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Dictation in the Presence of the Patient
John E. Sutherland, MD;
Nichole Egbert, MA;
Craig L. Gjerde, PhD;
Toni Pint-Burke, BS;
Cynthia Franklin, MSEd, NCC;
Dennis Walker, MD
Arch Fam Med. 1998;7:281-284.
ABSTRACT
We investigated the impact on patients' satisfaction and understanding of their condition and treatment recommendations when the care provider dictated the medical record in their presence. Providers' satisfaction and perceptions were also ascertained. Sixty patients were randomly placed into a treatment group where the provider dictated the medical record in their presence, and 60 patients were placed in a standard visit control group. Volunteer providers included residents, a faculty physician, and a physician assistant. A survey instrument completed with an interviewer measured patients' satisfaction with the provider, their care, the dictation technique, and their understanding of their diagnosis and treatment recommendations. The provider completed a similar questionnaire. Patients in both the dictation and control group were equally satisfied with their care, felt they understood what the provider told them about their medical conditions, and felt they understood their provider's recommendations. Within the dictation group, 44 (73%) liked the process, 24 (40%) believed they were helped to understand their condition, 22 (37%) believed they were helped in understanding recommendations, and 23 (38%) reported improved satisfaction with a visit that included dictation in their presence. In the dictation group, men felt more positive than women about dictation in their presence, including increased understanding of their condition and satisfaction with the visit. Patients aged 56 years and older were also more positive about dictation in their presence, including improvement in their understanding of the provider's recommendations. Providers were equally satisfied with encounters using either method.
INTRODUCTION
Substantive health services research has centered on provider-patient communication, linking it to patient satisfaction, adherence to prescribed treatments, and health improvement.1-2 Patient satisfaction is now deemed an important outcome measure for health services.3 The interpersonal skills of the provider, which lead to positive and personalized communication with the patient, are the cornerstone of effective medical practice.4-6 A number of investigations have explored the relational aspects of quality of care, communicative styles of providers, content of the physician-patient interaction, patient perceptions of their role in the medical visit, and physician behaviors. Researchers have also studied the impact of communication on a patient's decision to litigate,7-8 the importance of sex differences,9-10 the degree of patient understanding of medical condition and treatment plan after an encounter,11 patient expectations and desires,12 the "closing moments" of the medical visit,13 and the effectiveness of co-documentation.14
The potential for a communication gap between physician and patient is present in every encounter. Providers must take a history, perform an examination, make an assessment, develop a plan, and educate the patient in a time-efficient manner during every encounter. Patients need to understand their medical condition (diagnosis) and the treatment recommendations.
Sutherland15 has written about the impact of dictating in the presence of the patient. Several potential advantages of adapting this practice into routine patient care have been considered. The first, and most obvious, is that a dictated or written note is a function of every medical visit. It must be done sometime. Second, hearing the dictated summary of the visit might result in patients' having a better understanding of their medical conditions. Third, patients might be able to clarify the accuracy of the medical record if they hear what is being dictated and are asked to comment. Fourth, this added participation by the patient and time spent with the patient by the provider might lead to increased patient satisfaction with the encounter and provider.
The purpose of this study was to investigate the impact on the patients and providers when the providers dictated the medical record in the presence of the patients. We wanted to ascertain patient satisfaction, patient understanding of the medical condition, patient understanding of the provider's treatment recommendations, and provider satisfaction with the encounter.
PATIENTS AND METHODS
One hundred twenty patients were selected from the population of people who visited an urban residency program family practice center during a 3-week period. The clinic patient mix was representative of the US population as a whole, in both patient age distribution and percentage of minority population. The clinic averages 125 visits per day. All English-speaking patients of the participating providers aged 18 years or older, without regard to the reason for the visit, were asked to participate in a research project investigating health communication. Fewer than 10% of eligible patients declined to participate. Participating patients were assured confidentiality, informed of the time required for participation, and asked to sign a consent form. Sixty patients were randomly placed into a treatment group where the provider would dictate the record in their presence, and 60 were placed in the control group. A coin toss decided which participating provider would dictate and which would serve as a control for each half-day of time. Therefore, providers did not switch back and forth between dictation and control conditions. Patients saw the provider they were scheduled to see, and all 10 providers eventually served in both the dictation and control groups. Age and sex were not controlled variables in the study.
Two female and eight male care providers volunteered to participate. Eight providers were residents, 1 was a faculty member, and 1 was a physician assistant. These providers were informed that dictation was being investigated and were given specific information and training as to how the process should be performed. Except for engaging in the dictation protocol for half of the patients (the dictation group), providers were instructed that their communication behavior should be their "normal" routine until the end of the consultation, when they started the dictation protocol for patients assigned to the treatment group. Before dictating in the presence of patients, providers were instructed to explain that they were going to dictate a note for the patient's medical records and that, when they were finished, the patient was free to ask questions regarding the dictation or any other aspect of the consultation. After the dictation and questions, the provider requested that the patient wait in the examining room for a short meeting with an interviewer. After leaving the patient, the provider answered questions about his or her own general satisfaction with the encounter and perception of how well the patient understood the condition and the provider's recommendations.
A patient survey instrument measured the patient's satisfaction with the provider, the patient's rating of provider competencies, the time spent, satisfaction with care received, satisfaction with the dictation technique (dictated group only), understanding of the diagnosis, and understanding of the provider's recommendations. Patients responded to most of these questions by means of a 5-point scale with 5 representing highly positive, 3 neutral, and 1 negative. A typed copy of the questionnaire was provided so that patients could read the questions as the interviewer asked them. Responses were manually recorded by the interviewer. Information on age and sex were obtained from the patient's medical chart. Patients were categorized into 3 age groups: 18 to 29 years, 30 to 55 years, and 56 years and older. Data were analyzed by means of 1-way analysis of variance, t test, and Fisher exact test.
RESULTS
The treatment groups did not differ significantly with respect to patient age and sex. The mean age of the patients was 37.8 years (34.2 years in the control group and 41.6 years in the dictation group). There were 35 men (29%) and 85 women (71%) in the study. The control group was 23% male (14 patients) and 77% female (46 patients), whereas the dictation group was 35% male (21 patients) and 65% female (39 patients).
This study showed a high overall satisfaction with care by patients in both the control and dictation groups (Table 1); this included the ability to understand what the provider told them about their medical condition, what their provider recommended, and time with the provider. Groups did not differ significantly in their satisfaction with the time the provider spent with them. In general, providers were satisfied with their encounters.
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Table 1. Patient Assessment of Office Visit
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In the dictated group, additional responses were obtained to assess the patient view of the effects of dictation in their presence (Table 2). For both sexes combined, 44 patients (73%) liked the dictation, and many reported increased understanding of their medical condition, increased understanding of the provider's recommendations, and increased satisfaction with the visit because of the dictation. Thirty-nine patients (65%) reported that the provider invited them to ask questions about the dictation. Further explanation of dictation content was requested by 4 (7%) of the patients. Corrections or additions to the dictation were made by 8 (13%) of the patients.
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Table 2. Assessments of the Medical Visit by Sex in the Dictation Group
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Patients aged 56 years and older were significantly more positive in their responses for all aspects of dictation in their presence (Table 3): liking the dictation (P=.04), the value of dictation in increasing their understanding of their medical condition (P=.005), understanding the provider's recommendations (P<.001), and satisfaction with the visit (P=.003). In contrast to women, male patients gave significantly higher ratings to several aspects of the dictation: liking the dictation (P=.03), increased understanding of their condition (P=.02), and satisfaction with the visit (P=.02).
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Table 3. Responses of the Dictation Group by Age
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Table 4 summarizes providers' responses to questions about the patient encounters. Providers thought that women understood their medical conditions better than men (P=.03), but found no other sex difference in patients' understanding of providers' recommendations.
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Table 4. Provider Assessment of the Office Visit
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Providers identified no significant difference between the control and dictation groups in regard to their own satisfaction or in provider perception of patient understanding of the condition or of providers' recommendations. Providers were highly satisfied or somewhat satisfied with the encounter that included the dictation process in 58 (97%) of the encounters.
COMMENT
In this study, dictation of the medical record by the provider in the patient's presence led patients in the dictation group to report increased satisfaction, apparently compared with their previous experiences, although there was no clear difference from the control group. The vast majority of patients and providers liked the process, and more than a third of patients believed they were helped in understanding their condition and treatment recommendations; this resulted in improved satisfaction. This study also demonstrated a possible "halo" effect, common in many studies, in that there was virtually universal satisfaction by all patients in the study in regard to their care, their understanding of their condition and provider recommendations, and the time spent with them by the provider.
Patient satisfaction with care has been shown to be more strongly related to the receipt of information and effective support from the provider than to the receipt of examinations, tests, and medication.12 A provider's communication style that strengthens the affiliation between provider and patient (such as the provider questioning and counseling on psychosocial issues) is positively related to patient satisfaction.1, 16-18 It is a reasonable assumption that the process of dictation in the presence of the patient provides an extra opportunity for more information exchange, increased affiliation, and greater involvement. Dictation in the presence of the patient should help prevent misunderstanding and miscommunication, because patients have the opportunity to hear their story summarized by the provider and to make corrections or additions.
Of considerable note is that men were significantly more positive about hearing dictation than were women. It is possible that male patients routinely expect less communication from providers than female patients do, and therefore hearing the dictation exceeded their expectations for involvement in the encounter. Interviewing a female patient takes longer than interviewing a male patient, and female patients use more statements of agreement or disagreement and detailed explanations than male patients. Male patients have been shown to give more interpretations than female patients to what the provider tells them.19 This may relate to men's communication goal of problem solving and women's goal of achieving emotional intimacy.20 We might further hypothesize that these sex differences relate to men's tendency to negotiate status differences in interpersonal communication, in contrast to women, who tend to minimize differences. Because providers' possession of expert information is central in their role as professional authorities, dictation in the presence of men may function as an equalizer of status.
Of additional interest is that older people were significantly more positive about all aspects of dictation in their presence. Again, this may be because older patients do not expect as much communication from their provider as younger patients do. The process of dictation might be perceived as "added value" to the older patient. We could find no applicable comparative references on this age issue.
Dictation in the presence of the patient may provide "a shared direction" for the patient and provider and can facilitate closure of the visit. Nine patients in this study (15%) raised a question or made a correction during the dictation. The opportunity for a patient to review the assessment (medical condition) and plan (recommendations) that were communicated by the provider can result in greater understanding and agreement. This process may also offer some protection from litigation because the patient has heard and potentially corrected the chart notation. There is also the benefit of the increased time spent with the patient doing a task that is usually done separately. Dictation also provides the opportunity for greater patient responsibility through participation in the creation of an accurate medical record. In our opinion, this is particularly true with privileged and sensitive psychosocial or sexual issues.
The sample was relatively small. This research used providers, primarily residents, who were experienced in dictation but inexperienced with the format for dictation in the presence of the patient. The treatment and control groups were not matched for frequency of previous encounters with the provider and were loosely matched for patient age and sex. The sex of the providers was not used as a variable in the results.
This investigation represents a first step in determining the potential value of allowing patients to be exposed to the dictation process. Suggested avenues for future research include longitudinal studies of patient outcomes and provider efficiency as a result of similar dictation practices. In addition, several questions are raised by this study that deserve further investigation. These include the role of patient sex and age on the perceived impact of dictation and on immediate patient satisfaction and understanding. Also of interest is the impact of dictation in the presence of the patient on long-term satisfaction of the patient with a provider.
AUTHOR INFORMATION
Accepted for publication June 5, 1997.
We thank Mary Markland, MA, Educational Resources and Research Coordinator, Northeast Iowa Medical Education Foundation, for her assistance in data collection, editing, and research coordination.
Reprints: John E. Sutherland, MD, Northeast Iowa Family Practice Residency Program, 2055 Kimball Ave, Waterloo, IA 50702.
From the Northeast Iowa Family Practice Residency Program, Department of Family Medicine, University of Iowa, Waterloo (Drs Sutherland and Walker and Mss Pint-Burke and Franklin); University of Northern Iowa, Cedar Falls (Ms Egbert); and the Department of Family Medicine, University of Wisconsin, Madison (Dr Gjerde). Ms Egbert is now with the Speech and Communications Department, University of Georgia, Athens.
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