An extensive body of literature advocates a patient-centred approach to primary care,1 requiring the primary care provider to be mindful of and responsive to patients’ experiences and understandings of health and illness.2 This requires effective communication.2 Five key dimensions of patient-centredness include: the adoption of a bio-psychosocial perspective; perceiving the “patient-as-person”; sharing power and responsibility; approaching consultations as a therapeutic alliance; and perceiving the “doctor-as-person”.1 A patient-centred approach is also premised on a strong, trusting and lasting relationship, reflective of mutual participation between the doctor and patient.3 This approach increases patient satisfaction during consultations and improves health outcomes.2,4-5
While some attention has been paid to the relationship between patient-centred care and women’s health needs,6 there has been scant attention paid to the relationship between a patient-centred approach and the type of interaction men value when visiting their general practitioner.7 Female patients value a patient-centred approach and prefer female doctors, and female doctors are better at adopting a patient-centred approach than their male counterparts.8-10 That is, a patient-centred approach seems consistent with what women want, and what female physicians do best, within the context of primary care settings. Less is known about what men mean by patient-centredness and whether this differs from the views of women.
Men tend to delay seeking help, and there is a perception that men are reluctant users of health care and victims of their own behaviour. The social construction of masculinity has been used to explain this phenomenon. Recent Australian data, however, indicate that nearly 90% of men over the age of 40 have visited their GP in the previous 12 months.11-14 The victim-blaming mentality is now being challenged,13,15-17 with some claiming that assertions of male stoicism are overly simplistic14 and can trivialise help-seeking concerns noted among men.12
Researchers have begun to explore what men understand about their health and health practices,7,14,17-18 and the perspectives of health service providers are also being studied.14,19-21
The aim of our study was to examine the way men speak about their interactions with GPs, as a basis for describing the qualities and styles of communication that men prefer.
The Florey Adelaide Male Ageing Study (FAMAS) collects biopsychosocial data on 1195 randomly sampled men between the ages of 35 and 80 years. These participants were selected from the North West Adelaide region of South Australia using the Electronic White Pages telephone directory.22
Using strata relating to age and marital status, we invited 36 of the men from the larger FAMAS cohort to participate in a qualitative study exploring men’s help-seeking behaviour and health service use. Their views are analysed here.
All men in our study were born either in Australia (30) or the United Kingdom (6). There was a broad representation across age categories: 35–44 years (6), 45–54 years (8), 55–64 years (10) and ≥ 65 years (12). Nineteen men were married or living in a de facto relationship, 13 were divorced or separated, and four were widowed or never married. Twenty-nine participants had a post-secondary qualification. Income levels per annum were diverse: < $20 000 (11), $20 000–40 000 (9), $40 000–60 000 (5), $60 000–80 000 (6), and > $80 000 (5).
Semi-structured interviews, all undertaken by J A S, lasted an average of 90 minutes (range, 60–105 minutes). Interviews were conducted between January and November 2005. The majority were conducted in the homes of participants, except for four cases in which a university interview room or a participant’s workplace was used, at the request of participants. Participants were asked what they perceived was most important to them about their health, allowing for a detailed exploration of their help-seeking practices and health service use. Each interview was transcribed verbatim and, with the assistance of NVivo software, version 2.0 (QSR International, Melbourne, VIC), an inductive approach was used to thematically analyse the data.
Most of our participants said that physician gender was unimportant to them, except perhaps when it came to sexual or reproductive health issues, for which a male health care provider was occasionally preferred. Analysis of the interview data identified five core themes related to the qualities participants valued during a professional consultation with their GP:
Adoption of a “frank approach”;
Demonstrable competence;
Thoughtful use of humour;
Empathy; and
Prompt resolution of health issues.
These thematic areas were analysed in the context of what was already known in relation to gender and communication with GPs in primary care settings. To explore these issues, we mapped our interview data against the key dimensions of patient-centredness (Box 1).
The men interviewed favoured a concise, direct and matter-of-fact style of communication. This is consistent with what is known about male communication patterns, which involve direct, result-oriented and decisive communication:7,23-24
You don’t want someone who will talk in lingo that’s above your head . . . You know, just keep it simple. But at the same token, at the same time, make you aware of it. If something seriously needs to be discussed, it’s discussed, not swept under the carpet. If I’m gunna die of a heart attack or something like that, I’d want to know! I want someone who calls it as they see it, without beating around the bush. (David, 52)
Although a patient-centred approach incorporates a non-directive communication style, consistent with achieving a therapeutic alliance,1,23-24 for some men there was a preference of a directive as well as a direct approach:
[My GP] doesn’t mix his words. He calls a spade a spade. You know where you stand with him. He tells you if you’re not doing the right thing. He tells you “if you’re not going to bother with what I tell you, then don’t bother coming, because you’re wasting my time and your time”. He’s a good bloke. It’s the sort of thing that you need really. (Charlie, 54)
I like straightforwardness. No bullshitting. My doctor’s very straightforward. He knows me very, very, very well. He doesn’t put up with any crap. He’ll tell me straight out, “Claude, it’s time that you’ve got to do this”. And I’ll have my tests done . . . I know that I can’t get away with much with him. We’re very straightforward. If I go down there it’s yes, no, straight out, no messing about . . . I regard him as the best doctor I’ve ever had. (Claude, 59)
The use of the terms “he’s a good bloke” and “he knows me very, very, very well” indicates the value placed on respect and trust. This is concordant with key dimensions of patient-centredness, such as perceiving the patient-as-person and doctor-as-person.1 But this also creates a tension with other key dimensions of patient-centredness, such as sharing power and responsibility.1 Indeed, participants valued a directive approach that was more hierarchical, and which involved less shared decision making, than would usually be considered consistent with a patient-centred approach. We posit that the key element is the link between a high value being placed on a trusting relationship and both a direct and directive approach — “being told what to do” with respect to their health. Further research that examines the way in which power hierarchies operate in the context of men communicating with their GP is warranted.
We use the term “demonstrable competence” to refer to the assessment of a GP’s competence by the men in terms of the confidence and knowledge conveyed, and dexterity with physical tasks:
He ah impresses me as knowing what he’s talking about . . . I think it keeps in any profession, you know, you’ve got to do your homework and keep up with the latest developments in it. (Alexander, 75)
The men tended to use their own prior experience as a reference point as well as the reputation of the doctor in the broader community. For example:
Previous studies have described how humour can be used when communicating with men about their health (particularly sexual health).7,25 Our study also demonstrated that, when used appropriately, humour was appreciated as a tool to lessen the perceived seriousness of consultations, reduce tension and facilitate communication:
A sense of humour wouldn’t go astray, you know, because quite often it can sort of alleviate the seriousness. (Fred, 43)
I liked [the doctor] because, as a person, he was quite laid back, friendly — he joked. He didn’t make things too serious. (Tim, 52)
A thoughtful use of humour means more than just sharing a joke. It is about facilitating a laid-back and friendly environment in which men feel comfortable to speak openly about their health concerns.
Empathy is a core value of general practice consultations.26 The ability to communicate easily, at the same level as the patient, and listen and understand from the patient’s perspective was important to our participants:
You want to find someone who you can approach and talk to — and talk in terms that you can understand what is going on . . . A doctor who will sit down and explain what he’s doing and why he’s doing it. (Charlie, 54)
The synergies between patient-centredness and the adoption of an empathetic communication style are therefore paramount for effectively engaging men in primary care settings.
We have previously shown that men in our study self-monitor their health before seeking help and are therefore focused on having their health concerns promptly “fixed” once they have made the decision to visit their GP.17 This explains, in part, why the men in our study valued GPs who were able to resolve health issues promptly. A quick resolution was achieved in two ways: (a) a health issue was perceived to be fixed or a correct diagnosis was made; or (b) a prompt referral was made to another health professional and/or specialist. In most instances our participants reported that their GPs did this well.
A doctor who, on a previous occasion, had been correct with a diagnosis and up-front about uncertainty, but decisive with respect to the next step (eg, recommending further investigation or providing a referral), instilled a sense of confidence in participants:
He seems to think things out a lot more, and gets a better understanding of what he’s going to do, and how he was going to go about it. He wasn’t prepared to jump straight in. (Clancy, 53)
Taking time to think through and explain possible diagnoses and strategies to address the health concerns that male patients raise are two ways that GPs can work towards resolving health issues. As Michael commented:
The notion of being “shrugged off”, differs from a prompt referral. Indeed, a prompt referral was generally perceived as a positive quality:
I just want someone who can do their job, someone who I feel confident in, someone who doesn’t mess me around. If he doesn’t know, he sends you to a specialist straight away. (Ben, 74)
GPs who were perceived as acknowledging their own professional limitations, and who had networks of expert colleagues to whom they could refer, were highly regarded by our participants. Similar findings have been identified in at least one other study examining doctor–patient communication among male patients.7
In conclusion, our observations enable us to indentify five core qualities valued when communicating with GPs. These qualities are concordant with key dimensions of a patient-centred approach, such as perceiving the patient-as-person and doctor-as-person. Other dimensions such as sharing power and responsibility and approaching the consultation as a therapeutic alliance had slightly different meanings for the men in our study compared with the meanings attributed in a review of empirical literature relating to patient-centredness.1 Implications for practice and policy contexts are outlined in Box 2.
We acknowledge that these findings are not representative of all men living in Australia, such as young men or men from culturally and linguistically diverse backgrounds. However, in the context of this study, these core qualities have the potential to influence gender-focused education, as well as teaching and training programs targeted at health professionals. Identifying the similarities and differences in the ways men and women define patient-centredness will assist in developing a more robust gender focus within the health system at both practice and policy levels. This will ultimately provide a more supportive environment for men to be engaged in, and make use of, health programs and services.
1 Primary qualities men value when communicating with their general practitioner, mapped against key dimensions of patient-centredness
2 Implications for practice and policy contexts
Communication with men in primary care settings should be concise and direct, but should also be considered and thoughtful. This involves general practitioners:
Stating facts clearly during consultations;
Using terminology easily understandable by a lay person;
Keeping abreast of the latest developments and conveying these to patients during consultations;
Applying and explaining the role of “new” knowledge to patients when making diagnoses;
Alleviating the perceived seriousness of health concerns by using humour thoughtfully to facilitate the building of rapport;
Listening to, understanding and responding to patient needs to facilitate an empathetic style of communication based on respect and trust;
Demonstrating that they are aiming to “fix” health issues as quickly as possible; and
Referring patients on to other esteemed health professionals promptly, particularly if the problem remains unresolved.
Strategies to enhance the skills of GPs in this area might include:
Investment in medical and primary health care education and training that acknowledges the value of listening to men’s lay perspectives;
Development of a resource to equip GPs and other health professionals to effectively engage men in discussion about their health; and
Incorporation of the core qualities described here when planning, developing, implementing and evaluating preventive activities and primary care interventions aimed at men.
- James A Smith1
- Annette J Braunack-Mayer1
- Gary A Wittert2
- Megan J Warin3
- 1 Discipline of Public Health, University of Adelaide, Adelaide, SA.
- 2 School of Medicine, University of Adelaide, Adelaide, SA.
- 3 Department of Anthropology, Durham University, Durham, UK.
The authors acknowledge the financial support provided by the Florey Medical Research Foundation, the University of Adelaide, the South Australian Department of Health and the Northern Community Health Foundation. We would also like to acknowledge the support of the Florey Adelaide Male Ageing Study research team, and thank the Australian College of Health Service Executives (SA Branch) for providing support through the David Southern Award. Thanks also to Amanda Pilgrim and Brooke Smith for providing comments on earlier drafts of this article.
None identified.
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Abstract
Objective: To determine the core qualities that men value when communicating with general practitioners in primary care settings.
Design, setting and participants: In a qualitative study using semi-structured interviews in non-clinical environments, 36 white Australian men drawn from the Florey Adelaide Male Ageing Study, stratified by age and marital status, discussed their help-seeking behaviour and health service use. Participants were from the North West Adelaide region. Interviews were conducted between January and November 2005.
Results: The core qualities men value when communicating with GPs in primary care settings include the adoption of a “frank approach”, demonstrable competence, thoughtful use of humour, empathy, and prompt resolution of health issues.
Conclusions: The core qualities men value when communicating with GPs are concordant with most key dimensions of a patient-centred approach, but not necessarily all. Adopting these qualities has the potential to enhance communication with and care of men in primary care settings.