Exploring Patients' Insight, Concerns, and Expectations at Dermatology Clinic: An Observational Study in 2 Centers in Scotland and Spain.

BACKGROUND: Effective doctor-patient communication is of great importance in order to optimize medical consultation outcomes. However, it can be difficult to address all patients' concerns and expectations in clinic.
OBJECTIVE: To identify how much patients know about their medical condition, their fears and concerns, and their expectations, as well as evaluate the benefits of using a preconsultation questionnaire routinely.
METHODS: This study included consecutive patients attending dermatology outpatients from Dundee (Scotland) and Granada (Spain) who completed a simple preconsultation 3-part questionnaire. Answers to this questionnaire were discussed during clinic visits.
RESULTS: Two hundred patients participated in the study. Of all, 111 (55.5%) patients already knew their diagnosis or were able to describe their symptoms and/or feelings quite accurately at their visit to Dermatology. Most patients (85%) had fears regarding their dermatological problem. A majority of patients (97%) came to clinic with specific expectations, and many (41.5%) had multiple expectations. A high proportion of patients (74%) found the questionnaire useful.
CONCLUSION: Patients attend clinic with different levels of knowledge, fears, and expectations. We recommend using a brief and easy to use preconsultation questionnaire as a cost-effective way of enhancing doctor-patient communication.

Introduction

Effective doctor–patient communication is of great importance in order to optimize medical consultation outcomes. Traditionally, patients have been seen as passive recipients of health care. However, the modern approach of patient-centerd care gives patients a more active role creating a healthy dialogue with the clinician. Patients prefer to be treated by clinicians who are good listeners and, as has been pointed out by recent studies, those who actively take part in taking decisions regarding their medical care reach better clinical outcomes and show higher levels of satisfaction with the care provided by their physicians (1 –3).

Dermatologists have tended to focus on the biomedical approach to skin disease, and along with the lack of time in clinics, this may lead to patients’ psychological problems to be overlooked (4). However, some studies have shown that patients may have what has been called a “hidden agenda,” formed by unexpressed misunderstandings, fears, and concerns about their medical condition; as well as expectations about the care that their doctors will provide (5). These cognitive aspects of patient perceptions are particularly relevant in dermatology, as there is a high prevalence of distress and psychological morbidity (4 –7).

In order to optimize the communication with our patients, the authors use a simple preconsultation 3-part questionnaire for all new consultations influenced by a previous publication (5). The goal of the study was to clarify how much patients know about their medical condition, their fears and concerns and their expectations regarding the consultation, as well as evaluate the benefits of using the preconsultation questionnaire routinely. At the same time, we aimed to compare the results between 2 different populations: Dundee (Scotland) and Granada (Spain).

Material and Methods

This study was conducted with the participation of the School of Medicine of the University of Granada (Granada, Spain) and the Dermatology Departments at Granada University Hospital Complex (Granada, Spain) and Ninewells Hospital (Dundee, Scotland).

We studied consecutive patients referred to dermatology outpatients by their general practitioner (GP). One preconsultation questionnaire, with 3 open-ended questions, was handed to each patient while they were waiting to be seen by the dermatologist. The authors use the questionnaire routinely in their clinical practice. New patients are asked to complete the answers to the 3 questions if they wish, that is, it is optional. The 3 questions asked were as follows: “What do you understand about your skin condition and the reason you are here today?,” “Do you have any fears or concerns about your skin condition?,” and “What do you hope or expect to get out of the consultation today?” to explore insight, concerns, and expectations, respectively. In patients with difficulties completing the questionnaire (eg, young children) their caregivers were asked to fill the questionnaire on their behalf. The preconsultation questionnaire results were discussed with the dermatologist during the consultation, and the patient was asked for his/her opinion regarding the usefulness of the questionnaire.

Patient’s age, sex, and diagnosis were collected. For each patient, the dermatologist completed a questionnaire pointing out whether the preconsultation questionnaire had influenced therapeutic decisions, possible external factors that influenced patients’ expectations, and whether these were realistic or not. We considered external factors those elements that were not present in clinic but had an impact on patients’ expectations (such as friends, Internet, or mass media).

Patients’ answers were grouped by categories in order to facilitate the statistical analysis. Therefore, patients’ knowledge about their skin condition was classified as follows: he/she didn’t know anything, he/she poorly described his/her symptoms and/or feelings, he/she described his/her symptoms and/or feelings quite accurately, and he/she knew the diagnosis. Patients’ fears and concerns were grouped within the following categories: reassurance and advice, diagnosis, treatment, improve his/her symptoms, and get a definitive cure. Regarding patients’ expectations, the categories considered were reassurance and advice, diagnosis, treatment, improvement of symptoms, and a definitive cure. Finally, patients’ diagnoses were gathered between the following categories: skin cancer, benign skin lesions (eg, seborrheic keratosis), inflammatory dermatoses (eg, psoriasis), infectious dermatoses, and noninflammatory dermatoses (where pathologies not suitable for being classified within the other groups were included, such as vitiligo, hirsutism, or body image disorders).

Ethical Aspects

The questionnaire is routinely used in our clinics, therefore its use for this study did not require any additional intervention on patients’ care. Granada University Hospital and Dundee Hospital explored the need for ethical approval or Caldicott guardian approval—both were considered unnecessary and rather the project was felt appropriate to come under the category of “assessment of quality of service provision.” The information gathered in this study was analyzed ensuring that the anonymity of patients was strictly preserved.

Statistical Analysis

A descriptive analysis of the demographic features and the answers gathered in the questionnaires was performed. Subgroups of patients (established by: gender [male or female], age [over or under 30 years), diagnosis and city [Dundee or Granada]) were compared using the Chi-square test. Value of P < .05 was considered statically significant in tests. SPSS software (version 20.0.0; IBM Corp, Somers, New York) was used for the statistical analyses.

Results

A prospective sample of 200 (79 males and 121 females) patients, with a mean age of 47.55 years (range: 2-88) was studied (Table 1). Patients were grouped by diagnoses in Table 1. In the first question (“What do you understand about your skin condition and the reason you are here today?”) most patients showed a good level of knowledge regarding their dermatological condition. We found 111 (55.5%) patients who either knew their diagnosis or were able to describe their symptoms and/or feelings quite accurately. A minority of patients (27 [13.5%]) expressed no knowledge of their dermatological condition or left the question unanswered.

Table 1.

Summary of Patients’ Features and Answers.

Gender	Male	Female (n)
Spanish patients	33 (16.5%)	67 (33.5%)
Scottish patients	45 (22.5%)	54 (27%)
Age	Mean (range)	Standard deviation
Spanish patients	44.35 (2-88)	20.397
Scottish patients	51.52 (8-88)	20.807
Diagnosis	Number	%
Benign lesion	56	28
Skin cancer	55	27.5
Inflammatory dermatosis	54	27
Noninflammatory dermatosis	29	14.5
Infectious dermatosis	6	3
Patients’ fears	Number	%
No fear stated	30	15
One fear stated	133	66.5
Multiple fears stated	37	18.5
Fears grouped by categories	Number	%
Cancer	39	19.5
Symptoms	26	13
Persistence	37	18.5
Deterioration	25	12.5
Infectivity	4	2
Unsightliness	8	4
Scarring	8	4
Patients’ expectations	Number	%
No expectation stated	6	3
One expectation stated	111	55.5
Multiple expectations stated	83	41.5
Expectations grouped by categories	Number	%
Treatment	79	39.5
Diagnosis	69	34.5
Reassurance	66	33
Definitive cure	37	18.5
Improvement	34	17
External factors influencing expectations	Number	%
Family and friends	24	12
GP	23	11.5
Internet	3	1.5
Mass media	3	1.5
Others	7	3.5

Abbreviation: GP, general practitioner.

Answers to the second question (“Do you have any fears or concerns about your skin condition?”) are grouped by categories in Table 1. Fear to a future deterioration of their skin condition (ie, worsening of his/her psoriasis) was higher among women (19.8% vs 6.8%, Pearson Chi-square = 4.546, P = .033). Patients who were younger than 30 years showed higher fear regarding symptoms (40% vs 8.6%, Pearson Chi-square = 13.914, P < .001), persistence of the dermatological condition (53.1% vs 15.3%, Pearson Chi- square = 11.288, P = .001), future deterioration of their condition (28.9% vs 10.2%, Pearson Chi- square = 5.873, P = .015), and scarring (16.7% vs 0.6%, Pearson Chi-square = 17.881, P < .001). Patients attending clinic for inflammatory dermatoses showed more risk of presenting multiple fears (41.7% vs 17.3%, Pearson Chi- square = 5.406, P = .02) and were more worried about: symptoms (21.6% vs 11.2%, Pearson Chi-square = 4.444, P = .035) and persistence (64.5% vs 12.9%, Pearson Chi-square = 19.484, P < .001). There was no significant difference between Scottish and Spanish patients regarding their fears (Figure 1) although, interestingly, 4 Spanish patients stated fear of infectivity while no Scottish patient seemed to have this concern (although it was not possible to prove statically significant difference due to the low number of cases).

Figure 1.

Patients’ fears by country.

Patients’ expectations, gathered in the third question (“What do you hope or expect to get out of the consultation today?”), are grouped by categories in Table 1. Eighty-three (41.5%) patients stated multiple expectations. Assessing the answers, and after discussing with patients, it was noticed that 27% of them had been influenced by external factors (Table 1). Statistical analysis showed that Spanish GPs appear to have greater influence over patients’ expectations than Scottish GPs (20% vs 3%, Pearson Chi-square = 14.198, P < .001). According to the criteria of the doctor who saw the patient, most patients (185 [92.5%]) had realistic expectations, with 11 (5.5%) patients who requested a cure for an incurable condition. Interestingly, we found that patients with an inflammatory dermatosis had a higher proportion of nonrealistic expectations (14.7% vs 0.47%, Pearson Chi-square = 14.780, P = .001). Doctors reported that in 24 (12.5%) patients the information collected thanks to the questionnaire did modify the therapeutic approach.

Most patients completely or partially answered the preconsultation questionnaire (only 36 [18%] returned the questionnaire without having answered at least 1 of the 3 open questions). Three (1 was 2 years old and other 2 were 8 years old) children were unable to fulfil the questionnaire and were helped by their parents. When patients were asked for their feedback regarding the questionnaire: 148 (74%) patients thought that it had been useful, 22 (11.1%) considered that it had not been of any help, and 29 (14.5%) were not sure. Some examples of the patients’ feedback are shown in Table 2.

Table 2.

Patients’ Feedback on the Use of Questionnaire.

Positive Qualitative Feedback	Negative Qualitative Feedback
“Does concentrate one’s thoughts”“Liked feedback at the end”“Helps to cover things you might forget to say if nervous”“Sometimes easier to write things down about your feelings than talk about them”“Makes you stop and think and face the truth especially if in denial”	“I struggle with writing and would prefer to avoid it”“Danger of having too much paper”“Not for me”“More to help you than me”“Difficult to complete without my glasses”

Discussion

In order to understand and better help our patients, it is very important to address their misunderstandings, fears, and expectations. In the clinical setting, patients are rarely asked about their view of their illness. However, when a patient faces a health threat such as a new symptom or diagnosis, he/she will actively build cognitive models of this threat, and this mental representation will determine how they respond. The fascinating aspect of illness perceptions is how patients with the same illness can have widely different perceptions, and these perceptions are important in guiding coping strategies and illness-specific behaviours such as adherence to treatment (8 –10). Thus, the high value of disclosing patients’ insights regarding their condition.

Studies have shown that patients with long-term diseases who are more knowledgeable about their condition are more capable of coping with their symptoms and show better overall outcomes (11). On the other hand, patients with misbeliefs about their illness may fall into unhelpful coping strategies and, at the same time, are less prone to follow the recommendations given by their physicians. We believe that encouraging patients to share their knowledge about their condition is a good way of addressing patients’ misconceptions.

Patients’ fears and concerns have a huge role on their well-being and also on their therapeutic outcome. While it’s natural for anyone to feel fear under a health threat, irrational and excessive fear can lead into other problems such as anxiety and depression, which can be more dangerous than the original issue that motivated them. Some fears may prevent patients from seeking help or undergo diagnostic or therapeutic procedures. At the same time, rational and well managed fear can increase patients’ compliance with treatment (9, 10).

Our results highlight the great importance of doctor–patient communication, in any medical practice, which becomes especially relevant in dermatological patients (1 –3, 12), where patients have a wide range of fears and expectations that are frequently not volunteered during their visit to the dermatologists. Dermatological conditions and, their impact on patients’ well-being, can be underestimated, partially, because many dermatological problems are not life-threatening (13). Moreover, the general low level of dermatological knowledge among physicians may have also contributed to the trivialization of the skin conditions (14,15). Nevertheless, dermatological patients are complex, not only from the biological point of view but also psychologically. It has been reported that 35% to 43% of dermatological patients has psychological comorbidities which may be underrecognized (16).

Regarding patients’ expectations, it is essential to identify them and, as much as possible, meet them, since this has been reported as the most important predictor of patient satisfaction (17). Our results show that most patients have realistic expectations of treatment (39.5%), diagnosis (34.5%), and reassurance (33%). The first 2 aspects (treatment and diagnosis) have been largely addressed in medical literature and discussed in great detail in clinic letters. However, the importance given to providing appropriate and reassuring information to patients has been low, even though it is of high importance for patients (33% stated that they wished this attention). One must bear in mind that, offering detailed scientific explanations (frequently difficult to understand for nonmedical professionals) (18) or requesting diagnostic tests (which, sometimes, instead of reassuring the patient, may increase his/her level of anxiety) (19,20) may be inadequate to address patients’ real concerns. At this point, a doctor’s ability to identifying patient’s true fears and worries becomes essential, otherwise the patient may leave the consultation more concerned than before (19,21,22).

Although new technologies, for example, the Internet (23) may greatly influence many patients’ expectations, our results suggest that in our populations (Dundee and Granada) there are other factors of higher importance when it comes to creating expectations, that is, friends, family, and GPs. One explanation for this might be that patients are aware that not all information on the Internet is reliable, while comments or experiences from their close ones might have a more powerful impact in the way they understand their illness and how to manage it.

In this study, a preconsultation questionnaire was used to help recognize patients’ knowledge about their skin condition(s), fears and concerns, and expectations regarding their visits to our clinics. These issues may be easily overlooked in our busy clinics. We consider that this questionnaire provides several advantages in dermatological clinical practice. On one hand, a simple and easy to use questionnaire which can be completed by the patients while waiting to see the doctor can encourage the patient to take an active role in clinic from the first moment. Moreover, the questionnaire helps to “break the ice” and send an important and powerful message to the patient: his/her doctor is concerned about his/her feelings and personal point(s) of view. Another advantage is that it allows patients to put their thoughts together before meeting their dermatologist. Additionally, some patients find it easier to express their feelings by writing rather than talking, and the assessment of the questionnaire during clinic promotes the discussion of topics with high value for patients that, otherwise, could be omitted. Going over the answers to the 3 questions at the end of the consultation “blindly,” that is, not looking at the responses until the “standard” consultation is complete is a useful way to check whether any important details have been missed and, in repeating key points, is a form of active listening which may improve patient satisfaction.

Most of the patients in our study (74%) considered that the questionnaire had been useful for them. Although in most cases, the questionnaire did not modify the therapeutic approach, it must be highlighted that for 24 (12.5%) patients the information collected from the questionnaire (and its subsequent discussion in clinic) was of great value in this regard which emphasized the usefulness of the questionnaire. Moreover, even in those cases where the questionnaire did not modify the clinical approach and/or treatment choice, the active participation of patients in clinic, promoted by this questionnaire (among other actions to enhance doctor–patient communication), may improve adherence to treatment and therefore maximizes therapeutic outcomes (2,3,8,24).

Another interesting finding in our study is that, contrary to what might be expected, patients attended in Scotland and Spain showed similar results regarding their fears and expectations.

Study limitations include the lack of a control group; additional studies with control group will be required to accurately measure the impact of the questionnaire on patients’ satisfaction and clinical outcomes. Although most of our patients stated that the questionnaire had been useful for them, some of these patients may have stated it thinking that it would please their doctor. Additionally, the dermatologists taking part in this study are interested in psychosocial aspects of care, so may overemphasize the usefulness of the questionnaire in clinical practice (investigator bias). Three parents fulfil the questionnaire for their children, what implies that for those cases the questionnaire was not actually gathering the patients’ insights but their parents’.

Conclusions

Our results show that dermatological patients come to our clinic with a variable level of insights/knowledge about their skin disorder and often have several concerns and expectations which they may not express voluntarily. Clear patient–doctor communication is essential to identify and explore these issues and provide comprehensive holistic health care. In order to enhance this communication, we recommend using a brief and easy to use preconsultation questionnaire as a cost-effective way of breaking the ice.