A. Waylen,*1 G. Makoul2 and Y. Albeyatti3
IN BRIEF
• Explains that good and effective patient-
dentist communication improves patient health outcomes, satisfaction and adherence to treatment plans. • Suggests it is not sufficient to be able to communicate an idea; interpersonal skills that focus on the relational side of a consultation are also important. • Highlights that within a dental hospital setting most people rate their dentist’s communication skills as excellent.
Objective To undertake a pilot study and examine whether the communication assessment tool (CAT) is useful in assessing patient perceptions of dentists’ interpersonal skills. Design Cross-sectional questionnaire study. Setting Three speciality dental clinics in a University teaching hospital in the United Kingdom. Participants, materials and measures One hundred patients, seen by 20 dentists, were recruited to the study. Patients completed the CAT after their consultation. Main outcome measures Patient ratings of excellent interpersonal skills within a dental consultation according to dentists’ experience, gender and speciality. Results Complete data was received from 95 patients. On average, dentists’ communication skills were rated as excellent 73% of the time. Patients were least satisfied with opportunities to ask questions within their consultation and with their level of involvement in decision-making. There were suggested differences in patients’ perceived satisfaction with communication according to dentists’ experience and gender. Conclusion Overall, patients are satisfied with the quality of communication with their dentist. Our findings are comparable to those from larger studies suggesting that the CAT is an effective tool to use in a dental context. The CAT would be useful in documenting the development of dentists’ and students’ interpersonal skills. INTRODUCTION With the introduction of the Preparing for Practice guidance1 the GDC has highlighted the importance of both communication and interpersonal skills as essential elements of undergraduate dental training. The guidance states that by the end of their training, students should be able to demonstrate effective interaction with patients, their representatives, the public and colleagues as well as having a variety of other clinical, professional and management/leadership skills. There is a broad literature about the impact of communication in both medical and dental contexts. This shows that good and effective communication improves patient health outcomes,2–4 patient satisfaction5–7 and adherence8,9 and also that poor communication has a strong association with complaints and litigation.10,11 Previous work in dental contexts has highlighted that people seeking dental treatment want a dentist who is School of Oral and Dental Sciences, 3Bristol Dental Hospital, University of Bristol, Lower Maudlin St, Bristol, BS1 2LY; 2Professor of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA *Correspondence to: Dr Andrea Waylen Tel: +44 (0) 117 342 4281 Email: [email protected] 1
Refereed Paper Accepted 9 April 2015 DOI: 10.1038/sj.bdj.2015.389 © British Dental Journal 2015; 218: 585-588
friendly, listens and treats them with respect, who explains options and involves them in decision making about their treatment.4,11,12 It is important to consider the difference between communication as part of a specific tasks or observable behaviour (for example, taking a medical history, explaining a diagnosis, giving information in order to obtain informed consent or to promote adherence to a treatment regime) and the interpersonal skills that focus on the relational side of a consultation (showing respect and paying attention, wanting to relieve suffering and being interested in the patient’s ideas, values and concerns).6,13–16 Competence in communication tasks and observable behaviours can be assessed with the use of checklists to rate performance from high to low. However, the appropriate and reliable assessment of interpersonal behaviours requires examination of the patient perspective.7,13 One assessment tool that can do this is the communication assessment tool (CAT),17–19 designed to assess the interpersonal and communication skills of clinicians. This measure has been used in both practice and training environments, for both family and hospital medicine. The items within the questionnaire assess the issues noted above that dental patients identify as important. For example, respondents report that their clinicians ‘treated me with respect’, ‘talked in terms I could
BRITISH DENTAL JOURNAL VOLUME 218 NO. 10 MAY 22 2015
understand’ and ‘paid attention to me’. The questionnaire also contains items that assess individual participation in the decision making process for example, whether the clinician ‘encouraged me to ask questions’ and ‘involved me in decisions as much as I wanted’.17 Because the CAT assesses these patientcentred items we decided to use it to determine whether it could effectively assess clinicians’ interpersonal skills in dental as well as medical settings. We measured overall CAT scores for qualified dentists working in a teaching hospital in the United Kingdom and also examined differences in patient ratings according to individual characteristics: staff gender, experience and the department they worked in.
PARTICIPANTS, MATERIALS AND METHODS This is a cross sectional questionnaire study. Dentists working in oral medicine, restorative dentistry and oral surgery departments were told about the aims of the study and the nature of the questionnaire. Each dentist was asked for permission to approach their patients at the end of appointments but they did not know which clinics we would be attending. A convenience sample of adult dental patients from each department was approached to take part in the study after their appointment had finished and asked if 585
© 2015 Macmillan Publishers Limited. All rights reserved
RESEARCH
Patient-clinician communication in a dental setting: a pilot study
RESEARCH Table 1 Demographic characteristics of dental patients completing the CAT
Table 3 Proportion of excellent ratings and medians (IQRs) for individual CAT items
N
%
Female
56
60
Male
39
40
Gender
Age group 24 or younger
17
18
25-44
29
31
45-64
31
34
65+
16
17
Missing
2
Ethnic group White
83
Black or minority ethnic group
8
Missing
4
91 9
Had the patient seen this dentist before? No
75
79
Yes
20
21
Male
63
66
Female
32
34
Trainee (senior house officer, specialist registrar, special interest trainee)
33
35
Senior staff (clinical lecturer/ consultant)
62
65
Oral medicine
29
30
Restorative
36
38
Oral surgery
30
32
Gender of consulting dentist
Grade of consulting dentist
Department of consulting dentist
Table 2 Demographic characteristics of consulting dentists N
%
Female
9
47
Male
11
53
Trainee (senior house officer, specialist registrar, special interest trainee)
10
50
Senior staff (clinical lecturer/ consultant)
10
50
Gender
Grade
Department Oral medicine
6
30
Restorative
8
40
Oral surgery
6
30
they would complete a pen-and-paper questionnaire about the consultation. Those who agreed were shown to a private room where they could read the study information sheet,
CAT item
Ratings (% excellent)
Median (IQR)
Mean (SD)
1. Greeted me in a way that made me feel comfortable
71.6
5 (4, 5)
4.63 (0.64)
2. Treated me with respect
75.8
5 (5, 5)
4.71 (0.56)
3. Showed interest in my ideas about health
67.4
5 (4, 5)
4.54 (0.73)
4. Understood my main health concerns
71.6
5 (4, 5)
4.58 (0.74)
5. Paid attention to me (looked at me, listened carefully)
76.8
5 (5, 5)
4.71 (0.58)
6. Let me talk without interruptions
75.8
5 (5, 5)
4.71 (0.56)
7. Gave me as much information as I wanted
72.6
5 (4, 5)
4.64 (0.63)
8. Talked in terms I could understand
77.9
5 (5, 5)
4.71 (0.60)
9. Checked to be sure I understood everything
73.7
5 (4, 5)
4.62 (0.70)
10. Encouraged me to ask questions
62.1
5 (4,5)
4.42 (0.86)
11. Involved me in decisions as much as I wanted
64.2
5 (4, 5)
4.48 (0.80)
12. Discussed next steps, including any follow-up plans
74.7
5 (4, 5)
4.64 (0.68)
13. Showed care and concern
77.9
5 (5, 5)
4.67 (0.69)
14. Spent the right amount of time with me
72.6
5 (4, 5)
4.63 (0.65)
15. The dentist’s staff treated me with respect
84.2
5 (5, 5)
4.78 (0.51)
ask questions, consent to take part and complete the questionnaire in confidence. An envelope was provided so that patients could return their questionnaire anonymously. Ethical approval was gained from the Ethics Committee of the Faculty of Medicine and Dentistry at the University of Bristol. In addition, approval for the study was granted by the Question, Interview and Survey Approvals Committee on behalf of the University of Bristol Hospital Trust.
Communication assessment tool The CAT is a 15-item questionnaire which has been used widely to assess patient satisfaction with communication in a wide variety of medical settings.17,20 With permission from the original author we adapted the questionnaire and replaced the word ‘doctor’ with ‘dentist’ in each item. The 15 items refer to key aspects of communication including respect, access to information and time. Patients mark each item on a five point Likert response scale (1 = poor, 2 = fair, 3 = good, 4 = very good and 5 = excellent) in order to indicate how satisfied they are with the communication that took place with their clinician. The CAT is scored according to the proportion of items that are rated as excellent rather than relying on measures of central tendency. This is because psychometric analysis of the response scales suggests that ratings of excellent should be considered as signifying that a task was accomplished, whereas ‘poor’, ‘fair’, ‘good’ and ‘very good’ may suggest that it was not accomplished.17
Statistical analysis For each questionnaire, we calculated the proportion of individual item scores categorised as
586
excellent ie scoring five out of the number of items answered. The mean overall CAT score was calculated by adding all item scores and dividing by the number of items answered. The overall proportion of excellent scores and overall mean score were calculated across all questionnaires and stratified according to grade and gender of the dentist and department. We report the proportion of items rated excellent and also medians and inter-quartile ranges (IQRs) for each item as the data have skewed distributions (most people were satisfied with the communication in their consultations). We used Mann-Whitney U tests to analyse differences between two groups (dentist gender and grade) and KruskallWallis tests to analyses differences between the three departments. In order to facilitate comparisons with data from medical samples, we have also provided mean scores and standard deviations for each item.
Demographic data Patients were asked whether they were a new patient attending their first appointment or whether they had had previous appointments on this clinic. Data collected from the treating dentist included gender and staff grade.
RESULTS Complete data were collected from 95 dental patients. Demographic data from the patient and dentist samples are shown in Table 1. Twenty dentists took part in this study. Their demographic characteristics are reported in Table 2.
Overall CAT scores The overall proportion of excellent scores BRITISH DENTAL JOURNAL VOLUME 218 NO. 10 MAY 22 2015
© 2015 Macmillan Publishers Limited. All rights reserved
RESEARCH
Senior staff
Trainees
CAT item
N = 62
N = 33
p-value
1
64.5
84.8
0.047
2
71.0
84.8
0.134
3
64.5
72.7
0.230
4
69.4
75.8
0.321
a function of grade. House officers were more likely to be rated as excellent with respect to greeting their patients in a way that made them feel comfortable (item one, p = 0.047) and also paid attention to their patients (item five, p = 0.049). There was also marginal evidence of a difference according to grade for item 13 (showing care and concern, p = 0.79) and item 14 (spending the right amount of time with the patient, p = 0.060).
5
71.0
87.9
0.049
DISCUSSION AND CONCLUSION
6
71.0
84.8
0.106
7
67.7
81.8
0.155
8
75.8
81.8
0.507
9
69.4
81.8
0.140
10
59.7
66.7
0.327
11
59.7
72.7
0.114
12
71.0
81.8
0.156
13
72.6
87.9
0.079
14
66.1
84.8
0.060
15
79.0
93.9
0.063
Females
Males
CAT item
N = 63
N = 32
p-value
1
75.0
69.8
0.665
2
78.1
74.6
0.662
3
71.9
65.1
0.444
4
71.9
71.4
0.846
5
81.3
74.6
0.428
6
78.1
74.6
0.662
7
75.0
71.4
0.770
8
81.3
76.2
0.579
9
75.0
73.0
0.713
10
56.3
65.1
0.572
11
62.5
65.1
0.952
12
71.9
76.2
0.788
13
81.3
76.2
0.644
14
78.1
69.8
0.444
15
84.4
84.1
0.950
Overall, mean ratings on the CAT were high, showing that most patients believed that their dentists in this UK teaching hospital had excellent interpersonal skills. The largest proportion of excellent ratings were for items concerned with being treated with respect by the dentist’s staff, talking in terms that could be understood by the patient and paying attention to the patient. However, by considering the ratings for individual items it was apparent that satisfaction levels were lower in areas associated with a patient-centred approach to treatment planning: encouraging the patient to ask questions, involving the patient in decisions and showing interest in the patient’s ideas about their health. We also found weak evidence of differences in patient satisfaction according to grade with more senior staff being reported as less likely to make their patients feel comfortable when greeting them and less likely to make their patients feel they were paying attention to them. Our findings are consistent with those reported in previous studies in a medical context.17,20 Two of the highest ratings for dentists are in the top three ratings for medics: ‘paid attention to me’ and ‘treated me with respect’. Similarly those items rated lowest in our study are identical to the lowest rated items for medics: ‘involved me in decisions as much as I want’ and ‘encouraged me to ask questions’. To our knowledge this is the first time that the CAT has been used to assess dentists’ interpersonal skills. We have shown that this tool can be used reliably and efficiently in a variety of dental settings: it is easily administered and easy for patients to understand. Although this is a small pilot study, our results are very similar to those reported in much larger studies and even on this small sample we are able to report evidence of differences in communication according to staff grade in the expected direction. While the dentists were aware that we would be collecting data from their clinics, they did not know which clinics we would be attending and therefore it is unlikely that our results were affected by this. Our study can be considered to have set a baseline for patient satisfaction regarding consultation skills that are reported as
Table 4 Proportion of excellent ratings for individual CAT items by staff grade and gender % rated as excellent
across all items was 73.3%. The overall mean score (SD) was 4.6 (0.56). The proportion of excellent ratings for each CAT item, together with mean (SD) and median (IQR) scores, are shown in Table 3. Items most frequently rated as excellent were ‘the dentist’s staff treated me with respect’ (84.2%), and the dentist ‘showed care and concern’ (77.9%), ‘talked in terms I could understand’ (77.9%) and ‘paid attention to me (looked at me, listened carefully)’ (76.8%). Items rated least frequently as excellent were the dentist ‘encouraged me to ask questions’ (62.1%), ‘involved me in decisions as much as I wanted’ (64.2%) and ‘showed interest in my ideas about health’ (67.4%).
Differences by staff grade and gender Although there was no evidence of a statistical difference in the overall proportion of items scored as excellent according to staff grade (p = 0.322) there was an absolute difference: dental patients scored 75.4% and 69.9% of items as excellent if they were treated by trainee and senior staff respectively. Similarly there was no statistical evidence of a difference in overall excellence according to the gender of staff (p = 0.688) but there was an absolute difference: 74.8% and 69.3% of items were scored as excellent for female and male staff respectively (see Table 4). When the data were examined according to individual item, some differences occurred as
BRITISH DENTAL JOURNAL VOLUME 218 NO. 10 MAY 22 2015
587 © 2015 Macmillan Publishers Limited. All rights reserved
RESEARCH important for oral health related quality of life in a dental context.12 The main weakness of our study is that it comprises a very small convenience sample collected from fewer than the recommended 20 patients per clinician.17 Also, we did not record the first language of either dentist or patient and so there may be some confounding according to issues of translation. However, given that our findings are so similar to those reported from large samples of medical consultations, we believe this is unlikely. While the findings of our study suggest that dentists need to make more effort to involve their patients in the decision-making process it should be remembered that these data are from a small pilot study. It is important now to replicate these findings using a larger sample of dentists (both those who are qualified and those at different levels of training) and patients in a variety of dental contexts. Using this tool as a way to systematically assess communication and interpersonal scores means that individuals can be provided with feedback according to their respective strengths and weaknesses. CAT scores can also be used to provide a comparison with other clinicians working in the same setting.20 The CAT can be used reliably in a dental context and is effective in assessing patient perceptions of dentists’ communication
COMMENTARY This paper describes the use of a communication assessment tool in a dental setting. As the authors point out, the GDC make it clear to dental schools that good communication and interpersonal skills are a key requisite for registration as a dental professional. Thus, all undergraduate dental programmes and training organisations should, in theory, be able to demonstrate to the GDC that their students are competent in these areas, and yet very few tools for objectively assessing communication in the dental setting exist.1 Importantly, this study describes a method in which the assessment of the clinician’s ability to communicate with their patients is undertaken by the patient and not another clinician. As the paper reveals, having a senior clinician judging a trainee’s communication would not be at all appropriate. Therefore, this study is extremely timely and helpful as it introduces a method by which not only competence in communication can be measured, but differences between groups can also be
skills. Medical studies have shown that it can be used with both qualified and trainee physicians and so there are potentially opportunities to use it as both an evaluation and a training tool for dentists. In this way students and qualified dentists would be able to document their progress in the development of interpersonal skills and demonstrate their competence as required by the GDC. 1. General Dental Council. Preparing for practice. 2011. Online information available at http://www.gdc-uk. org/dentalprofessionals/education/pages/dentalteam-learning-outcomes.aspx (accessed April 2015). 2. Hall J A, Roter D L. Do patients talk differently to male and female physicians? A meta-analytic review. Patient Educ Couns 2002; 48: 217–224. 3. Fallowfield L, Hall A, Maguire G P, Baum M. Psychological outcomes in women with early breast-cancer. BMJ 1990; 301: 575–580. 4. Fox C. Evidence summary: what do we know from qualitative research about people’s care-seeking about oral health? Br Dent J 2010; 209: 225–231. 5. Jackson J L, Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med 2001; 52: 609–620. 6. Winning T A, Kinnell A, Wener M E, Mazurat N, J Schoenwetter D. Validity of scores from communication skills instruments for patients and their dental student-clinicians. Eur J Dent Educ 2013; 17: 93–100. 7. Yamalik N. Dentist-patient relationship and quality care 3. Communication. Int Dent J 2005; 55: 254–256. 8. DiMatteo M R, Haskard-Zolnierek K B, Martin L R. Improving patient adherence: a three-factor model to guide practice. Health Psychol Rev 2012; 6: 74–91. 9. Shigli K, Awinashe V. Patient-dentist communication: an adjunct to successful complete denture treatment. J Prosthodont 2010; 19: 491–493.
revealed. Thus, it provides a means by which support and training for performance in communication, for people and groups who are not relating to their patients in the optimal way, can be appropriately targeted. The communication assessment tool (CAT) is a 15 item questionnaire which is succinct and manageable and, therefore, avoids the ‘questionnaire fatigue’ which overly long survey instruments tend to induce in their patients. To use the CAT, patients simply rate their dentist on a scale from ‘poor’ to ‘excellent’. The questions fall into three themes – ‘respect’, ‘access to information’ and ‘time’, which makes the results easy to interpret and makes identification of areas for improvement, simple. And the fact that the scoring is carried out according to the proportions of ‘excellent’ results, rather than measuring a mean score, is a highly important attribute in a measurement tool, as this drives aspiration to excellence rather than adequacy. It also helps to ensure that feedback to participants is reported positively.
588
10. Levinson W, Roter D L, Mullooly J P, Dull V T, Frankel R M. Physician-patient communication – the relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997; 277: 553–559. 11. Newsome P R H, Wright G H. A review of patient satisfaction: 2. Dental patient satisfaction: an appraisal of recent literature. Br Dent J 1999; 186: 166–170. 12. Muirhead V E, Marcenes W, Wright D. Do health provider-patient relationships matter? Exploring dentist-patient relationships and oral health-related quality of life in older people. Age Ageing 2014; 43: 399–405. 13. Duffy F, Gordon G, Whelan G et al., participants in the American Academy on physician and patient’s conference on education and evaluation of competence in communication and interpersonal skills. Assessing competence in communcation and interpersonal skills: the Kalamazoo II report. Acad Med 2004; 79: 495–507. 14. Lahti S, Tuutti H, Hausen H, Kaariainen R. Dentist and patient opinions about the ideal dentist and patient developing a compact questionnaire. Community Dent Oral Epidemiol 1992; 20: 229–234. 15. Al-Mobeeriek A. Dentist-patient communication as perceived by patients in Riyadh, Saudi Arabia. Int J Occup Med Environ Health 2012; 25: 89–96. 16. Chandarana P V, Hill K B. What makes a good dentist? A pilot study. Dent Update 2014; 41: 156–160. 17. Makoul G, Krupat E, Chang C H. Measuring patient views of physician communication skills: development and testing of the Communication Assessment Tool. Patient Educ Couns 2007; 67: 333–342. 18. Makoul G, Curry R H. The value of assessing and addressing communication skills. JAMA 2007; 298: 1057–1059. 19. Makoul G. Improving communication with all patients. Med Educ 2008; 42: 1050–1052. 20. Myerholtz L, Simons L, Felix S et al. Using the Communication Assessment Tool in family medicine residency programs. Fam Med 2010; 42: 567–573.
The paper exposes two extremely interesting trends. Senior staff seem to communicate less well than their younger counterparts, and females seem to have the edge over males when relationships with patients are under scrutiny. This paper is potentially of great interest to practitioners who seek to drive up the quality of the service they provide to patients, as it shows that the CAT is can be reliably and efficiently used in dentistry, that it is relatively easy to administer, that it is easily understood by patients, and finally that the results are simple to interpret and feed back to participants. It could therefore (although the authors do not suggest this) prove to be a very useful tool indeed for practices wishing to undertake audits of interpersonal communication. Professor Elizabeth Kay BDS MPH FDSRCPS FDSRCS FFGDP Foundation Dean Peninsula Dental School 1. Theaker E D, Kay E J, Gill S. Development and preliminary evaluation of an instrument designed to assess dental students’ communication skills. Br Dent J 2000; 188: 40–44.
BRITISH DENTAL JOURNAL VOLUME 218 NO. 10 MAY 22 2015 © 2015 Macmillan Publishers Limited. All rights reserved
IN BRIEF
• Explains that good and effective patient-
dentist communication improves patient health outcomes, satisfaction and adherence to treatment plans. • Suggests it is not sufficient to be able to communicate an idea; interpersonal skills that focus on the relational side of a consultation are also important. • Highlights that within a dental hospital setting most people rate their dentist’s communication skills as excellent.
Objective To undertake a pilot study and examine whether the communication assessment tool (CAT) is useful in assessing patient perceptions of dentists’ interpersonal skills. Design Cross-sectional questionnaire study. Setting Three speciality dental clinics in a University teaching hospital in the United Kingdom. Participants, materials and measures One hundred patients, seen by 20 dentists, were recruited to the study. Patients completed the CAT after their consultation. Main outcome measures Patient ratings of excellent interpersonal skills within a dental consultation according to dentists’ experience, gender and speciality. Results Complete data was received from 95 patients. On average, dentists’ communication skills were rated as excellent 73% of the time. Patients were least satisfied with opportunities to ask questions within their consultation and with their level of involvement in decision-making. There were suggested differences in patients’ perceived satisfaction with communication according to dentists’ experience and gender. Conclusion Overall, patients are satisfied with the quality of communication with their dentist. Our findings are comparable to those from larger studies suggesting that the CAT is an effective tool to use in a dental context. The CAT would be useful in documenting the development of dentists’ and students’ interpersonal skills. INTRODUCTION With the introduction of the Preparing for Practice guidance1 the GDC has highlighted the importance of both communication and interpersonal skills as essential elements of undergraduate dental training. The guidance states that by the end of their training, students should be able to demonstrate effective interaction with patients, their representatives, the public and colleagues as well as having a variety of other clinical, professional and management/leadership skills. There is a broad literature about the impact of communication in both medical and dental contexts. This shows that good and effective communication improves patient health outcomes,2–4 patient satisfaction5–7 and adherence8,9 and also that poor communication has a strong association with complaints and litigation.10,11 Previous work in dental contexts has highlighted that people seeking dental treatment want a dentist who is School of Oral and Dental Sciences, 3Bristol Dental Hospital, University of Bristol, Lower Maudlin St, Bristol, BS1 2LY; 2Professor of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA *Correspondence to: Dr Andrea Waylen Tel: +44 (0) 117 342 4281 Email: [email protected] 1
Refereed Paper Accepted 9 April 2015 DOI: 10.1038/sj.bdj.2015.389 © British Dental Journal 2015; 218: 585-588
friendly, listens and treats them with respect, who explains options and involves them in decision making about their treatment.4,11,12 It is important to consider the difference between communication as part of a specific tasks or observable behaviour (for example, taking a medical history, explaining a diagnosis, giving information in order to obtain informed consent or to promote adherence to a treatment regime) and the interpersonal skills that focus on the relational side of a consultation (showing respect and paying attention, wanting to relieve suffering and being interested in the patient’s ideas, values and concerns).6,13–16 Competence in communication tasks and observable behaviours can be assessed with the use of checklists to rate performance from high to low. However, the appropriate and reliable assessment of interpersonal behaviours requires examination of the patient perspective.7,13 One assessment tool that can do this is the communication assessment tool (CAT),17–19 designed to assess the interpersonal and communication skills of clinicians. This measure has been used in both practice and training environments, for both family and hospital medicine. The items within the questionnaire assess the issues noted above that dental patients identify as important. For example, respondents report that their clinicians ‘treated me with respect’, ‘talked in terms I could
BRITISH DENTAL JOURNAL VOLUME 218 NO. 10 MAY 22 2015
understand’ and ‘paid attention to me’. The questionnaire also contains items that assess individual participation in the decision making process for example, whether the clinician ‘encouraged me to ask questions’ and ‘involved me in decisions as much as I wanted’.17 Because the CAT assesses these patientcentred items we decided to use it to determine whether it could effectively assess clinicians’ interpersonal skills in dental as well as medical settings. We measured overall CAT scores for qualified dentists working in a teaching hospital in the United Kingdom and also examined differences in patient ratings according to individual characteristics: staff gender, experience and the department they worked in.
PARTICIPANTS, MATERIALS AND METHODS This is a cross sectional questionnaire study. Dentists working in oral medicine, restorative dentistry and oral surgery departments were told about the aims of the study and the nature of the questionnaire. Each dentist was asked for permission to approach their patients at the end of appointments but they did not know which clinics we would be attending. A convenience sample of adult dental patients from each department was approached to take part in the study after their appointment had finished and asked if 585
© 2015 Macmillan Publishers Limited. All rights reserved
RESEARCH
Patient-clinician communication in a dental setting: a pilot study
RESEARCH Table 1 Demographic characteristics of dental patients completing the CAT
Table 3 Proportion of excellent ratings and medians (IQRs) for individual CAT items
N
%
Female
56
60
Male
39
40
Gender
Age group 24 or younger
17
18
25-44
29
31
45-64
31
34
65+
16
17
Missing
2
Ethnic group White
83
Black or minority ethnic group
8
Missing
4
91 9
Had the patient seen this dentist before? No
75
79
Yes
20
21
Male
63
66
Female
32
34
Trainee (senior house officer, specialist registrar, special interest trainee)
33
35
Senior staff (clinical lecturer/ consultant)
62
65
Oral medicine
29
30
Restorative
36
38
Oral surgery
30
32
Gender of consulting dentist
Grade of consulting dentist
Department of consulting dentist
Table 2 Demographic characteristics of consulting dentists N
%
Female
9
47
Male
11
53
Trainee (senior house officer, specialist registrar, special interest trainee)
10
50
Senior staff (clinical lecturer/ consultant)
10
50
Gender
Grade
Department Oral medicine
6
30
Restorative
8
40
Oral surgery
6
30
they would complete a pen-and-paper questionnaire about the consultation. Those who agreed were shown to a private room where they could read the study information sheet,
CAT item
Ratings (% excellent)
Median (IQR)
Mean (SD)
1. Greeted me in a way that made me feel comfortable
71.6
5 (4, 5)
4.63 (0.64)
2. Treated me with respect
75.8
5 (5, 5)
4.71 (0.56)
3. Showed interest in my ideas about health
67.4
5 (4, 5)
4.54 (0.73)
4. Understood my main health concerns
71.6
5 (4, 5)
4.58 (0.74)
5. Paid attention to me (looked at me, listened carefully)
76.8
5 (5, 5)
4.71 (0.58)
6. Let me talk without interruptions
75.8
5 (5, 5)
4.71 (0.56)
7. Gave me as much information as I wanted
72.6
5 (4, 5)
4.64 (0.63)
8. Talked in terms I could understand
77.9
5 (5, 5)
4.71 (0.60)
9. Checked to be sure I understood everything
73.7
5 (4, 5)
4.62 (0.70)
10. Encouraged me to ask questions
62.1
5 (4,5)
4.42 (0.86)
11. Involved me in decisions as much as I wanted
64.2
5 (4, 5)
4.48 (0.80)
12. Discussed next steps, including any follow-up plans
74.7
5 (4, 5)
4.64 (0.68)
13. Showed care and concern
77.9
5 (5, 5)
4.67 (0.69)
14. Spent the right amount of time with me
72.6
5 (4, 5)
4.63 (0.65)
15. The dentist’s staff treated me with respect
84.2
5 (5, 5)
4.78 (0.51)
ask questions, consent to take part and complete the questionnaire in confidence. An envelope was provided so that patients could return their questionnaire anonymously. Ethical approval was gained from the Ethics Committee of the Faculty of Medicine and Dentistry at the University of Bristol. In addition, approval for the study was granted by the Question, Interview and Survey Approvals Committee on behalf of the University of Bristol Hospital Trust.
Communication assessment tool The CAT is a 15-item questionnaire which has been used widely to assess patient satisfaction with communication in a wide variety of medical settings.17,20 With permission from the original author we adapted the questionnaire and replaced the word ‘doctor’ with ‘dentist’ in each item. The 15 items refer to key aspects of communication including respect, access to information and time. Patients mark each item on a five point Likert response scale (1 = poor, 2 = fair, 3 = good, 4 = very good and 5 = excellent) in order to indicate how satisfied they are with the communication that took place with their clinician. The CAT is scored according to the proportion of items that are rated as excellent rather than relying on measures of central tendency. This is because psychometric analysis of the response scales suggests that ratings of excellent should be considered as signifying that a task was accomplished, whereas ‘poor’, ‘fair’, ‘good’ and ‘very good’ may suggest that it was not accomplished.17
Statistical analysis For each questionnaire, we calculated the proportion of individual item scores categorised as
586
excellent ie scoring five out of the number of items answered. The mean overall CAT score was calculated by adding all item scores and dividing by the number of items answered. The overall proportion of excellent scores and overall mean score were calculated across all questionnaires and stratified according to grade and gender of the dentist and department. We report the proportion of items rated excellent and also medians and inter-quartile ranges (IQRs) for each item as the data have skewed distributions (most people were satisfied with the communication in their consultations). We used Mann-Whitney U tests to analyse differences between two groups (dentist gender and grade) and KruskallWallis tests to analyses differences between the three departments. In order to facilitate comparisons with data from medical samples, we have also provided mean scores and standard deviations for each item.
Demographic data Patients were asked whether they were a new patient attending their first appointment or whether they had had previous appointments on this clinic. Data collected from the treating dentist included gender and staff grade.
RESULTS Complete data were collected from 95 dental patients. Demographic data from the patient and dentist samples are shown in Table 1. Twenty dentists took part in this study. Their demographic characteristics are reported in Table 2.
Overall CAT scores The overall proportion of excellent scores BRITISH DENTAL JOURNAL VOLUME 218 NO. 10 MAY 22 2015
© 2015 Macmillan Publishers Limited. All rights reserved
RESEARCH
Senior staff
Trainees
CAT item
N = 62
N = 33
p-value
1
64.5
84.8
0.047
2
71.0
84.8
0.134
3
64.5
72.7
0.230
4
69.4
75.8
0.321
a function of grade. House officers were more likely to be rated as excellent with respect to greeting their patients in a way that made them feel comfortable (item one, p = 0.047) and also paid attention to their patients (item five, p = 0.049). There was also marginal evidence of a difference according to grade for item 13 (showing care and concern, p = 0.79) and item 14 (spending the right amount of time with the patient, p = 0.060).
5
71.0
87.9
0.049
DISCUSSION AND CONCLUSION
6
71.0
84.8
0.106
7
67.7
81.8
0.155
8
75.8
81.8
0.507
9
69.4
81.8
0.140
10
59.7
66.7
0.327
11
59.7
72.7
0.114
12
71.0
81.8
0.156
13
72.6
87.9
0.079
14
66.1
84.8
0.060
15
79.0
93.9
0.063
Females
Males
CAT item
N = 63
N = 32
p-value
1
75.0
69.8
0.665
2
78.1
74.6
0.662
3
71.9
65.1
0.444
4
71.9
71.4
0.846
5
81.3
74.6
0.428
6
78.1
74.6
0.662
7
75.0
71.4
0.770
8
81.3
76.2
0.579
9
75.0
73.0
0.713
10
56.3
65.1
0.572
11
62.5
65.1
0.952
12
71.9
76.2
0.788
13
81.3
76.2
0.644
14
78.1
69.8
0.444
15
84.4
84.1
0.950
Overall, mean ratings on the CAT were high, showing that most patients believed that their dentists in this UK teaching hospital had excellent interpersonal skills. The largest proportion of excellent ratings were for items concerned with being treated with respect by the dentist’s staff, talking in terms that could be understood by the patient and paying attention to the patient. However, by considering the ratings for individual items it was apparent that satisfaction levels were lower in areas associated with a patient-centred approach to treatment planning: encouraging the patient to ask questions, involving the patient in decisions and showing interest in the patient’s ideas about their health. We also found weak evidence of differences in patient satisfaction according to grade with more senior staff being reported as less likely to make their patients feel comfortable when greeting them and less likely to make their patients feel they were paying attention to them. Our findings are consistent with those reported in previous studies in a medical context.17,20 Two of the highest ratings for dentists are in the top three ratings for medics: ‘paid attention to me’ and ‘treated me with respect’. Similarly those items rated lowest in our study are identical to the lowest rated items for medics: ‘involved me in decisions as much as I want’ and ‘encouraged me to ask questions’. To our knowledge this is the first time that the CAT has been used to assess dentists’ interpersonal skills. We have shown that this tool can be used reliably and efficiently in a variety of dental settings: it is easily administered and easy for patients to understand. Although this is a small pilot study, our results are very similar to those reported in much larger studies and even on this small sample we are able to report evidence of differences in communication according to staff grade in the expected direction. While the dentists were aware that we would be collecting data from their clinics, they did not know which clinics we would be attending and therefore it is unlikely that our results were affected by this. Our study can be considered to have set a baseline for patient satisfaction regarding consultation skills that are reported as
Table 4 Proportion of excellent ratings for individual CAT items by staff grade and gender % rated as excellent
across all items was 73.3%. The overall mean score (SD) was 4.6 (0.56). The proportion of excellent ratings for each CAT item, together with mean (SD) and median (IQR) scores, are shown in Table 3. Items most frequently rated as excellent were ‘the dentist’s staff treated me with respect’ (84.2%), and the dentist ‘showed care and concern’ (77.9%), ‘talked in terms I could understand’ (77.9%) and ‘paid attention to me (looked at me, listened carefully)’ (76.8%). Items rated least frequently as excellent were the dentist ‘encouraged me to ask questions’ (62.1%), ‘involved me in decisions as much as I wanted’ (64.2%) and ‘showed interest in my ideas about health’ (67.4%).
Differences by staff grade and gender Although there was no evidence of a statistical difference in the overall proportion of items scored as excellent according to staff grade (p = 0.322) there was an absolute difference: dental patients scored 75.4% and 69.9% of items as excellent if they were treated by trainee and senior staff respectively. Similarly there was no statistical evidence of a difference in overall excellence according to the gender of staff (p = 0.688) but there was an absolute difference: 74.8% and 69.3% of items were scored as excellent for female and male staff respectively (see Table 4). When the data were examined according to individual item, some differences occurred as
BRITISH DENTAL JOURNAL VOLUME 218 NO. 10 MAY 22 2015
587 © 2015 Macmillan Publishers Limited. All rights reserved
RESEARCH important for oral health related quality of life in a dental context.12 The main weakness of our study is that it comprises a very small convenience sample collected from fewer than the recommended 20 patients per clinician.17 Also, we did not record the first language of either dentist or patient and so there may be some confounding according to issues of translation. However, given that our findings are so similar to those reported from large samples of medical consultations, we believe this is unlikely. While the findings of our study suggest that dentists need to make more effort to involve their patients in the decision-making process it should be remembered that these data are from a small pilot study. It is important now to replicate these findings using a larger sample of dentists (both those who are qualified and those at different levels of training) and patients in a variety of dental contexts. Using this tool as a way to systematically assess communication and interpersonal scores means that individuals can be provided with feedback according to their respective strengths and weaknesses. CAT scores can also be used to provide a comparison with other clinicians working in the same setting.20 The CAT can be used reliably in a dental context and is effective in assessing patient perceptions of dentists’ communication
COMMENTARY This paper describes the use of a communication assessment tool in a dental setting. As the authors point out, the GDC make it clear to dental schools that good communication and interpersonal skills are a key requisite for registration as a dental professional. Thus, all undergraduate dental programmes and training organisations should, in theory, be able to demonstrate to the GDC that their students are competent in these areas, and yet very few tools for objectively assessing communication in the dental setting exist.1 Importantly, this study describes a method in which the assessment of the clinician’s ability to communicate with their patients is undertaken by the patient and not another clinician. As the paper reveals, having a senior clinician judging a trainee’s communication would not be at all appropriate. Therefore, this study is extremely timely and helpful as it introduces a method by which not only competence in communication can be measured, but differences between groups can also be
skills. Medical studies have shown that it can be used with both qualified and trainee physicians and so there are potentially opportunities to use it as both an evaluation and a training tool for dentists. In this way students and qualified dentists would be able to document their progress in the development of interpersonal skills and demonstrate their competence as required by the GDC. 1. General Dental Council. Preparing for practice. 2011. Online information available at http://www.gdc-uk. org/dentalprofessionals/education/pages/dentalteam-learning-outcomes.aspx (accessed April 2015). 2. Hall J A, Roter D L. Do patients talk differently to male and female physicians? A meta-analytic review. Patient Educ Couns 2002; 48: 217–224. 3. Fallowfield L, Hall A, Maguire G P, Baum M. Psychological outcomes in women with early breast-cancer. BMJ 1990; 301: 575–580. 4. Fox C. Evidence summary: what do we know from qualitative research about people’s care-seeking about oral health? Br Dent J 2010; 209: 225–231. 5. Jackson J L, Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med 2001; 52: 609–620. 6. Winning T A, Kinnell A, Wener M E, Mazurat N, J Schoenwetter D. Validity of scores from communication skills instruments for patients and their dental student-clinicians. Eur J Dent Educ 2013; 17: 93–100. 7. Yamalik N. Dentist-patient relationship and quality care 3. Communication. Int Dent J 2005; 55: 254–256. 8. DiMatteo M R, Haskard-Zolnierek K B, Martin L R. Improving patient adherence: a three-factor model to guide practice. Health Psychol Rev 2012; 6: 74–91. 9. Shigli K, Awinashe V. Patient-dentist communication: an adjunct to successful complete denture treatment. J Prosthodont 2010; 19: 491–493.
revealed. Thus, it provides a means by which support and training for performance in communication, for people and groups who are not relating to their patients in the optimal way, can be appropriately targeted. The communication assessment tool (CAT) is a 15 item questionnaire which is succinct and manageable and, therefore, avoids the ‘questionnaire fatigue’ which overly long survey instruments tend to induce in their patients. To use the CAT, patients simply rate their dentist on a scale from ‘poor’ to ‘excellent’. The questions fall into three themes – ‘respect’, ‘access to information’ and ‘time’, which makes the results easy to interpret and makes identification of areas for improvement, simple. And the fact that the scoring is carried out according to the proportions of ‘excellent’ results, rather than measuring a mean score, is a highly important attribute in a measurement tool, as this drives aspiration to excellence rather than adequacy. It also helps to ensure that feedback to participants is reported positively.
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10. Levinson W, Roter D L, Mullooly J P, Dull V T, Frankel R M. Physician-patient communication – the relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997; 277: 553–559. 11. Newsome P R H, Wright G H. A review of patient satisfaction: 2. Dental patient satisfaction: an appraisal of recent literature. Br Dent J 1999; 186: 166–170. 12. Muirhead V E, Marcenes W, Wright D. Do health provider-patient relationships matter? Exploring dentist-patient relationships and oral health-related quality of life in older people. Age Ageing 2014; 43: 399–405. 13. Duffy F, Gordon G, Whelan G et al., participants in the American Academy on physician and patient’s conference on education and evaluation of competence in communication and interpersonal skills. Assessing competence in communcation and interpersonal skills: the Kalamazoo II report. Acad Med 2004; 79: 495–507. 14. Lahti S, Tuutti H, Hausen H, Kaariainen R. Dentist and patient opinions about the ideal dentist and patient developing a compact questionnaire. Community Dent Oral Epidemiol 1992; 20: 229–234. 15. Al-Mobeeriek A. Dentist-patient communication as perceived by patients in Riyadh, Saudi Arabia. Int J Occup Med Environ Health 2012; 25: 89–96. 16. Chandarana P V, Hill K B. What makes a good dentist? A pilot study. Dent Update 2014; 41: 156–160. 17. Makoul G, Krupat E, Chang C H. Measuring patient views of physician communication skills: development and testing of the Communication Assessment Tool. Patient Educ Couns 2007; 67: 333–342. 18. Makoul G, Curry R H. The value of assessing and addressing communication skills. JAMA 2007; 298: 1057–1059. 19. Makoul G. Improving communication with all patients. Med Educ 2008; 42: 1050–1052. 20. Myerholtz L, Simons L, Felix S et al. Using the Communication Assessment Tool in family medicine residency programs. Fam Med 2010; 42: 567–573.
The paper exposes two extremely interesting trends. Senior staff seem to communicate less well than their younger counterparts, and females seem to have the edge over males when relationships with patients are under scrutiny. This paper is potentially of great interest to practitioners who seek to drive up the quality of the service they provide to patients, as it shows that the CAT is can be reliably and efficiently used in dentistry, that it is relatively easy to administer, that it is easily understood by patients, and finally that the results are simple to interpret and feed back to participants. It could therefore (although the authors do not suggest this) prove to be a very useful tool indeed for practices wishing to undertake audits of interpersonal communication. Professor Elizabeth Kay BDS MPH FDSRCPS FDSRCS FFGDP Foundation Dean Peninsula Dental School 1. Theaker E D, Kay E J, Gill S. Development and preliminary evaluation of an instrument designed to assess dental students’ communication skills. Br Dent J 2000; 188: 40–44.
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