staff. This data and the observed reduction of the interruptions in Step III are listed in Table 4.

Improvements in the perception of communication in the Step III study were similar in patients who had previously visited the center and had participated in Step I (n = 183), compared with those who were new to the center (n = 217; Table 5).

Table 6 lists the difference in the mean sum of communication perception (sum of all questions answered “yes”) in Step I and Step III. Overall mean communication perception was better in Step III compared with Step I (P < .001). In subgroup analysis, satisfaction was significantly better for older patients and manual workers (Table 6).

DISCUSSION

In this study, we have found that a survey of the perception of the quality of communication following a communication strategy resulted in major improvements in patients’ perceptions of communication.

Our Step I findings were surprising because it was frequently perceived by our faculty and staff that most of our patients were either unable or unwilling to better understand their disease status, and that they were generally comfortable with a passive role in communication.

The results of Step I were very important to motivate our faculty, staff, and our hospital administration to establish the strategy to improve the situation. Our findings regarding communication are consistent with those previously published in the Developed world.^9-16 However, the findings in our own patient population were important to make our target points for improvement more defined and to secure the personal commitment of each member of our faculty and administration.

The short and simple, “yes or no” format of this questionnaire resulted in excellent compliance with minimal coaching, as demonstrated by the universal compliance with all questions in both Step I and Step III. Future studies should attempt to develop more sophisticated tools capable of capturing the patients’ perceptions about the quality of communication and decision making in more depth.

Our faculty and administration were particularly concerned about the great level of discomfort expressed by patients regarding privacy. Although establishing independent examining rooms was impossible because of lack of budget, adding simple curtains with a “Do Not Disturb” sign and a rearrangement of the waiting area resulted in a shift in satisfaction with privacy from 5% to 70%. These findings suggest that contrary to previous assumptions patients in Developing countries also value privacy and that this can be achieved by very simple means. However, due to limited resources in Developing countries, apparently simple changes such as the rearrangement of clinic layout, avoidance of interruptions, or instituting appropriate time for communication can be complex or overwhelming. Therefore, a major concerted effort between clinicians and administrators is required for successful implementation of these changes.

The improvement in communication was perceived by new patients who had not visited the center before, as well as by patients who had experienced the previous communication process during Step I (Table 5). These findings suggest that the improvement was not perceived simply as a change from the previous level of care, but that this new strategy is likely to be perceived as satisfactory by all future patients. Long-term follow-up surveys are required to assess the stability of the changes in physician-communication behavior.

Our findings regarding better perception of communication among older patients and manual workers (Table 6), both before and after the communication strategy was implemented, probably reflect the lower expectations of overall care among these patients. If these findings are confirmed in other studies, centers with a higher proportion of older and blue collar workers will likely report higher overall satisfaction with communication, and this will need to be taken into consideration both in research and in the audit of clinical care.

The improvement in the specific communication technique, including checking what the patient knows, using clear language, and clearing of doubts at the end of the visit probably reflect successful participation by the faculty after education. Previous studies have documented similar results.^17-23 Some intervention studies have not only demonstrated changes in physicians’ knowledge, attitudes, and beliefs but also demonstrated changes in practice patterns.^23-27 Our findings and those of Sureshkumar and Rajagopal²⁸ clearly show that patients in Developing countries have expectations regarding physician-patient communication, and our findings confirm that simple interventions can significantly improve the quality of this communication. Unfortunately, the research is limited, and therefore it is not possible to establish standards for quality of communication in different areas of the world. The development of assessment tools appropriate to the needs and education level of patients in the Developing world and the establishment of education programs in these regions is likely to have a major impact on the quality of communication and overall patient care in the Developing world.

We conclude that cancer patients in the Developing world have many unmet needs regarding communication. Simple changes in clinic layout and oncologist education can result in major improvement in the perception of communication.

Authors’ Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.