Developing and using quantitative instruments for measuringdoctor–patient communication about drugs

Linda Jenkinsa,*, Nicky Brittena, Fiona Stevensond, Nick Barberb, Colin Bradleyc

aDepartment of General Practice and Primary Care, Guy’s King’s and St. Thomas’ School of Medicine,

5 Lambeth Walk, London SE11 6SP, UKbThe School of Pharmacy, University of London, London, UK

cDepartment of General Practice, University College Cork, Cork, IrelanddDepartment of Primary Care & Population Sciences, Royal Free and University College School of Medicine, London, UK

Received 28 March 2002; received in revised form 30 September 2002; accepted 2 December 2002

Abstract

Previous qualitative work has identified communication problems between doctors and patients in general practice consultations,

particularly in relation to prescribing. This study aimed to develop quantitative measures to extend the research and provide instruments

for both researchers and practitioners to use in monitoring communication and prescribing. Questionnaires were developed from existing

instruments. When used with patients and doctors in a variety of general practices, the instruments appeared to be acceptable and had high

response rates. While many consultations were satisfactory in terms of patients’ expectations and their experiences with medicines, only 38%

did not have any poor outcome. The results using quantitative instruments were similar to but less striking compared to our previous

qualitative work. The research was developmental and findings suggest that unnecessary prescribing and problems in communication are

more likely to lead to poor outcomes in terms of non-adherence and patients having barriers to using their medication.

# 2003 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Expectations; Communication; Prescribing; Adherence

1. Introduction

Our previous qualitative work has identified communica-

tion problems between doctors and patients in general

practice consultations, particularly in relation to prescribing

[1]. We found that patients have complex agendas that are

not always revealed or explored [2] and that the levels of

self-treatment and non-adherence to prescribed medicines

are largely unknown to the doctor [3]. We found evidence

that misunderstandings between doctors and patients can

lead to poor outcomes [4].

The study reported here aimed to extend the qualitative

research by developing quantitative measures. Instruments

were therefore needed that would identify what patients

expected from their visit, the extent to which their expecta-

tions were met and how patients used prescribed medication.

Information was also required from doctors on their percep-

tions, so that comparisons could be made between patients’

and doctors’ perceptions. Results from the quantitative

instruments would be used to examine the relationship

between these doctor–patient measures and outcomes, such

as unwanted or unnecessary prescriptions, medicines not

being taken as prescribed, and patients experiencing pro-

blems with their medication. The intention was to develop

instruments which could be used in research and by practi-

tioners wishing to monitor their own communication and

prescribing.

The study was designed to develop and test the data

collection instruments, rather than collecting sufficient data

to test hypotheses and identify statistically significant find-

ings. The findings are, however, expected to raise specific

questions that help to focus further work in this area.

2. Methods

A similar pattern of data collection was used to the

previous qualitative work [5], gathering information from

doctors and patients before and after consultations in general

practice. The instruments also needed to be suitable for more

routine use, by being relatively simple to administer and

Patient Education and Counseling 50 (2003) 273–278

* Corresponding author. Tel.: þ44-20-7848-4100.

E-mail address: linda.jenkins@kcl.ac.uk (L. Jenkins).

0738-3991/$ – see front matter # 2003 Elsevier Science Ireland Ltd. All rights reserved.

doi:10.1016/S0738-3991(03)00049-1

taking only a few minutes to complete. Rather than inventing

new instruments, we looked for existing and validated

measures from published research, although these did not

always meet our needs, and required some adaptation.

In addition to the patient and doctor data collection

instruments, we audiotaped consultations and where possi-

ble obtained computerised information on other concurrent

conditions and medications to make an independent assess-

ment of inappropriate prescribing. During development, the

instruments were examined by the research team for face

and content validity, piloted tested and revised. They were

used by groups of general practitioners (GPs) with an

interest in improving doctor–patient communication about

drugs. Doctors were recruited via personal communication

and from the response to a mailing to GP trainers in one

health authority area. Although a self-selected convenience

sample, the three groups of GPs taking part served a range of

urban, provincial and rural populations.

2.1. Pre-consultation questionnaire for patients

We began by using Middleton’s Patient Agenda Form [6].

However, this open-ended format that required answers to be

written in the patients’ own words often produced a brief

response containing little detail. Patients described symp-

toms but said little or nothing about expectations, attitudes,

beliefs or other aspects of communication that our earlier

work had suggested were important.

A more appropriate instrument for our purposes was the

Patient Requests Form (PRF), developed and used by Sal-

mon et al. [7] and Valori et al. [8]. This form consists of 42

questions which provide specific prompts for a wide range of

things patients want or would like from their doctor on a

particular day. Several adaptations were made to the PRF

to make it suitable for this study. First, we added questions

that we had previously found were important to patients in

relation to prescribing and the provision of information on

medicines. Secondly, as the instrument was considered too

long for completion in the time patients had or were pre-

pared to give, we removed questions which our qualitative

work had found to be of little interest to the study or ones that

had already been covered. A version which enquired about

more than one health problem was also tested out but did

not work satisfactorily. This was because of the time it took

to complete and the confusion caused by repetition of the

questions.

Although the PRF was designed to quantify the intentions

of patients visiting their general practitioner and refers to

what patients want, our pilot work had shown that patients

(when unprompted) had very few requests for their doctor.

The qualitative work had also shown a reluctance to voice

them. At the start of our modified version of the PRF we

therefore encouraged patients to tell us what they wanted or

expected. Throughout this paper, we refer to their answers as

what patients ‘wanted’, as this was the wording used in the

majority of questions.

The pre-consultation questionnaire was completed by

94% of the patients who agreed to take part. The researcher

provided help to those who had difficulty with reading

or writing. Completion time varied enormously between

patients, but was usually achievable within the time avail-

able.

2.2. Post-consultation questionnaire for patients

This instrument was designed to repeat some of the

questions asked in the pre-consultation questionnaire, asking

for patients’ perceptions of what had occurred in the con-

sultation. With even less time to complete, this instrument

was kept as brief as possible, by excluding some questions

that we could answer by listening to the audiotape. The

post-consultation questionnaire took approximately 1 min

to complete and was returned by 90% of the participating

patients.

2.3. Follow-up interview of patients

This part of the data collection differed from the self-

complete questionnaire formats described so far. It took the

form of a telephone interview by a researcher contacting all

patients who had received a prescription. The interview

format was used since we needed to know when it was

completed to assess non-adherence, and interviews usually

get better response rates compared to self-complete forms.

At least three attempts at different times of day were made to

contact patients by telephone.

The telephone interview schedule was developed based on

a successful format used previously by Barber et al. [9], and

included the most relevant questions from the Beliefs about

Medication Questionnaire [10], the Brief Medication Ques-

tionnaire (BMQ) [11] and the Satisfaction with Information

about Medicines Scale (SIMS) [12].

The Brief Medication Questionnaire [11] identifies poten-

tial non-adherents and people with belief barriers (problems

or concerns with their medication), and has been validated

against the MEMs device that electronically records when a

medicine bottle is opened and closed. We pilot-tested the

self-complete BMQ and found it useful in identifying rea-

sons people had for stopping taking their medication and

the areas that bothered them. However, in other respects the

response was poor, making it difficult to interpret whether

a non-response was a refusal to answer or because the

question did not apply to a patient’s situation. We, therefore,

incorporated the questions on adherence into the telephone

interview with the aim of improving the response.

The Satisfaction with Information about Medicines

Scale [12] was also designed as a self-complete form,

and at first we tried using this as part of the post-consultation

questionnaire. It got a poor response (74%) compared to

the other questionnaires and was felt to impose an unreason-

able burden on patients compared to the information it

elicited.

274 L. Jenkins et al. / Patient Education and Counseling 50 (2003) 273–278

The telephone interview schedule therefore included the

adherence questions from the Brief Medication Question-

naire, the most relevant items from SIMS, plus specific

questions to cover the information gained from the pilot-

testing of the Brief Medication Questionnaire. Minor adapta-

tions were made so that this part of the interview asked about

specific medicines over a specific time period. Five questions

from the Beliefs about Medicines Questionnaire [10] were

used to ask about medicine-taking generally.

Patients provided a home or mobile telephone number. On

rare occasions, when a telephone interview was not possible,

the patient was contacted by post to arrange for the interview

schedule to be completed. The follow-up telephone inter-

view was successfully carried out with 91% of the partici-

pating patients. The interview took less than 5 minutes to

complete.

2.4. Doctor questionnaire

A questionnaire was developed for GPs to use immedi-

ately after each consultation based on Britten and Ukou-

munne’s questionnaire [13]. It was designed to be completed

in approximately 1 min, and recorded the GP’s assessment

of how the consultation went, including their understanding

of the patient’s views, and whether they felt uncomfortable

or pressured in their prescribing decisions. GPs were asked if

the medication prescribed was strictly indicated, and replies

were used to identify unnecessary prescriptions. The ques-

tionnaire was quick and simple to use and, of all the instru-

ments described here, achieved the highest response rate

(98%).

3. Results

One GP session was used for each of the 18 participating

GPs and data was collected from a total of 186 patients.

Researchers asked patients attending the health centre if

they wished to take part, and 86% of those approached

agreed. An estimated 10–20% of those attending were

not approached due to lack of the researchers’ time to

recruit them or insufficient time for the patient to complete

the questionnaire before seeing the doctor. Compared to

England figures for 1998 (from the Royal College of

General Practitioners’ website http://www.rcgp.org.uk)

the study included typical proportions of males and females,

but included fewer children and more people aged over

65 years.

3.1. What patients wanted

Before seeing the GP, patients were asked whether they

wanted a prescription for their main problem (see Table 1).

A substantial proportion (42%) said they did, and fewer than

one in five (18%) said they did not. This left over a quarter

(28%) who were uncertain about wanting a prescription

and 12% not answering. When asked if they would rather

not have a prescription if it was not really necessary,

nearly half (44%) agreed, with many (38%) uncertain or

not replying.

What most patients wanted was for their GP to talk with

them about their problem. Over half the patients also would

like to participate in treatment decisions, wanted the GP to

listen to what the patient thought was wrong, the GP to

explain both the nature of the problem and the treatment, and

to provide a diagnosis. Patients were also clear about some

of the things they did not want. For example, 60% did not

want to be taken off medication, 60% were not seeking other

changes in their medication, and 57% did not want emo-

tional help. Less than one in three would have liked to be

offered a choice of treatments.

3.2. Extent to which patients got what they wanted

By comparing what patients told us before the consulta-

tion with what they said when they came out, we found a

small proportion got less than they wanted (Table 2). This

happened most for ‘choice of treatment’ (43% disappointed)

and ‘reassurance’ (13% disappointed), with lower percen-

tages for people feeling they had not participated in the

treatment decision, and that their views on treatment had not

been heard.

Further investigation of mismatches between what

patients wanted and what they felt they had received showed

that doctors frequently provided more than the patients had

expected. In fact for all the items in the table apart from one

(being offered a choice of treatments), the numbers and

proportions of patients getting more than they wanted far

exceeded those getting less than they wanted.

Table 1

What patients wanted (N ¼ 174)

What patients wanted immediately before the consultation

80% wanted the doctor to talk with them about their problem

60% would like to participate in decisions about treatment

57% wanted the doctor to listen to what the patient thinks is wrong

57% wanted the doctor to explain the problem

56% wanted the doctor to explain the treatment

55% wanted a diagnosis

47% would rather not have a prescription unless really necessary

42% wanted advice on treatment

42% wanted a prescription

41% wanted to be examined

41% wanted reassurance that there is nothing wrong

37% wanted advice on medication

32% would like to be offered a choice of treatment

30% would like emotional support

29% wanted the doctor to listen to the treatment the patient

thinks they need

21% wanted tests

12% want to be referred

10% wanted help with emotional problems

7% wanted to change their medication

5% wanted to come off medication

L. Jenkins et al. / Patient Education and Counseling 50 (2003) 273–278 275

Eight of the patients who had said before the consultation

they did not want a prescription, received one. These

unwanted prescriptions occurred for 7% of the consultations

when medication was prescribed, and 5% of all consulta-

tions.

3.3. Patients’ subsequent use of medicines

About two-thirds (121 out of 185, 65%) of the consulta-

tions involved writing a prescription. There were also

occasions when doctors recommended patients to buy

medicines over the counter (OTC), although OTC recom-

mendations were only recorded for three patients (less than

2%). One week after the consultation, we telephoned all

the patients who had received a written prescription and

asked about their use of medicines during the preceding

7 days.

About one in five (18%) appeared to be potential non-

adherents, as they could not recollect receiving the prescrip-

tion, had not cashed it, had not started taking it, had stopped

early, had missed doses or did not answer. These questions

related specifically to the medication prescribed at the study

consultation a week before.

A larger proportion (25%) indicated there was a belief

barrier with the prescribed medication, in other words, they

thought it did not work well or they had one of a number

of worries or concerns about it. Those who were potential

non-adherents were also more likely to have belief barriers

(odds ratio 4.6, with 95% confidence limits 2.0–10.4).

When asked if they would have liked to have received

more information about their medication, eight people (5%)

said they would. These patients wanted to know how to take

or how long they would have to take the medicine, and

whether it might interfere with other medicines.

3.4. Doctors’ assessments

Doctors recorded information about each consultation,

saying that only 13 consultations (5%) went ‘not particularly

well’ or ‘badly’. They recorded if there was more than one

problem and the prescriptions associated with each problem.

In 84% of consultations, doctors felt they understood the

patients’ views about their illness and nearly as many felt

they understood the treatment the patient would like (79%).

Occasionally (3% of consultations) they felt ‘very pres-

sured’ by the patient to prescribe, and they reported feeling

‘slightly’ or ‘definitely’ uncomfortable in nine consultations

(5%) about their prescribing decisions. Doctors recorded

when prescriptions were not strictly indicated. One in five

prescriptions fell in this category and we have referred to

them as ‘unnecessary’ prescriptions. Unnecessary prescrip-

tions occurred in 17% of consultations.

3.5. Differences between patients’ and doctors’

assessments

It was usually the case that doctors and patients recorded

the same main problem (98%), and any discrepancies

were in the sequence the problems appeared. There was

also good agreement between doctors and patients on the

second problem (91%), although doctors recorded more

problems than the patient had indicated in advance. Overall

87% of patients were in agreement when doctors thought

that the patient had raised all the health problems they

wanted to.

At the end of the consultation, doctors often felt that they

understood the patients’ views about their problem. This

coincided with patients’ perceptions 93% of the time, but for

a small number (eight patients) the patient had not agreed

that the doctor had listened (Table 3).

When we looked at the number of doctors who felt they

had understood the patients’ views of the treatment they

would find acceptable, the number of mismatches went

up. This time there was agreement for 80% of the patients

with 21 not agreeing that the doctor had listened to the

treatment the patient thought they needed (Table 4).

Doctors’ perceptions of whether a patient wanted a pre-

scription or not, were right just over half the time (53%).

Table 2

Extent to which patients got what they wanted (N ¼ 167)

Item Comparison of patient

responses before and after

consultation

Number

who

wanted

Number who

wanted but

did not get

The doctor to talk with them 133 1 (1)

Participate in treatment decisions 104 9 (9)

The doctor to listen to their problem 96 0 (0)

The doctor to explain the problem 96 3 (3)

The doctor to explain the treatment 94 4 (4)

The doctor to diagnose what is wrong 91 3 (3)

Reassurance 68 9 (13)

Advice on medication 64 1 (2)

Choice of treatments 54 23 (43)

Emotional support 52 1 (2)

The doctor to listen to the treatment

the patient thinks they need

48 4 (8)

Help with emotional problems 17 0 (0)

Values in parentheses are percentages.

Table 3

Views on whether the doctor understood what the patient thought was

wrong

Number of times the

doctor felt they

understood what the

patient thought was

wrong (Q5)

Number of patients who felt the doctor had

listened to what the patient thought was wrong

(Q6 post-consultation)

Agree Uncertain/disagree

Yes 113 8

No/do not know 17 2

Total 130 10

276 L. Jenkins et al. / Patient Education and Counseling 50 (2003) 273–278

This was partly because patients were often uncertain or did

not reply when doctors thought patients did have a prefer-

ence. This meant that when doctors thought patients did

want a prescription, 3% of these patients did not and 32% did

not indicate a preference (Table 5).

There was a strong relationship between whether the

doctor thought the patient wanted a prescription and whether

one was written (odds ratio 38, 95% confidence limits 15–95).

3.6. Relationships between mismatches and

misunderstandings and outcomes

We looked for evidence that mismatches in patients’

expectations and misunderstandings between doctors and

patients were associated with adverse outcomes. For this

comparison, we took only the consultations where patients

clearly got less than expected or disagreed with what doctors

thought had occurred, which meant excluding consultations

when patients expressed uncertainty or had not replied to the

relevant questions. The outcomes examined were unwanted

medication, unnecessary prescribing, non-adherence or pro-

blems with their medicines (belief barriers).

When looking at the patients’ assessments, there was no

evidence of poorer outcomes for patients who got less than

they had wanted. This was partly because these mismatches

were comparatively rare and numbers too small for statis-

tical significance. Even when the numbers of mismatches

were higher (for patients wanting and not getting reassur-

ance, an explanation of the problem, a choice of treatments

and participation in treatment decisions), no difference

could be seen in the proportion of unwanted and unnecessary

medicines. Similarly, there was no relationship between

patients getting less than expected and subsequent non-

adherence or other problems with medication.

It was also unusual for patients to say something had not

occurred in the consultation when doctors thought it had,

and there was little evidence that these mismatches were

associated with poor outcomes. However, regarding under-

standing the treatment patients would find acceptable, when

the doctor felt that they had understood the patients’ views

but patients felt the doctor had not listened, this was more

likely to be followed by non-adherence or other problems

with medication (Table 6).

Overall, we found 116 (62%) of the consultations had at

least one kind of problem (a patient getting less than they

Table 4

Views on whether the doctor understood what treatment would be

acceptable

Number of times the doctor

felt they understood what

treatment the patient would

find acceptable (Q6)

Number of patients who felt that the

doctor had listened to the treatment

the patient thought they needed

(Q12 post-consultation)

Agree Uncertain/disagree

Yes 82 21

No/do not know 16 5

Total 98 26

Table 5

Views on whether the patient wanted a prescription

Number of times the doctor thought the patient

wanted a prescription (Q7)

Number of patients who said they wanted a prescription (Q10 pre-consultation)

Agree Disagree Uncertain/no response

Definitely/probably wanted 59 3 29

Definitely/probably did not want 8 22 27

Do not know 3 6 4

Total 70 31 60

Table 6

Outcomes for consultations with differences in doctors’ and patients’ views

Number of patients with each outcome

Unwanted

prescription

Unnecessary

prescription

Non-adherent Belief barrier

Clear difference in doctors’ and patients’ views on whether:

All the patient’s health problems had been raised (N ¼ 3) 0 (0) 0 (0) 0 (0) 1 (33)

The doctor understood/listened to what the patient

thought was wrong (N ¼ 3)

1 (33) 0 (0) 1 (33) 0 (0)

The doctor understood/listened to what treatment the patient

would find acceptable (N ¼ 12)

1 (8) 2 (17) 4 (33) 5 (42)

The consultation had gone well/to the patients’ satisfaction (N ¼ 2) 0 (0) 0 (0) 0 (0) 1 (50)

Occurrence of this outcome for all consultations (N ¼ 167) 5 17 18 25

Values in parentheses are percentages.

L. Jenkins et al. / Patient Education and Counseling 50 (2003) 273–278 277

wanted, a mismatch in patient and doctor perceptions, an

unwanted prescription, an unnecessary prescription, inap-

propriate prescribing, patient non-adherence or problems

with their medication).

4. Discussion and conclusion

4.1. Conclusion

The questionnaires were used with patients and doctors in

a variety of general practices, and the length and content of

the questionnaires appear to be acceptable given the high

response rates. Good response rates enabled comparisons

between different points of time or between the perceptions

of patients and doctors to be made successfully.

It was noted that many consultations were satisfactory in

terms of patients’ expectations and their experiences with

medicines, even though patients had high expectations for

communication and participation in the consultation. Never-

theless, only 38% were free of any poor outcome, and the

data suggested that unnecessary prescribing and problems

in communication may lead to poor outcomes in terms of

non-adherence and patients having barriers to using their

medication.

In comparison to the qualitative work the quantitative

instruments appear less sensitive and less able to identify

problems, as seen for example on occasions when patients

did not give a view or were uncertain. Using questionnaires

loses some of the depth of response from patients, but

provides significant gains in the time and costs to patients

and researchers. Existing validated questionnaires had to be

changed when they did not work well for us or did not cover

the focus of our research. These changes were carried out

reluctantly, were based on findings from our previous work

and were pilot-tested. It should be noted that they have not

been subject to any more rigorous validity checks.

Although the links between communication and poor

outcomes were less salient than in our previous qualitative

work, the quantitative instruments have produced similar

findings. Some differences would be expected as the earlier

work deliberately included more people with prescribing

issues and more new problems than would appear by chance.

4.2. Practice implications

The instruments appear suitable for use by general practi-

tioners or educators for monitoring prescribing or aspects

of communication with patients, and a pack containing the

research instruments has been developed.

Acknowledgements

The research project was funded as part of the Department

of Health prescribing research initiative. The views expres-

sed in this paper are those of the authors and not the

Department of Health. Nicky Britten was supported by a

British Academy/Leverhulme Trust senior research fellow-

ship and Fiona Stevenson was supported by Sir Siegmund

Warburg’s voluntary settlement. The authors gratefully

acknowledge the help of Kate Cox with data collection,

Beryl Stevens with data entry, and the GPs, practice staff and

patients who took part.

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