Lecture 4

Lecture 4. Doctor–patient communication and the role of health professionals’ health beliefs.

WHAT IS COMPLIANCE?. Haynes et al. (1979) defined compliance as ‘the extent to which the patient’s behavior (in terms of taking medications, following diets or other lifestyle changes) coincides with medical or health advice’. Compliance has excited an enormous amount of clinical and academic interest over the past few decades and it has been calculated that 3200 articles on compliance in English were listed between 1979 and 1985 (Trostle 1988). Compliance is regarded as important primarily because following the recommendations of health professionals is considered essential to patient recovery. However, studies estimate that about half of the patients with chronic illnesses, such as diabetes and hypertension, are non-compliant with their medication regimens and that even compliance for a behavior as apparently simple as using an inhaler for asthma is poor (e.g. Dekker et al. 1992). Further, compliance also has financial implications as money is wasted when drugs are prescribed, prescriptions are cashed, but the drugs not taken..

PREDICTING WHETHER PATIENTS ARE COMPLIANT: THE WORK OF LEY.

Patient satisfaction. Ley (1988) examined the extent of patient satisfaction with the consultation. He reviewed 21 studies of hospital patients and found that 41 percent of patients were dissatisfied with their treatment and that 28 percent of general practice patients were dissatisfied. Studies by Haynes et al. (1979) and Ley (1988), found that levels of patient satisfaction stem from various components of the consultation, in particular the affective aspects (e.g. emotional support and understanding), the behavioural aspects (e.g. prescribing, adequate explanation) and the competence (e.g. appropriateness of referral, diagnosis) of the health professional. Ley (1989) also reported that satisfaction is determined by the content of the consultation and that patients want to know as much information as possible, even if this is bad news. For example, in studies looking at cancer diagnosis, patients showed improved satisfaction if they were given a diagnosis of cancer rather than if they were protected from this information..

Understanding Satisfaction Memory Fig. Ley's model of compliance Compliance.

Berry et al. (2003) explored the impact of making information more personal to the patient on satisfaction. Participants were asked to read some information about medication and then to rate their satisfaction. Some were given personalized information such as, ‘If you take this medicine, there is a substantial chance of you getting one or more of its side effects’ whereas some were given non personalized information, ‘A substantial proportion of people who take this medication get one or more of its side effects’. The results showed that a more personalized style was related to greater satisfaction, lower ratings of the risks of side effects and lower ratings of the risk to health..

Sala et al. (2002) explored the relationship between humor in consultation and patient satisfaction. The authors coded recorded consultations for their humor content and for the type of humor used. They then looked for differences between high and low satisfaction rated consultations. The results showed that high satisfaction was related to the use of more light humor, more humor that relieved tension, more self-effacing humor and more positive-function humor. Patient satisfaction is increasingly used in health care assessment as an indirect measure of health outcome based on the assumption that a satisfied patient will be a more healthy patient. This has resulted in the development of a multitude of patient satisfaction measures and a lack of agreement as to what patient satisfaction actually is (see Fitzpatrick 1993). However, even though there are problems with patient satisfaction, some studies suggest that aspects of patient satisfaction may correlate with compliance with the advice given during the consultation..

Patient understanding. Several studies have also examined the extent to which patients understand the content of the consultation. Boyle (1970) examined patients’ definitions of different illnesses and reported that when given a checklist only 85 per cent correctly defined arthritis, 77 per cent correctly defined jaundice, 52 per cent correctly defined palpitations and 80 per cent correctly defined bronchitis. Boyle further examined patients’ perceptions of the location of organs and found that only 42 per cent correctly located the heart, 20 per cent located the stomach and 49 per cent located the liver. This suggests that understanding of the content of the consultation may well be low. Further studies have examined the understanding of illness in terms of causality and seriousness..

Roth (1979) asked patients what they thought peptic ulcers were caused by and found a variety of responses, such as problems with teeth and gums, food, digestive problems or excessive stomach acid. He also asked individuals what they thought caused lung cancer, and found that although the understanding of the causality of lung cancer was high in terms of smoking behavior, 50 per cent of individuals thought that lung cancer caused by smoking had a good prognosis. Roth also reported that 30 per cent of patients believed that hypertension could be cured by treatment. If the doctor gives advice to the patient or suggests that they follow a particular treatment program and the patient does not understand the causes of their illness, the correct location of the relevant organ or the processes involved in the treatment, then this lack of understanding is likely to affect their compliance with this advice..

FOCUS ON RESEARCH 4.1: TESTING A THEORY - PATIENT SATISFACTION A study to examine the effects of a general practitioner's consulting style on patient satisfaction (Savage and Armstrong 1990). This study examined the effect Of an directive consulting style and a sharing patient-centred consulting style on patient satisfaction. This is interesting for both methodological and theoretical reasons. Methodologically, it uses a random control design in a naturalistic setting. 'Ihis means that it is possible to compare the effects of the two Of consulting style without the problem Of identifying individual differences are controlled for by the design) and without the problem Of an artificial experi- ment (the study took place in a natural environment). Theoretically. the study examines the prediction that the educational rncxlel of doctor—patient communication is problem- atic (i.e. is the approach a suitable one?) and examines patient preferences for the method Of doctor—patient communic%ition. Background A traditional model Of doctor—patient communication regards the doctor as an expert who communicates their to the naive patient. Within this framework, the doctor is regarded as an authority figure who instructs and directs the patient. However, recent research has suggested that the communication proæss may be if a sharing, patient-centred consulting style is adopted. This approach emphasizes an inter- action between the doctor and the patient and this style may in greater patient commitment to any advice given, potentially higher levels of compliance and greater patient satisfaction. Savage and Armstrong (1990) aimed to examine patients' to receiving either a consulting style' or a 'sharing/ consulting style'..

Methodology Subjects The study was undertaken in a group practice in an inner city area of London. Four patients from each surgery for one doctor, over four months were.

randomly selected for the study. Patients were selected if they were aged 16—75, did not have a life-threatening condition, if they were not attending for administrative/ preventive reasons, and if the GP involved considered that they would not be upset by the project. Overall, 359 patient were invited to take part in the study and a total Of 200 patients completed all assessments and were included in the data analysis. Design The study involved a randomized controlled design with two conditions: (1) sharing consulting style and (2) directive consulting style. Patients were randomly allo- cated to one condition and received a consultation with the GP involving the appropriate consulting style. Procedure A set of cards was designed to randomly allocate each patient to a condi- tion. When a patient entered the consulting room they were greeted and asked to describe their problem. When this was completed, the GP turned over a card to determine the appropriate style Of consultation. Advice and treatment were then given by the GP in that style. For example, the doctor's judgment on the consultation could have been either, 'This is a serious problem/l don't think this is a serious problem' (a directive style) or, 'Why do you think this has happened?' (a sharing style). For the diagnosis, the doctor could say either, 'You are suffering from ... ' (a directive style) or, 'What do you think is wrong?' (a sharing style). For the treatment advice the doctor could say either, 'It is essential that you take this medicine' (a directive style) or, 'What were you hoping I would be able to do?' (a sharing style). Each consultation was recorded and assessed by an independent assessor to check that the consulting style used was in accordance with that selected..

Measures All subjects were asked to complete a questionnaire immediately after each consultation and one week later. This contained questions about the patient's satisfaction with the consultation in terms of the following factors: The doctor's understanding of the problem. This was measured by items such as 'I perceived the general practitioner to have a complete understanding'. The adequacy of the explanation of the problem. This was measured by items such as 'I received an excellent explanation'. Feeling helped. This was measured by the statements 'I felt greatly helped' and 'I felt much better'. Results The results were analysed to evaluate differences in aspects of patient satisfaction between those patients who had received a directive versus a sharing consulting style. In addition, this difference was also examined in relation to patient characteristics (whether the patient had a physical problem, whether they received a prescription, had any tests and were infrequent attenders)..

The results showed that although all subjects reported high levels Of satisfaction immediately after the consultation in terms of doctor's understanding, explanation and being helped, this was higher in those subjects who had received a directive style in their consultation. In addition, this difference was also found after one week. When the results were analysed to examine the role Of patient characteristics on satisfaction, the results indicated that the directive style produced higher levels of satisfaction in those patients who rarely attended the surgery, had a physical problem, did not receive tests and received a prescription. Conclusion The results suggest that a directive consulting style was associated with higher levels of patient satisfaction than a sharing consulting style. This provides support for the educational model Of doctor—patient communication with the doctor as the 'expert' and the patient as the 'layperson'. In addition, it suggests that patients in the present study preferred an authority figure who offered a formal diagnosis rather than a sharing doctor who asked for the patient's views. Therefore, although recent research has criticized the traditional educational model of doctor—patient communication, the results from this study suggest that some patients may prefer this approach..

Patient’s recall. Researchers also examined the process of recall of the information given during the consultation. Bain (1977) examined the recall from a sample of patients who had attended a GP consultation and found that 37 per cent could not recall the name of the drug, 23 per cent could not recall the frequency of the dose and 25 per cent could not recall the duration of the treatment. A further study by Crichton et al. (1978), found that 22 per cent of patients had forgotten the treatment regime recommended by their doctors. In a meta-analysis of the research into recall of consultation information, Ley (1981, 1989) found that recall is influenced by a multitude of factors. For example, Ley argued that anxiety, medical knowledge, intellectual level, the importance of the statement, primacy effect and the number of statements increase recall. However, he concluded that recall is not influenced by the age of the patient, which is contrary to some predictions of the effect of ageing on memory and some of the myths and counter- myths of the ageing process. Recalling information after the consultation may be related to compliance..

HOW CAN COMPLIANCE BE IMPROVED?. Compliance is considered to be essential to patient well-being. Therefore, studies have been carried out to examine which factors can be used in order to improve compliance..

The role of information. Researchers have examined the role of information and the type of information on improving patient compliance with recommendations made during the consultation by health professionals. Using meta-analysis, Mullen et al. (1985) looked at the effects of instructional and educational information on compliance and found that 64 per cent of patients were more compliant when using such information. Haynes (1982) took a baseline of 52 per cent compliance with recommendations made during a consultation, and found that information generally only improved compliance to a level of 66 per cent. However, Haynes reported that behavioural and individualized instruction improved compliance to 75 per cent. Information giving may therefore be a means of improving compliance..

Recommendations for improving compliance. Several recommendations have been made in order to improve communication and therefore improve compliance..

Oral information. Ley (1989) suggested that one way of improving compliance is to improve communication in terms of the content of an oral communication. He believes the following factors are important: primacy effect – patients have a tendency to remember the first thing they are told; to stress the importance of compliance; to simplify the information; to use repetition; to be specific; to follow up the consultation with additional interviews..

Written information. Researchers also looked at the use of written information in improving compliance. Ley and Morris (1984) examined the effect of written information about medication and found that it increased knowledge in 90 per cent of the studies, increased compliance in 60 per cent of the studies, and improved outcome in 57 per cent of the studies. Ley’s cognitive hypothesis model, and its emphasis on patient satisfaction, understanding and recall, has been influential in terms of promoting research into the communication between health professionals and patients. In addition, the model has prompted the examination of using information to improve the communication process. As a result of this, the role of information has been explored further in terms of its effect on recovery and outcome..

THE WIDER ROLE OF INFORMATION IN ILLNESS. Information and recovery from surgery Information may also be related to recovery and outcome following illness and surgery. On the basis that the stress caused by surgery may be related to later recovery, Janis (1958) interviewed patients before and after surgery to examine the effects of pre-operative fear on post-operative recovery. Janis examined the differences between pre- operative extreme fear, moderate fear and little or no fear on outcome. Extreme fear was reflected in patients’ constant concern, anxiety and reports of vulnerability, moderate fear was reflected in reality orientation with the individual seeking out information, and little or no fear was reflected by a state of denial. The results were that moderate pre-operative fear (i.e. a reality orientation and information seeking) was related to a decrease in post-operative distress. Janis suggested that moderate fear results in the individual developing a defense mechanism, developing coping strategies, seeking out relevant information, and rehearsing the outcome of the surgery. This approach may lead to increased confidence in the outcome, which is reflected in the decreased post-operative distress. However, there is conflicting evidence regarding this ‘U’ shaped relationship between anxiety and outcome.

Using information to improve recovery. If stress is related to recovery from surgery, then obviously information could be an important way of reducing this stress. There are different types of information that could be used to affect the outcome of recovery from a medical intervention. These have been described as (1) sensory information, which can be used to help individuals deal with their feelings or to reflect on these feelings; (2) procedural information, which enables individuals to learn how the process or the intervention will actually be done; (3) coping skills information, which can educate the individual about possible coping strategies; and (4) behavioral instructions, which teach the individual how to behave in terms of factors such as coughing and relaxing..

Researchers have evaluated the relative roles of these different types of information in promoting recovery and reducing distress. Johnson and Leventhal (1974) gave sensory information (i.e. information about feelings) to patients before an endoscopic examination and noted a reduction in the level of distress experienced by these patients. Egbert et al. (1964) gave sensory information (i.e. about feelings), and coping skills information (i.e. about what coping skills could be used), to patients in hospital undergoing abdominal surgery. They reported that sensory and coping information reduced the need for pain killers and in addition reduced the hospital stay by three days. Young and Humphrey (1985) gave information to patients going into hospital, and found that information specific to how they could survive hospital reduced the distress and their length of stay in the hospital. Research has also specifically examined the role of pre- operative information..

Johnston (1980) found that pre-operative information can influence recovery and reduce anxiety, pain rating, length of hospitalization and analgesic intake. Further, in a detailed meta-analysis of the published and unpublished literature on preparation for surgery, Johnston and Vogele (1993) concluded that preparation for surgery in the form of both procedural information (i.e. what will happen) and behavioural instructions (i.e. how to behave afterwards) resulted in significant benefits on all outcome variables explored, including mood, pain, recovery, physiological indices and satisfaction. Although the reasons why pre-operative information is so successful remain unclear, it is possible that pre-operative information may be beneficial to the individual in terms of the reduction of anxiety by enabling the patient to mentally rehearse their anticipated worries, fears and changes following the operation; thus any changes become predictable. These results therefore suggest that information communicated correctly by the doctor or the health professional may be an important part of reducing the distress following hospitalization or a hospital intervention..

THE ROLE OF KNOWLEDGE IN DOCTOR–PATIENT COMMUNICATION.

Boyle (1970), although emphasizing patients’ knowledge, also provided some insights into doctors’ knowledge of the location of organs and the causes of a variety of illnesses. The results showed that although the doctor’s knowledge was superior to that of the patient’s, some doctors wrongly located organs such as the heart and wrongly defined problems such as ‘constipation’ and ‘diarrhea’. It has also been found that health professionals show inaccurate knowledge about diabetes (Etzwiler 1967; Scheiderich et al. 1983) and asthma (Anderson et al. 1983). Over recent years, due to government documents such as Health for All and the Health of the Nation, primary care team members are spending more time on health promotion practices, which often involve making recommendations about changing behaviors such as smoking, drinking and diet. Research has consequently examined health professionals’ knowledge about these practices. Murray et al. (1993) examined the dietary knowledge of primary care professionals in Scotland. GPs, community nurses and practice nurses completed a questionnaire consisting of a series of commonly heard statements about diet and were asked to state whether they agreed or disagreed with them. The results showed high levels of correct knowledge for statements such as ‘most people should eat less sugar’ and ‘most people should eat more fibre’, and relatively poor accuracy for statements such as ‘cholesterol in food is the most important dietary factor in controlling blood lipid levels’..

Problems with the traditional approach to doctor–patient communication.

The adherence model of communication. In an attempt to further our understanding of the communication process, Stanton (1987) developed the model of adherence. The shift in terminology from ‘compliance’ to ‘adherence’ illustrates the attempt of the model to depart from the traditional view of doctor as an expert who gives advice to a compliant patient. The adherence model suggested that communication from the health professional results in enhanced patient knowledge and patient satisfaction and an adherence to the recommended medical regime. This aspect of the adherence model is similar to Ley’s model. In addition, how- ever, it suggested that patients’ beliefs are important and the model emphasized the patient’s locus of control, perceived social support and the disruption of lifestyle involved in adherence. Therefore, the model progresses from Ley’s model, in that it includes aspects of the patients and emphasizes the interaction between the health professionals and the patients..

However, yet again this model of communication assumes that the health professionals’ information is based on objective knowledge and is not influenced by their own health beliefs. Patients are regarded as laypeople who have their own varying beliefs and perspectives that need to be dealt with by the doctors and addressed in terms of the language and content of the communication. In contrast, doctors are regarded as objective and holding only professional views..

THE PROBLEM OF DOCTOR VARIABILITY. Traditionally, doctors are regarded as having an objective knowledge set that comes from their extensive medical education. If this were the case then it could be predicted that doctors with similar levels of knowledge and training would behave in similar ways..

In addition, if doctors’ behavior were objective then their behavior would be consistent. However, considerable variability among doctors in terms of different aspects of their practice has been found. For example, Anderson et al. (1983) reported that doctors differ in their diagnosis of asthma. Mapes (1980) suggested that they vary in terms of their prescribing behavior, with a variation of 15–90 per cent of patients receiving drugs. Bucknall et al. (1986) reported variation in the methods used by doctors to measure blood pressure and Marteau and Baum (1984) also reported that doctors vary in their treatment of diabetes. According to a traditional educational model of doctor–patient communication, this variability could be understood in terms of differing levels of knowledge and expertise. However, this variability can also be understood by examining the other factors involved in the clinical decision-making process..

Explaining variability – clinical decision making as problem solving.

The stages involved are as follows: 1 Understand the nature of the problem and develop an internal representation. At this stage, the individual needs to formulate an internal representation of the problem. This process involves understanding the goal of the problem, evaluating any given conditions and assessing the nature of the available data. 2 Develop a plan of action for solving the problem. Newell and Simon differentiated between two types of plans: heuristics and algorithms. An algorithm is a set of rules that will provide a correct solution if applied correctly (e.g. addition, multiplication, etc. involve algorithms). However, most human problem solving involves heuristics, which are rules of thumb. Heuristics are less definite and specific but provide guidance and direction for the problem his solver. Heuristics may involve developing parallels between the present problem and previous similar ones..

3 Apply heuristics. Once developed, the plans are then applied to the given situation. 4 Determine whether heuristics have been fruitful. The individual then decides whether the heuristics have been successful in the attempt to solve the given problem. If they are considered unsuccessful, the individual may need to develop a new approach to the problem. 5 Determine whether an acceptable solution has been obtained. 6 Finish and verify the solution. The end-point of the problem-solving process involves the individual deciding that an acceptable solution to the problem has been reached and that this solution provides a suitable outcome..

Understand problem and develop representation Break problem up into units Prior Derive and apply heuristics experience Appraise success of heuristics Appraise acceptability of solution Finish and verify solution Fig. 4-2 A simplified model of problem solving.

Clinical decisions as problem solving Clinical decisions can be conceptualized as a form of problem solving and involve the development of hypotheses early on in the consultation process. These hypotheses are subsequently tested by the doctor’s selection of questions. Models of problem solving have been applied to clinical decision making by several authors (e.g. MacWhinney 1973; Weinman 1987), who have argued that the process of formulating a clinical decision involves the following stages 1. Accessing information about the patient’s symptoms. The initial questions in any consultation from health professional to the patient will enable the health professional to understand the nature of the problem and to form an internal representation of the type of problem..

2 Developing hypotheses. Early on in the problem-solving process, the health professional develops hypotheses about the possible causes and solutions to the problem. 3 Search for attributes. The health professional then proceeds to test the hypotheses by searching for factors either to confirm or to refute their hypotheses. Research into the hypothesis testing process has indicated that although doctors aim to either confirm or refute their hypothesis by asking balanced questions, most of their questioning is biased towards confirmation of their original hypothesis. Therefore, an initial hypothesis that a patient has a psychological problem may cause the doctor to focus on the patient’s psychological state and ignore the patient’s attempt to talk about their physical symptoms. Studies have shown that doctors’ clinical information collected subsequent to the development of a hypothesis may be systematically distorted to support the original hypothesis.

4 Making a management decision. The outcome of the clinical decision-making process involves the health professional deciding on the way forward. Weinman (1987) suggested that it is important to realize that the outcome of a consultation and a diagnosis is not an absolute entity, but is itself a hypothesis and an informed guess that will be either confirmed or refuted by future events..

Signs, symptoms Hypotheses Revise Search for attributions Management decision Diagnosis as a form of problem solving Prior knowledge Of patient.

Explaining variability Variability in the behavior of health professionals can therefore be understood in terms of the processes involved in clinical decisions. For example, health professionals may: access different information about the patient’s symptoms; develop different hypotheses; access different attributes either to confirm or to refute their hypotheses; have differing degrees of a bias towards confirmation; consequently reach different management decisions..

Explaining variability – the role of health professionals’ health beliefs.

The beliefs involved in making the original hypothesis can be categorized as follows: 1 The health professional’s own beliefs about the nature of clinical problems. Health professionals have their own beliefs about health and illness. This pre-existing factor will influence their choice of hypothesis. For example, if a health professional believes that health and illness are determined by biomedical factors (e.g. lesions, bacteria, viruses) then they will develop a hypothesis about the patient’s problem that reflects this perspective (e.g. a patient who reports feeling tired all the time may be anemic). However, a health professional who views health and illness as relating to psychosocial factors may develop hypotheses reflecting this perspective (e.g. a patient who reports feeling tired all the time may be under stress)..

2 The health professional’s estimate of the probability of the hypothesis and disease. Health professionals will have pre-existing beliefs about the prevalence and incidence of any given health problem that will influence the process of developing a hypothesis. For example, some doctors may regard childhood asthma as a common complaint and hypothesize that a child presenting with a cough has asthma, whereas others may believe that childhood asthma is rare and so will not consider this hypothesis..

3 The seriousness and treatability of the disease. Weinman (1987) argued that health professionals are motivated to consider the ‘pay-off’ involved in reaching a correct diagnosis and that this will influence their choice of hypothesis. He suggested that this pay-off is related to their beliefs about the seriousness and treatability of an illness. For example, a child presenting with abdominal pain may result in an original hypothesis of appendicitis as this is both a serious and treatable condition, and the benefits of arriving at the correct diagnosis for this condition far outweigh the costs involved (such as time-wasting) if this hypothesis is refuted. Marteau and Baum (1984) have argued that health professionals vary in their perceptions of the serious- ness of diabetes and that these beliefs will influence their recommendations for treatment. Brewin (1984) carried out a study looking at the relationship between medical students’ perceptions of the controllability of a patient’s life events and the hypothetical prescription of antidepressants. The results showed that the students reported variability in their beliefs about the controllability of life events; if the patient was seen not to be in control (i.e. the patient was seen as a victim), the students were more likely to prescribe antidepressants than if the patient was seen to be in control. This suggests that not only do health professionals report inconsistency and variability in their beliefs, this variability may be translated into variability in their behavior..

4 Personal knowledge of the patient. The original hypothesis will also be related to the health professional’s existing knowledge of the patient. Such factors may include the patient’s medical history, knowledge about their psychological state, an under- standing of their psychosocial environment and a belief about why the patient uses the medical services. 5 The health professional’s stereotypes. Stereotypes are sometimes seen as problematic and as confounding the decision-making process. However, most meetings between health professionals and patients are time-limited and consequently stereotypes play a central role in developing and testing a hypothesis and reaching a management decision. Stereotypes reflect the process of ‘cognitive economy’ and may be developed according to a multitude of factors such as how the patient looks/talks/ walks or whether they remind the health professional of previous patients. Without stereotypes, consultations between health professionals and patients would be extremely time-consuming..

Other factors which may influence the development of the original hypothesis include: 1 The health professional’s mood. The health professional’s mood may influence the choice of hypotheses and the subsequent process of testing this hypothesis. Isen et al. (1991) manipulated mood in a group of medical students and evaluated the effect of induced positive affect on their decision-making processes. Positive affect was induced by informing subjects in this group that they had performed in the top 3 per cent of all graduate students nationwide in an anagram task. All subjects were then given a set of hypothetical patients and asked to decide which one was most likely to have lung cancer. The results showed that those subjects in the positive affect group spent less time to reach the correct decision and showed greater interest in the case histories by going beyond the assigned task. The authors therefore concluded that mood influenced the subjects’ decision-making processes..

2 The profile characteristics of the health professional. Factors such as age, sex, weight, geographical location, previous experience and the health professional’s own behavior may also effect the decision-making process. For example, smoking doctors have been shown to spend more time counselling about smoking than their non- smoking counterparts (Stokes and Rigotti 1988). Further, thinner practice nurses have been shown to have different beliefs about obesity and offer different advice to obese patients than overweight practice nurses (Hoppe and Ogden 1997)..

Explaining variability – an interaction between health professional and patient.

Agreement between health professional and patient.

The role of agreement in patient outcomes. If doctors and patients have different beliefs about illness, different beliefs about the role of the doctor and about medicines, does this lack of agreement relate to patient out- comes? It is possible that such disagreement may result in poor compliance to medication (‘why should I take antidepressants if I am not depressed?’), poor compliance to any recommended changes in behavior (‘why should I eat less if obesity is caused by hormones?’) or low satisfaction with the consultation (‘I wanted emotional support and the GP gave me a prescription’). To date little research has explored these possibilities. One study did, however, examine the extent to which a patient’s expectations of a GP consultation were met by the GP and whether this predicted patient satisfaction. Williams et al. (1995) asked 504 general practice patients to complete a measure of their expectations of the consultation with their GP prior to it taking place and a measure of whether their expectations were actually met afterwards..