Listen to my story: Contribution of patients to their healthcare through effective communication with doctors

Abstract

In the era of patient centered healthcare, patients are educated, more aware and demanding than ever. However, there is a significant misalignment between patients and doctors due to improper communication resulting in broken patient-doctor therapeutic relationships and degraded quality of healthcare. This suggests that patients have a greater and mature role to play in their healthcare. The paper aims to fill this gap by studying the contribution of patients in their healthcare through patientdoctor communication in selected Indian multispeciality hospitals. Qualitative multi-case study was steered and in-depth interviews of thirteen patients, twelve doctors were conducted along with the secondary data analysis of more than 600 pages of the documents from the official websites of the sample hospitals. Grounded theory three level coding revealed the themes of contribution of patients in through effective communication. The results indicate that patients contribute to their healthcare through effective communication by demonstrating association with doctors, reflecting reciprocally, resolving communication challenges and supporting their overall treatment process. The paper extends the literature on patient’s contribution in their healthcare. It presents clear and succinct implementable implications and distinctive ways in which patients cooperate with the doctors, work mutually, improves communication and strengthen their overall healthcare process.

Keywords

case study doctor communication hospital patient communication patient contribution

Introduction

Communication of patients with the doctors is widely regarded as the core element of patient care in hospitals. Researchers, doctors, and patients themselves strongly agree that the communication itself can make or break the treatment of the patients.¹ Clear signals indicate that in-patients communicate with doctors to express their daily thoughts and emotions such as pain or discomfort, clarify disease and medication-related doubts and understand the opinions of concerned doctors on the immediate future course of action and precautions that patients need to take post-discharge.² In line with the choices of in-patients, researchers argue that verbal, face to face communication is the most powerful way to communicate effectively with the doctors.³

Constructs of patient–doctor communication

Effective communication is ‘exchange of thoughts, emotions, facts or opinions of two or more persons’.⁴ Effective communication can lead to reassurance, provide motivation incentives and support to the patients. It strengthens the self-confidence of the in-patients, provides tangible paybacks such as higher patient satisfaction.⁵ The most impactful communication between in-patients and doctors is friendly, encouraging, verbally recognizes each other's involvement, open, empathetic, relaxed, attentive and leaves a long-lasting positive imprint. As a result, outcomes such as physical, mental and emotional health of the patient improve.⁶ Patients add value in their healthcare by building a positive relationship with the doctors^7,8 and clarifying their disease-specific doubts.^9,10 Researchers also believe that patients follow the process of treatment as suggested by the concerned doctors.^11,12 Doctors provide the necessary details and council the patients as required.^13,14

Changing paradigms and challenges of in-patients in communicating with doctors

Researchers pointed out the need for significant changes in the requirements, patterns, duration, and tactics in the way patients communicate with doctors. The landscape of patient communication is tending towards patient-centeredness.¹⁵ Patients are more educated, aware and further demanding than ever and hence need additional information regarding their healthcare from doctors.¹⁶ Researchers argue that effective communication goes beyond meeting regular objectives of communication (such as mere conveying the message) to more meaningful and impactful contribution of patients in their healthcare,¹⁷ such as taking the initiatives to solve the problems they face while communicating and going extra mile (being proactive and empathetic) in the regular interaction with the doctors.⁵

Gaps in literature and practice

Literature, however, suggests that several in-patients hesitate to inquire about their disease-related clarifications from concerned doctors, get angry, nervous and act violently, distress with doctors resulting in poor and ineffective communication.¹⁸ Due to knowledge asymmetry, the communication between in-patients and doctors is generally one way, when doctors explain complex medical aspects of health care to the patients.¹⁹ Lack of appropriate communication leads patients to non-adherence of medication.²⁰ Researchers claim that if these barriers are not addressed, they will severely hamper patient-doctor therapeutic relationships, experience, and quality of healthcare that the hospitals deliver.²¹

In India, the issue of patient-doctor communication is more problematic in private multi-speciality hospitals, as compared to government hospitals (due to higher patients to doctor ratio and doctors giving less time per patient) which absorbs nearly 74% of the country’s healthcare spending.²² Such a gap is critical to fill as poor communication with patients is leading to severe medical errors, increase in mis-behaviour of the patients such as disagreement on treatment approaches, non-cooperation and lower patient satisfaction ratings to the hospitals.²³ The literature is void in explaining how the patients contribute to their healthcare through effective communication with doctors in the context of Indian multi-speciality hospitals. To brighten this uncharted area, we explored the patient-doctor communication in the nominated multi-speciality hospitals in Delhi-National Capital Region in India by undertaking the research question ‘How can in-patients contribute to their healthcare through effective communication with doctors, from the perspectives of in-patients and doctors in the multispeciality hospital environment?’.

Methodology

To answer the research question, it is required to interpret the meaning and the basis of patient-doctor communication in the current multi-speciality hospital environment. Hence, the study needed the involved participation of the researcher to dig deeper and explore the peculiarities of the phenomena of patient-doctor communication and evaluate explanations for the perceptions and behaviour of patients and doctors. The understanding of the phenomena in the current business environment of multi-speciality hospitals is at the emergent phase, therefore qualitative case study approach was most appropriate for the research.²⁴ A case study is ‘an empirical inquiry that investigates a contemporary phenomenon within its real-life context’.²⁵ The case study method was found suitable because patient-doctor communication is intricate and context (hospital) - dependent phenomenon and comprises social processes such as interaction, accommodation, and cooperation.²⁶ Patient-doctor communication in India is underdeveloped, under-researched phenomena and is observable in private multi-speciality hospitals which dominate India’s healthcare expenditure, hence the focus of the study was on private multi-speciality hospitals.

In this paper, we consider patient-doctor communication as an individual level construct. The individuals are patients and doctors whose standpoints were captured through the multi-case study Purposeful sampling was selected to identify doctors as experts and patients as subjects undergoing the phenomena. Theoretical sampling was accepted as it supports to collect, code and analyze the data and simultaneously helps to decide the subsequent set of data to be collected.²⁷ To align with the research question and scope the data collection process, the selection criteria of hospitals were carefully self-crafted as to include only those hospitals which have 1000+ beds, more than 12 specialities, which were established before 1985 and spread across more than one location in India. This criterion led to only five hospitals in India. . Finally, only two hospitals (out of originally selected five hospitals))permitted to take the interviews of the doctors.

Participant characteristics

None of the hospitals agreed to take the interviews of the admitted patients due to the restrictive and patient data protection healthcare policies and the possibility of spreading the infection to the admitted patients, therefore the researcher identified people (from personal acquaintances). The sample constituted thirteen such patients.

Those doctors were selected who communicated the most with the in-patients, understand the nuances/challenges/idiosyncrasies of the communication and will be able to describe their experiences by responding to the interview questions. Also, the literature mapping constructs (column 5, Table 2) indicated that such participants can throw light on varied dimensions of doctor-patient communication. Clinical care co-ordinator doctors (no gender bifurcation) were selected as these doctors were also the medium of communication between patients, patient´s relatives, the team of other doctors and nurses who operated the patients. The population constituted 22 doctors (for the purpose of this research) the final sample was 12 doctors including both the hospitals. The sample doctors were not the ones who treated the sample patients. Participant demographics is illustrated in Table 1. The sample was selected considering the experience of communication of the participants to unveil the phenomena associated with the research question.

Table 1.

Participant demographics.

Demographics	Criteria	Patients count	Justification	Criteria	Doctors count	Justification
Age (Years)	25–35	6	Patients can address the interview questions well.	25-35	0	Minimum mid-career experienced doctors with significant patient interaction in their career.
	36–45	3		36-45	8
	46–55	4		46-55	4
Education	Any Graduation	13		MBBS (Latin: Medicinae Baccalaureus Baccalaureus Chirurgiae)	12
Experience	NA	NA	NA	10–15	3
				16–20	7
				21–25	2
Category	In-patients	13	In-patients spend the longest time in the hospitals under consistent environment as compared to any other patient category^2,7 and the majority of the revenue of private multispeciality hospitals comes from in-patients.²²	Clinical care co-ordinator	12	These doctors interacted the most with the patients during their shifts and were the in-charge of those in-patient departments (cardiology, critical care, emergency, endocrinology, gastroenterology, general surgery, respiratory medicine, and rheumatology) whose access was granted to conduct the interviews.
Patient health condition	Surgeries in past 30 days	8	Patients should clearly remember/recall the instances of communication with the doctors.	NA	NA	NA
Patient health condition	Surgeries in past 30–60 days	5		NA	NA	NA
Patient admission duration	Admitted for 5–7 continuous days	9		NA	NA	NA
	Admitted for 8–10 continuous days	4		NA	NA	NA
Relationship with each other	No relationship	–	Belong to different families.	Colleagues	12	–
Relationship to the researcher	Friends	4	Hospitals denied the access to the currently admitted patients.	No relationship	–	–
	Close relative	6
	Colleagues	3

Source: Prepared for current research.

Other factors such as gender, ethnic/economic/social status, residential location (rural/urban) of doctors and patients and any specific health condition, current disease, type of surgery of the patients or any other circumstances were not considered because the research question doesn’t require such a focus.

Data collection

Two different sources of data had been acknowledged. First, semi-structured interviews with selected patients and doctors. Second, data from secondary sources such as hospital official artefacts accessible on the websites of the sample hospitals. Data were collected from January 2018 to June 2018. Each patient and doctor were interviewed for an approximately 1-hour duration (patients at their respective home locations and doctors at the hospitals) and interviews were audio recorded with the due permission of the patients and doctors, and transcribed verbatim. Nearly 600 pages of artefacts posted on the hospital's official websites, including annual reports, patient news, events, articles, investors presentations, and patient testimonial texts were collected. Audios and videos of testimonials of ten patients and ten doctors as uploaded on the website of each of the hospitals were transcribed verbatim and coded.

Table 2 contains the secondary data selection and sampling details. Column 1 explains the type of documents collected, column 2 explains the details of the documents, column 3 details the relevance of the content in the documents, column 4 explains the justification of the selection of the documents and column 5 mentions relevant literature construct mappings.

Table 2.

Secondary data selection and sampling.

Type of documents	Document details	Relevant content in documents	Justification for selection	Literature construct mapping
Annual Reports	Annual Reports of 2016, 2017, 2018 for both sample hospitals	The message of board members, operation reviews, various reports, awards & accolades, patient feedbacks	Examples of patient- doctor communication, patient experience and satisfaction due to effective communication	Paying attention,¹,³,⁷ self-participation,³,⁷,¹³ describing findings,⁶,⁹ rapport-building,^5,10 trusting relationship⁵,¹⁸
Events	Multiple event documents from 2016 to March 2018 for both sample hospitals	Patient awareness/counselling campaigns, blood donation camps, World Heart, Cancer days, etc.	Evidence of shared decision making, rapport-building, trusting relationship, facing hospital environment, managing frustration/anger, staying calm
Patient News, Articles	Multiple news and article documents from 2016 to March 2018 for both sample hospitals	Articles on specific diseases, health tips, extraordinary surgeries performed, patient/doctor feedbacks, monthly newsletters consisting of updates on hospital, disease, and patients	Examples/direct quotes of patient- doctor communication, patient experience and satisfaction due to effective communication	Listening,¹,³ paying attention,¹,³,⁷ self-participation,³,⁷,¹³ addressing feelings,¹⁵,¹⁷ providing feedback,²,¹¹ thorough examination,⁷,¹³ describing findings,⁶,⁹ describing causes,⁷,¹¹ questions asked,²,⁸ shared decision making,³,⁶ rapport-building,^5,10 trusting relationship,⁵,¹⁸ facing hospital environment,⁷,¹² managing frustration/anger,⁹,¹¹ staying calm⁷,⁸
Investor presentations	Quarterly investor presentation from Jan 2017 to Jun 2018 of both sample hospitals	The message of board members, operation reviews, new developments on surgeries and processes
Patient/doctor testimonials	Text testimonials, Audio testimonials, Video testimonials (Jan 2017 to Jun 2018, both the sample hospitals)	Direct quotes of patient/doctor feedback on their experience of healthcare	Evidence of shared decision making, rapport building, trusting relationship, facing hospital environment, managing frustration/anger, staying calm

Source: Prepared for current research.

The interplay of primary and secondary data

The patient and doctor interviews and secondary data analysis worked in parallel to complement each other. The interviews covered the first-hand experience of the perspectives of patients and doctors, while the secondary data displayed the communication aspects of patients and doctors from the instances in the past. Table 3 contains sample (indicative) interview questions asked to the patients and doctors.

Table 3.

Sample interview questions (non-exhaustive, only indicative, excluding on-the-spot probing questions to get further insights).

Research question	The phase of patient treatment lifecycle	Literature construct mapping	Sample interview questions (same question to both patient and doctor separately, with the flipped recipient and/or context)
How can in-patients contribute to their healthcare through effective communication with doctors from the perspectives of in-patients and doctors in the multispeciality hospital environment?’.	Medical problem¹,²,³,⁷,¹¹,¹³,¹⁵,¹⁷	Listening	How you ensured that you were listening whenever the doctor spoke with you? Please quote an example.
		Paying attention	How did you pay attention when doctors were explaining to you the problem?
		History of illness	Were you asked to explain the history of your illness? If yes, how did you explain that? Please quote an example.
		Self-participation	Were there any questions from the doctor’s side when you were explaining the medical problem to him? How did you respond to the question?
		Listening without interruption	Were you interrupted by anything while you were explaining the problem to the doctor? If yes, how did you handled the interruption? Please quote an example.
		Addressing feelings	Did you explain your concerns/feelings/anxieties related to your problem to the doctor? If yes, how?
		Understanding	How did you understand your medical problem clearly and in details?
		Providing feedback	Did you provide any feedback to the doctor on your understanding of the medical problem? If yes, how? Please quote an example.
	Diagnosis ⁶,⁷,⁹,¹³	Thorough examination	What discussion took place while doctors were diagnosing or examining you? What did you say specifically at that time?
	Diagnosis ⁶,⁷,⁹,¹³	Describing findings	What discussion took place while doctors described the findings of the diagnosis to you? What did you say specifically at that time? Please quote an example.
	Treatment options²,³,⁷,⁸,¹¹,¹³	Describing causes	What discussion took place while doctors described the causes of your medical problem? What did you say specifically at that time?
		Providing feedback	Did you provide any feedback to the doctor on your understanding of the treatment options? If yes, how? Please quote an example.
		Any questions asked	Did you ask any questions/ clarified any doubts you had on the line of treatment that doctors decided for you?
	Attitude of Patients³,^5–12,18	Confirm understanding	Did you confirm your understanding of the daily procedures with the doctor?
		Shared decision making	Were you involved in making day to day medical decisions along with the doctor? Please quote an example.
		Rapport building	Did you build rapport with doctors who treated you? If yes, how? Please quote an example.
		Trusting relationship	Did you build a trusting relationship with doctors who treated you? If yes, how? Please quote an example.
		Facing the hospital environment	How did you cope up with the ICU environment? Did you face ICU psychosis? If yes, how did you overcome that?
		Managing frustration/anger	Did you feel anger or frustration at any time during your stay at the hospital? If yes, how did you dealt with this? Please quote an example.
		Staying calm	How you managed to stay calm? Please quote an example.

Source: Prepared for current research.

Qualitative data collection is an unceasing learning and improvement process.²⁸ As interviews advanced, new thoughts were generated, reviewed and incorporated based on the merit. For example, the first patient was reluctant to quote the direct example of his communication with doctors when he was feeling pain at his chest. The researcher requested the other patients to quote the direct example of their communication aspects (as asked per interview guidelines prepared by identifying the constructs from the literature review (refer to Table 2) to help understand the situation better. Similarly, such direct examples of patient quotes were looked in the secondary dataset as well. This approach resulted in enhanced quality and depth of data collection by integrating wider perspectives of the patients.

Data analysis

As the objective of the data analysis was to explore the contribution of in-patients in their healthcare through effective communication at multi-speciality hospitals (through regular comparison and interplay between data gathering and data analysis) grounded theory approach was found to be most appropriate. It theorizes the social progressions and is tested and proven to be the preferred methodology in naturalistic inquiry in under-researched areas²⁹ such as in-patient communication. Figure 1 displays the entire coding process.

Figure1.

Coding Process diagram (interplay of primary and secondary data analysis). Source: Prepared for current research.

Data were analyzed with three levels of coding approach. Coding was initiated by taking all transcripts of interviews of patients and doctors and coding to three levels (open, selective and theoretical). The term “theme” is used to define a fundamental unit of data with meaning that is necessary to present qualitative research findings. It is a recurring uniformity emerging from the exploration of qualitative data and captures the essence of experience or meaning.³⁰ As the final themes appeared, a second data source from hospital artefacts was coded. Proposed changes at any stage were incorporated in the coding and the process was repeated until theoretical saturation was reached.³¹

While coding the transcript of the thirteenth patient and twelfth doctor, no new insights were found. All of the responses seemed to be repeated to the responses of the previous patients and doctors respectively. The same repetition happened at evaluating the 20th patient testimonial, 15th doctor testimonial (all formats) and nearly 600 pages of text evaluation from the secondary data. Hence this point was the theoretical saturation and the final themes had been recognized and re-validated to confirm the sanity and duplicate codes merged.

Results

The results demonstrated the emergence of four different themes throughout the entire dataset. These themes are: demonstrating association, reflecting reciprocally, resolving challenges and supporting treatment.

Traceability from data analysis, coding to the finally emerged themes

The theme ‘demonstrating association’ was based on the collaboration that patients developed with doctors through communication to receive successful treatment.

Patient1: “Trust was developed after a thorough check-up. More trust was developed once I got a successful kidney transplant.”

Doctor4: “Yes, I give a lot of time to each patient personally to build trust. Once trust is built, half of the job is done!”.

Patient3: “No trust was developed. The doctor taking the round was in a hurry. He finished up quickly by prescribing medication.”

Doctor1: “There were a lot of patients to attend, it takes a lot of time to build trust”.

The quotes display the trust and rapport that the patients developed with the doctors. Hence, the first level code formed was ‘Patient taking help of a doctor and developing good rapport and trust.’ All the first-level codes were evaluated to form second-level codes such as mutual understanding, building emotional connect, building trust with doctors, and following post-treatment rehabilitation plan. All the second-level codes pointed out that patients demonstrated an association with doctors through their communication. Hence the final theme appeared. Patients demonstrated association with the doctors by developing bonding with them.

The theme ‘reflecting reciprocally’ was grounded in the active contribution of patients in their healthcare process through better communication with the doctors.

Patient2: “Yes, I asked a lot of queries during my entire 5 days stay at the hospital. All doctors and nurses were supportive and attended me well. The queries were regarding my current health status, medication, food restrictions and exercises post-discharge.”

Doctor7: “One patient was very active; he and his attendants (patient´s relatives) googled a lot of information in their cell phones and asked a lot of questions.”

Patient5: “I didn’t ask any queries as such. I was in pain. My attendants might have asked. I wanted to get relieved as soon as possible.”

Doctor3: “Few patients are shy; they don’t speak much. I ask them, do you have any doubts?”

The main point of the above quotes moves around the patient asking his healthcare process details from doctors to quench his anxiety. Hence the first-level code as ‘patient asking the doctor about the medical process and feeling confident’. Patients were active and wanted to gather as much information as possible about their medical condition and treatment. They were not hesitant to ask for clarifications and know the positive behavior expected out of them. All the first-level codes lead to the second-level codes as clarifying doubts, asking the relevant disease-specific information, confirming self-understanding and providing feedback. Evaluation of all the second-level codes indicates that patients were reflecting reciprocally in their healthcare, hence the final theme appeared. Patients reflected reciprocally by speaking up their side of the story.

Theme ‘resolving challenges’ was based on the challenges that patients were facing while communicating with the doctors.

Patient1: “Doctor who attended me was quite sincere. She always listened to me calmly and without any disturbance. She also spent enough time to hear my feelings and lifted my moral for recovery.”

Doctor3: “I ensured that there are no disturbances. We have a specific time for attendants to meet the patients, cell phones in the ICU are not allowed.”

Patient6: “There was a lot of noise in the morning. I was hearing a couple of ringtones of mobiles; a new patient was shifted to the ICU and another nurse was shouting to call the doctor because something happened to another patient. I called the doctor but he didn’t listen to me.”

Doctor11: “There can be few sound disturbances at times. I have an emergency mobile phone that rings at any time. I can’t avoid taking calls as there can be medical emergency any time.”

Patients expressed their challenges in communicating with the doctors. Patients not only expressed their frustration but also controlled it and asked the doctors to eliminate the source of the disturbance. Hence the first-level code formed was ‘patient facing communication challenge, managed frustration and asked for help’. Entire first-level codes formed second-level codes as resolving listening and speaking problems, agreeing and aligning with treatment approach, raising voice to remove communication interruptions, overcoming self-frustration and anger. All second-level codes indicated that patients were trying to resolve the communication challenges hence the final theme emerged as ‘resolving challenges’. Patients resolved challenges by taking relevent actions actively.

Finally, the theme ‘supporting treatment’ suggests active and matured role of patients in their healthcare process.

Patient7: “It was a mutual understanding. I asked the doctor to avoid injection at that time, he agreed and provided me with the alternative medication. He asked me to avoid certain food and I agreed.”

Doctor8: “Some patients are very nice and co-operative, specially today’s young generation. They fully co-operate and follow the directions.”

Patient12: “No, the doctor was not interested in discussion. He prescribed the medication and explained the format and timing of medicine consumption.”

Doctor2: “The patient was not much supportive. This was a severe road accident case. He shouted all the time and was difficult to manage.”

The patients were counselled by the doctors during their stay at the hospital. Patients also cooperated with the doctor and followed the directions. Hence the first-level code formed was ‘patient was counselled by doctor and patient cooperated and followed the instructions.’ With all first-level codes, second-level codes formed were: showing openness and comfort with doctors, receiving the required education/counselling, enhancing mutual understanding and cooperation with the doctor and following all instructions and the behaviour change as suggested by the doctor. There is a clear indication of patients supporting their treatment, hence the final theme. Patients supported their treatment by contributing from their side in the overall healthcare.

Discussion

The most important finding of the current investigation is that in-patients contribute to their healthcare through effective communication by demonstrating association with doctors, reflecting reciprocally, resolving challenges and supporting their overall treatment process.

Patients demonstrated an association in communicating effectively with the doctors. Patients build trust by becoming more friendly, opening up regarding any secrets specific to the history of their illness, their present conditions such as pain or discomfort or regarding the compliance with the medical protocol while at the hospital. However, referring to the doctors and patients quotes corresponding to the ‘demonstrating association’ theme from the results section, few patients and doctors reported inconsistencies in developing trust. From the data analysis, it has been interpreted that the trust is developed when doctors understand the cultural aspects of communication and spend enough time with patients, listens to the patients, acts to resolve their problems.^5,32 The result, however, goes beyond the literature and demonstrates that during their stay in the hospital, patients gradually build emotional connect with doctors by treating them as their own family members, communicating more often and following the instructions.

Patients reflected reciprocally by getting their doubts clarified regarding the vital signs such as blood pressure, body temperature, heartbeat etc. However, the doctors and patients’ quotations point out discrepancies in asking queries to the doctors. The possible reason behind this may be that the proactiveness of the patients to ask for clarifications depends upon their current health status and behaviour of doctors towards the patients. In line with the literature, patients asked their queries about their diseases to the doctors and contributed to co-create the health along with the doctors.^12,33 As is not directly evident from the literature, patients confirmed the understanding of their present health condition and any other critical information provided by the doctors by confirming the details in their own words. This action of the patients developed confidence within themselves and with the doctors who treated them. Finally, patients provided the feedback to the doctors about giving them the proper time, detailed explanation and clarity about their present health condition. All such information from the patients was not asked directly by the doctors, but patients displayed the signs of reciprocation thus showing contribution in their healthcare.

Patients tried to resolve the challenges they faced while communicating with doctors. The result ties well with the previous studies wherein patients indicated their agreement and alignment with the overall treatment approach as suggested by the doctors.^15,34 Nevertheless, the doctors and patients quote hints at the inconsistency in managing interruptions in the communication. This may be due to the differences in cultural values of doctors and patients. Culture can have vital clinical consequences in patient-doctor communication. Both patients and doctors need to be culturally competent to communicate effectively. India being a high context culture, authors argue that cultural factors such as language, confronting behaviour and beliefs, religion, individuality and authority impacts the patient-doctor communication by influencing the time to build a mutual relationship, trust and rapport.^33,34 Alternatively, the doctors are sometimes busy dealing with multiple situations at the same time, such as looking after multiple patients, attending the phone calls or relatives of the patients.

However, the novel findings suggest that the patients were self-aware and overcame their negative behaviour such as frustration and anger to co-operate with the doctors in the overall treatment process. They also expressed their feelings openly to the doctors and asked for help in the frustration and anger management. Patients displayed an active role in resolving the barriers in communication such as external noises and disturbances. They were not hesitant to ask for help in communicating as and whenever required. They raised their voices to remove the barriers to communication such as external noises and disturbances.

Patients supported their overall treatment process by displaying openness and widening the scope of the communication. As the literature suggests, few patients who were not proficient in the spoken languages especially Hindi, supported the alignment of the language interpreters and then showed openness and easiness with doctors and received the due counselling and education by doctors on their disease, treatment processes, pre and post-operative precautions, and medication.³⁵ The distinctive results show that the patients improved the mutual understanding with the doctors by letting them know the specific needs such as to request any specific food item, request change in any specific medication due to the side effects or to call their relatives for any formalities. Nevertheless, the doctors and patients quote points at the divergence in mutual understanding. It appears that mutual understanding in case of medical decision making depends upon the specific medical situation that patient is facing and the temperament of the doctors. Doctors might agree to the suggestion of the patients if that looks feasible to the doctors as per line of the treatment.

Patients displayed a desire to get relieved from their current medical condition and hence followed suggestions, guidelines, and adopted positive behaviour during the treatment process. Patients get encouraged and agreed to follow the desired actions to support their treatment.

Establishing confirmability, credibility, dependability, and transferability of the research

Chain of evidence is established by validating each theme against each data source (primary and secondary) and helped to establish confirmability, dependability, and richness.^28,29 Table 4 refers to the chain of evidence that also triangulates the results methods wise and theme-wise.

Table 4.

Identified themes, establishing a chain of evidence and triangulation.

Theme/result	Level 2 codes	Distinct contribution/literature mapping	Patient interviews	Doctors interviews	Hospital artefacts
Theme/result	Level 2 codes	Distinct contribution/literature mapping	Patients	Doctors	Annual reports	Events	Patient news	Articles	Investor presentations	Patient/doctor testimonials (video, audio, text)
Demonstrating association	Building emotional connect by considering medical staff as family members	Distinct	A.P	A.D	N.P	N.P	✓	N.P	N.P	✓
	Building trust by not hiding any information	Distinct	A.P	A.D	✓	✓	✓	N.P	N.P	✓
	Following a post-treatment rehabilitation plan	Distinct	A.P	A.D	N.P	✓	✓	✓	N.P	✓
	Developing mutual understanding	7,8	A.P	A.D	✓	✓	✓	✓	✓	✓
Reflecting reciprocally	Asking the relevant disease-specific information	9,10	A.P	A.D	N.P	✓	✓	N.P	✓	✓
	Clarifying doubts regarding the vital signs that the body of the patient is displaying	Distinct	A.P	A.D	N.P	✓	✓	✓	N.P	✓
	Confirming self-understanding	Distinct	A.P	A.D	✓	✓	✓	✓	N.P	✓
	Providing feedback on improving the communication	Distinct	✓	N.D	✓	✓	✓	✓	N.P	✓
Resolving challenges	Agreeing and aligning with treatment approach	11,12	A.P	A.D	✓	✓	✓	✓	✓	✓
	Overcoming self-frustration and anger	Distinct	A.P	A.D	N.P	✓	✓	✓	N.P	✓
	Raising voice to remove communication interruptions	Distinct	A.P	N.D	✓	N.P	✓	✓	N.P	✓
	Resolving listening and speaking problems	Distinct	A.P	A.D	✓	N.P	✓	✓	N.P	✓
Supporting treatment	Enhancing mutual understanding by letting the doctors know specifically the kind of support the patient wants	Distinct	A.P	A.D	✓	✓	✓	✓	✓	✓
	Changing the behaviour as suggested by the doctor	Distinct	A.P	A.D	✓	✓	✓	✓	N.P	✓
	Receiving the required education/counselling	13,14	A.P	A.D	✓	✓	✓	✓	✓	✓
	Showing openness and comfort with the doctor	Distinct	A.P	A.D	✓	✓	✓	✓	✓	✓

A.P: All Patients; A.D: All Doctors; N.P: Not Present; N.D: Not discussed in details.

Source: Prepared for current research.

There were certain cases with the inconsistency or diversion in the words of different patients and doctors on the response to the same questions. Discussion section explains the discrepancies against each theme with respect to the direct quotes of the patients and doctors(refer to the results section), the possible explanation of the discrepancies from the data analysis itself and the mapping with the equivalent theme. Such cases build credibility and strengths the grounding.^29,31

The case study and secondary data analysis as standard research methods, purposeful and theoretical sampling of patients and doctors as key informants and triangulation within the interview data of patients and doctors and within the secondary data itself also established the credibility of the research.²⁸ As applicable, direct quotes of patients and doctors have been presented (refer to results section) to provision thick description of the patient-doctor communication phenomena. Although, findings are descriptive in nature, rich and regular comparisons to explore and define patient-doctor communication may support transferability in a similar hospital and sample context environments.²⁹ Coding the data to the three levels was a regular comparison process leading to the generation of new thoughts, ideas, and insights from the data. Aligning with specific requirements of writing qualitative research, Table 5 details the COREQ checklist execution with respect to methodology, findings and reporting.^36,37

Table 5.

Writing qualitative research: methodology, findings and reporting.

Domain: study design
Theoretical framework
1	Methodological orientation and Theory	The study applied the grounded theory as methodological orientation
Participant selection
2	Sampling	Purposeful sampling was selected to identify doctors as experts and patients as subjects undergoing the phenomena. Theoretical sampling was accepted as it supports to collect, code and analyze the data and simultaneously helps to decide the subsequent set of data to be collected.²⁷
3	Method of approach	Doctors and patients were approached face to face.
4	Sample size	Thirteen patients and twelve doctors. The final sample was a result of theoretical saturation while coding the data.
5	Non-participation	Three Patients (out of 16 contacted) and five doctors (out of 22) refused to participate due to their non-availability. Finally, 13 patients and 12 doctors were interviewed.
Setting
6	Setting of the data collection	Interviews of patients happened at their respective homes and of doctors at the respective hospitals.
7	Presence of non-participants	Patient’s interviews happened in one on one settings while there were random visits of hospital staff at the hospital locations where interviews of doctors happened.
8	Description of sample	Described in Tables 1 and 2.
Data collection
9	Interview guide	Interview questions are described in Table 3.
10	Repeat Interviews	No repeat interviews were carried out.
11	Audio/visual recording	Audio recording was used to record all the interviews.
12	Field notes	Field notes were made and duly used in the data analysis process.
13	Duration	Interviews ranged from 45 minutes to an hour and a half.
14	Data saturation	Data saturation is discussed in data analysis section.
15	Transcripts returned	Transcripts were not returned to the participants.
Domain: analysis and findings
Data analysis
16	Number of data coders	Primary researcher coded the data with validation by the corresponding author.
17	Description of the coding tree	Coding tree is explained in Figure 1.
18	Derivation of the themes	Themes were identified from the data analysis.
19	Software	Coding was done manually without using any software.
	Participant checking	Results were triangulated with different data collection methods but participant feedback was not collected.
Reporting
20	Quotation presented	Participant quotations are presented along with participant identification.
21	Data and findings consistent	Table on Identified themes, establishing a chain of evidence and triangulation describes the consistency in findings across multiple sources of the data.
22	Clarity of major themes	4 major themes were identified and clearly stated in the result section.
23	Clarity of minor themes	Diverse cases have been explained in the discussion section.

Source: Prepared for current research.

Conclusion

The paper concludes by arguing that the in-patients can contribute to their healthcare through effective communication at multi-specialty hospitals by demonstrating an association, reflecting reciprocally, resolving communication specific challenges and supporting their treatment. Results demonstrated that patients establish association by developing an affinity, building emotional link and trust with doctors and strictly following rehabilitation plan. Patients reflect reciprocally by clarifying worries, asking the appropriate disease-specific information, validating self-understanding and providing feedback. The present findings confirm that patients resolve communication problems by resolving listening and speaking issues, agreeing and aligning with treatment method, raising voice to remove communication disruptions and overcoming self-frustration and annoyance. Patients strengthen the treatment by displaying openness and comfort with doctors, receiving the required education/counselling, enhancing mutual understanding and collaboration with doctors and following all instructions and the behavior change as recommended by doctors. Broadly translated, the findings indicate that effective communication by patients helps them in their overall treatment process. Importantly, the results provide evidence for the crucial role of patients in effectively communicating with doctors to improve the overall healthcare experience and high context cultural factors such as resisting behavior, language, influencing power play a pivotal role in doctor-patient communication.

Implications

The results identified are an addition to the patient-doctor communication literature in multispeciality hospitals context. Table 6 highlights the specific learning outcomes of research for patients, doctors, patient´s relatives, and hospitals. The learning outcomes are mapped against each of the four themes as mentioned in column 1, column 2 shows the level 2 codes, column 3, 4 and 5 mentions specific learning outcomes for patients, doctors, and hospitals respectively. Clear and implementable action points are evidently mentioned for each of these stakeholders to contribute towards successful effective patient-doctor communication.

Table 6.

Learning outcomes of research for doctors, patients, patient´s relatives, and hospitals.

Theme/Result	Level 2 codes	Learning outcomes for Patients/Relatives	Learning outcomes for Doctors	Learning outcomes for Hospitals
Demonstrating association	building emotional connect by considering medical staff as family members	Build trust and rapport with doctors by following their instructions regarding treatment, medication, dietary and precautions to take. Follow the post-treatment plan of rehabilitation as prescribed by the doctors.	Be culture-sensitive and communicate effectively with the patients by building trust and rapport and explaining the treatment, medication, dietary and precautions to take, in a friendly and detailed manner.	Encourage doctors and patients for better, clear and sufficient communication.Take patients and doctors feedback on daily progress, manage and resolve patient complaintsFacilitate the emotional, trust and rapport-based relationship between patients and doctors
	building trust by not hiding any information
	following a post-treatment rehabilitation plan
	developing rapport
Reflecting reciprocally	asking the relevant disease-specific information	Ask and clarify all treatment-related doubts, understand your disease, its implications on your life, precautions and medication to take post-treatment, confirm and validate your understanding after discussions, counselling and education sessions by the doctors, provide feedback on the way the communication with doctors is happening and anything to alter, improve.	Appreciate and encourage patients to share their concerns and queries, validate whether patients understood what has been explained to them and take the feedback of the patients to improve effective communication.	Encourage patients to communicate as much as possible and required, validate their understanding and register their feedback on effective communication improvement areas, implement the patient feedback to improve the contribution of patients in effective communication with doctors
	clarifying doubts regarding the vital signs that the body of the patient is displaying
	confirming self-understanding
	providing feedback on improving the communication
Resolving challenges	agreeing and aligning with treatment approach	Follow the entire treatment process as suggested by doctors, control frustration and stay calm, be proactive to raise concern to eliminate any barriers to speaking and listening with doctors	Encourage the patients to align with the overall treatment process, be friendly and counsel the patients to manage their frustration and fear, be aware of and remove any barriers to the communication with patients	Validate the mutual communication-based alignment between patients and doctors, keep track of and remove any physical disturbances in the ICUs, patient wards as much as possible
	overcoming self-frustration and anger
	raising voice to remove communication interruptions
	resolving listening and speaking problems
Supporting treatment	enhancing mutual understanding by letting the doctors know specifically the kind of support the patient wants	Develop and improve the mutual coordination with the doctors, behave in a supportive way and co-operate in the entire treatment process, be concealable with the doctors, be honest and friendly with the doctors	Develop mutual coordination with the patients, support the patients to help them change their negative behaviour, counsel, educate and be approachable and easy with the patients	Keep track of and facilitate the improvement in the overall patient behaviour towards his/her treatment, ensure that patients are educated and counselled regularly and effectively, validate the patient-doctor comfort levels and remove hindrances if any
	changing the behaviour as suggested by the doctor
	receiving the required education/counselling
	showing openness and comfort with the doctor

Source: Prepared for current research.

Research ethics

Each patient and doctor as a key informant were clearly explained the objective of the research and written and informed agreement was obtained to conduct and record the interviews. No personal/disease specific or confidential information has been asked from any of the key informants. Entire raw data were protected as confidential with availability only to the researchers. Hospital/patient/doctor names have neither been documented nor quoted anywhere.

Limitations

This study presents only the perspective of doctors and in-patients on effective patient communication. Future research can include the perspectives of medical staff such as nurses, physiotherapists, dieticians, technicians, healthcare psychologists, social workers and the hospital management, which may reinforce the developed results or un-cover new results altogether. Future researchers can also focus on understanding the views of in/out-patients of less or no literacy, who speak languages other than English, who have hearing or speaking impairments, conduct research based on specific gender or patients and/or doctors or focus on patients with a specific disease, living in a specific residential location (rural/suburban/urban), with particular race/religion, medical history, consider government hospitals or single-speciality hospitals. Inclusion of the perspectives of speciality or out-patient doctors, embracing other qualitative methods such as observation of patient-doctor consultations, focus more on high context Indian cultural impact on communication, conduct action research or consider the non-verbal communication between patients and medical staff. Finally, researchers can focus on the willingness and ability of the doctors to be patient-centric as the influencing factor on doctor-patient communication.

Supplemental Material

sj-pdf-1-hsm-10.1177_0951484820952308 - Supplemental material for Listen to my story: Contribution of patients to their healthcare through effective communication with doctors

Supplemental material, sj-pdf-1-hsm-10.1177_0951484820952308 for Listen to my story: Contribution of patients to their healthcare through effective communication with doctors by Harbir Singh and Ajoy Kumar Dey in Health Services Management Research

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Harbir Singh

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