Doctor–Couple Communication During Assisted Reproductive Technology Visits

D. Leone; L. Borghi; S. Del Negro; C. Becattini; E. Chelo; M. Costa; L. De Lauretis; A.P. Ferraretti; G. Giuffrida; C. Livi; A. Luehwink; R. Palermo; A. Revelli; G. Tomasi; F. Tomei; C. Filippini; E. Vegni

Disclosures

Hum Reprod. 2018;33(5):877-886. 

In This Article

Discussion

Assisted reproductive medicine is a complex field not only from a biomedical point of view, but also for the ethical, psychological and legal implications. Therefore it is surprising that data on communication issues are limited (Leite et al., 2005; Grill, 2015). The present study is one of the first studies on actual doctor–patient communicative behavior in ART consultations. Firstly, it is interesting to note that the ART patient response rate in our study was lower (62.2%) than the response rate in other medical contexts, such as emergency medicine, internal medicine and family practice or infectious disease medicine (Paasche-Orlow and Roter, 2003; McCarthy et al., 2013; Borghi et al., 2016). It would be interesting to explore whether this result is strictly related to the Italian context, where ART may still be considered taboo among patients today, or whether it would also be observed in other countries.

Regarding the first aim, as found in other studies (Roter et al., 1997; McCarthy et al., 2013), the results showed physician verbal dominance during the spoken exchange. The ratio of physician verbal dominance was even higher than in other studies (Paasche-Orlow and Roter, 2003; McCarthy et al., 2013). Roter et al. (1997) showed that the highest level of physician verbal dominance was evident in a specific pattern of communication, defined as 'consumerist'. This pattern was characterized by the use of the physician as a consultant who answers questions and provides information, and corresponded to the informative model described by Emanuel and Emanuel (1992). Our findings showed that the most representative category for physicians was biomedical information provision, and, together with the quite low PCI score (μ = 0.51 ± 0.28), revealed a more disorder-oriented approach of physicians during the visit, mainly focused on providing information and counseling. The PCI score is lower than in other contexts such as internal medicine and general practice (Cooper et al., 2003; Helitzer et al., 2011; Paasche-Orlow and Roter, 2003), but is quite similar to the score observed by McCarthy et al. (2013) in the emergency medicine context. As hypothesized by McCarthy et al. (2013), it could be that also in a specific context like ART, where patients want to be assertive and prefer to play an active role in medical decisions and procedures (Malin et al., 2001; Dancet et al., 2011; Peddie et al., 2004, 2005), being 'patient centered' could imply a focus on the biomedical rather than on psychosocial and socioemotional issues. However, the ART physicians in our study seemed able to make room for socioemotional aspects during the visit too, balancing their talk among other RIAS categories: emotional talk, positive talk, facilitation and procedural talk. Some authors underscored that ART clinicians feel they are unprepared when it comes to addressing patients' emotions, needs and preferences (Aarts et al., 2011; Huppelschoten et al., 2013) and although they often have to deliver bad news, little research has been carried out into ways to improve communication (Grill, 2015).

Our data revealed the influence of some demographic and clinical variables on the Patient Centredness Index. In particular, the visits in which the treatment indication was for an heterologous fertilization were more patient-centered. This did not apply however to the visits in which the indication was ending treatment. It could be that the clinicians felt the visits in which the treatment indication was for an heterologous fertilization as more delicate, using more socioemotional RIAS categories as a consequences. Finally, consistently with literature (Roter et al., 2002), our data showed that the female clinicians were more patient-centered than the male clinicians.

Providing biomedical information is the most representative category for patients too. Interestingly, positive talk (agreement, approvals, compliments, laughter and jokes) is the second most representative category for patients. This data could be consistent with the 'consumerist' pattern of communication described by Roter et al. (1997), where a high level of patient positive talk was considered as a response to the information provided by the physician. We can suppose that patient positive talk may also reveal a need to feel comfortable during the consultation by seeking the doctor's approval and/or by joking. In a context in which it has been found that the psychological impact of infertility is comparable to breast cancer and other serious medical conditions (Domar et al., 1993), we can hypothesize that the use of jokes and laughter during the visit could have a sort of 'defensive' function for couples, as if the emotional burden of the visit was minimized by laughter.

As to the differences between the communication content of male and female patients, our findings showed that women reported a greater number of utterances in almost all RIAS composite categories, regardless the cause of infertility. In greater detail, females reported significantly more utterances than expected in biomedical information, positive talk and procedural talk. This result should not be considered surprising, considering that all the physicians were gynecologists, used to interacting with female patients, and considering that women have the burden of being required to undergo the majority of the treatments. Nonetheless, in a context in which the patient is the couple, which should be considered as two separate individuals (Lalos, 1999; Leone et al., 2017), the real patient seems to remain the woman while men are left (or put themselves) aside. Literature (Wright et al., 1991; Hjelmstedt et al., 1999) has shown the existence of gender differences in psychological reactions to infertility. In greater detail, it seems that women reacted more strongly to their infertility than men, showing higher psychological distress (such as anxiety, depression, etc.). It is possible that female dominance during ART visits reflects these psychological gender differences, in the sense that a more stressed and anxious patient may have a stronger need to maintain control of the visit. This gender difference could also explain the finding that positive categories were particularly used by women: women might feel a stronger need to minimize the emotional burden of the visit, as we have previously suggested. Further research should better explore the role of the male patient during the ART visit. Literature shows that during triadic medical consultations, partners may assume a variety of roles (from emotional to informative support) (Laidsaar-Powell et al., 2013). It could be interesting to understand whether male patients at the ART visit take on (or are considered to have) a role as a companion or whether they are also seen as patients, as should be the case.

In conclusion, the results showed the complexity of doctor–patient communication during ART consultations, including their triadic characteristic. Clinicians should be trained to manage these complex aspects and to take into account perspectives of both male and female patients.

Limitations

This study has some limitations: the results are preliminary, observational and only regard Italy. It would be useful to repeat the study in other countries. Additionally, communication during the visit may have been biased as the professionals who agreed to participate showed an interest in communication issues. Another limitation is represented by a possible Hawthorne effect due to the fact that participants were aware of being videotaped. This limitation could not be avoided for ethical reasons, but previous studies found that recording visits does not significantly alter physician behavior (Jordan and Henderson, 1995).

Despite its limitations, this is one of the first studies on actual doctor–patient communicative behavior during ART consultations. Moreover, the study is not based on self-reporting or self-perception of communication styles, but instead applies the RIAS as a method of data analysis, a validated cross-cultural method (Roter and Larson, 2002).

Future Directions

The present work is a starting point about the theme of communicational aspects in ART visits. Results of the present study could be a call for more in depth research to come to an increased understanding in this topic. In order to develop specific strategies for supporting clinicians in optimizing triadic consultations involving two patients, the most relevant areas for future research appear to be: the function of the use of positive talk by ART patients, the relationship between the PCI and patient satisfaction, the educational needs of ART clinicians regarding communication skills (in order to develop specific communication training) and the role of the male patient during the ART visit. Moreover, a qualitative study could better explore why clinicians were more patient centered in visits in which the indication treatment was for heterologous fertilization. Finally, further research should be done to better understand which communicational style could best meet patients' needs during ART visits in order to engage them in the care process.

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