The Use of Different Technologies During a Medical Interview: Effects on Perceived Quality of Care

This two-phase study examines a physician’s use of one of five different types of technology to note a patient’s symptoms during the medical interview. In this between-subjects design, 342 undergraduates viewed one of several videos that demonstrated one condition of the doctor/patient interaction. After viewing the interaction, each participant completed a series of questionnaires that evaluated their general satisfaction with the quality of care demonstrated in the medical interview. A main effect of technology condition was present in both phases. Further, in Phase 2 we found that drawing the participant’s attention to the type of technology used has a divergent effect on their general satisfaction with the doctor/patient interaction depending on the technology condition. These findings have implications for healthcare providers such as how to address technology and which type of technology to use. Medical Technology 3 The Use of Different Technologies During a Medical Interview: Effects on Perceived Quality of Care Few people go an entire year without a visit to some variety of the doctor’s office. Healthcare is a top priority in political platforms, a major driving force for research, and a substantial portion of yearly expenditures. In fact, in the US, an upwards of 400 billion dollars are spent each year on health-care related paperwork alone (Gladwell, 2005). Because of healthcare’s ubiquitous importance, the recent focus on the quality of care in the medical office follows logically. Nuances of the Doctor-Patient Interaction Arguably, the interaction between doctor and patient during the medical consultation is the most critical point for transferring information and the delivery of excellent healthcare (Bertakis, 1991; Ong, de Haes, Hoos, & Lammes, 1995; Russuvuori, 2001). During a successful medical interview, several steps must take place. The physician must become familiar with the patient’s history through direct communication, consultation with medical records if available, or a combination of the two. In order to obtain useful information from the patient, the physician must first determine the patient’s problems. The patient must be able to convey their symptoms in a way that is meaningful to the physician. Once the patient has explained the symptoms, the physician must mentally translate from laymen’s terms to medical vernacular, use prior Medical Technology 4 knowledge or reference materials to diagnose, and suggest treatment. Each step of this interaction is complicated by the context of individuals of non-equal positions of power and status (Ong et al., 1995; Steilhaug & Malterud, 2003). Quality of Care There are at least two aspects to healthcare quality: actual patient outcome (observable consequences due to a medical encounter); and perceived quality of care (the patient’s personal perception of the quality of care). Actual patient outcome can be measured in several ways including: adherence to doctor recommendations, recall of information given during consultation, and understanding of diagnosis (Ong et al., 1995). Perceived quality of care (QoC) is a good predictor of actual patient outcome (Ong et al.). The most widely accepted assessment of perceived QoC, and the measure that is considered in this study, is patient satisfaction. Ong et al. report that patients evaluate their overall healthcare experience on their doctor’s interpersonal skills; skills which are largely interpreted through the use of non-verbal communication. Verbal Versus Non-verbal Communication At the time when the importance of the medical interview first came under researchers’ scrutiny, only the verbal components of communication were studied. Since then, the focus has shifted to non-verbal components of communication. Non-verbal communication has been operationalized as body positioning, posture, gaze, voice tone, etc. These non-verbal components, or visual cues, make up 77% of perceived interpersonal communication (Ong et al., 1995). Although the verbal communication that takes place in each step of a medical interview is also important, this study focuses on non-verbal communication. Shifting focus. While conducting the medical interview, a physician must often times consult two major sources of information simultaneously: a) the patient’s medical records and b) Medical Technology 5 the patients themselves. Previous research has shown that patients often believe that their physician is not listening to them when attention is shifted from the patient to the records (Ruusuvuori, 2001). This attentional shift often entails a physical shift of the physician’s head or head and upper torso depending on the way the physician is oriented relative to the patient and the patient’s records (Ruusuvuori). Even the most minimal physical shift still requires that the doctor’s gaze move from the patient to the records, thus making eye contact between the doctor and patient impossible to maintain. Eye contact. During any face-to-face conversation, eye contact lets the speaker know that the recipient is focused on them. For a patient who may be anxious the need to know the physician is engaged in the conversation is heightened. Commonly, tactics are employed by speakers to regain eye contact with an intended recipient whose gaze has wandered. One such tactic is achieved by pausing mid-sentence, or engaging in other speech discontinuities until the recipient’s gaze is regained (Goodwin, 1981). This same occurrence has been observed during medical interviews, indicating that the patient is perturbed by the loss of their physician’s gaze (Ruusuvuori, 2001). Body orientation. A final form of non-verbal communication examined in this study is body positioning. Even when eye contact is maintained, the speaker’s torso may or may not be facing the recipient. When the speaker’s torso is squared off with the recipient, the speaker’s head may remain in its resting state. This scenario is termed a 0o body orientation in the current study. The other case examined in this study is one where the speaker’s torso is facing 90o with respect to the recipient. The 90o body orientation requires the speaker to torque in order to face the recipient (see Figure 1). Evidence has shown that people prefer the 0o body orientation to the 90o when speaking to someone (Ruusuvuori, 2001; Furnham, Petrides, & Temple, 2006; Ong et Medical Technology 6 al., 1995). Note Taking Earlier, the potentially problematic situation of simultaneous consultation of both the patient and the patient’s medical records was discussed. There is a third component, namely, the notes a physician may take during the medical interview. Taking notes allows a health provider to a) record the patient’s symptoms and concerns in order to update medical records and b) refer back to different points of the interview to seek further clarification if needed. Ruusuvuori (2001) would argue that note taking affords a crucial written record because doctors otherwise tend to overlook problems presented subsequent to the beginning of the medical interview. Notes may be taken during the interview with the use of pen and paper, an electronic device, or not at all until the doctor leaves the examination room. Although healthcare providers differ in their mode of note talking, little research has examined the effect of these differences on patient satisfaction. Technology’s Influence on Non-verbal Cues Caldwell, Mauney, Lyon, et al. conducted Phase 1 of this investigation of technology use on patient satisfaction (2006). The authors employed a novel methodology in which participants viewed a prerecorded doctor-patient interaction and then completed questionnaires that assessed their evaluation of the QoC. Phase 1 used a between-subjects design that exposed participants to the doctor’s use of one of several different technologies. One major finding from that study was that participants were unsatisfied with the doctor’s use of a desktop computer. This condition was rated significantly lower than others with regard to every subscale of perceived QoC, which supported the authors’ hypothesis that perceived quality of care will increase when technology is less obtrusive. Medical Technology 7 Other Influences In addition to examining different technologies, Caldwell et al. also examined the influence of body orientation and gender. The overwhelming suggestion in the literature is that body position and gender matching of the doctor and patient do have an effect on reported satisfaction (Steilhaug & Malterud, 2003; Ruusuvuori, 2001; Furnham, Petrides, & Temple, 2006; Ong et al., 1995). Although Caldwell et al. did not find a significant main effect for body position or gender; they did find a general trend that the 0 degree condition led to higher reported likelihood of a return visit in some technology conditions. The authors concluded that body orientation might be an influence in some conditions, but not others. Phase 2 Phase 2 is a replication and extension of the work of Caldwell et al. (2006). In Phase 1, the type of technology used in each condition was not explicitly pointed out or explained to the participants until the debriefing period. As a result, it remained unclear whether participants could distinguish the type of technology the doctor was using in each condition. Specifically, the most novel form of technology, a wearable computer, may have been confused for a more common device, such as a personal digital assistant (PDA). It may be that the explicit mentioning of the doctor’s use of technology will cause the patient to include the technology in their QoC evaluation. Furthermore, the mentioning of technology prior to viewing may draw the participant’s attention to the fact that the doctor is not taking notes in the ‘nothing’ condition. For this reason, the current study included a one to two sentence explanation of the doctor’s notetaking technology stated prior to the video viewing (see App