Medical service provided by all medical personnel ought to be safe, compelling, qualified, satisfactory, and centering on the patients . Nowadays, a wide run of constructive approaches, which were developed to handle the doctor-oriented issues begun to be actual around the world. These approaches include trainings as well as workshops such as stress and emotion management, proper motivational interviewing and empathy . They are mostly aimed at teaching doctor-patient communication skills to healthcare professionals, doctors and medical students . Various scholars have revealed that developing skills and qualities mentioned above are crucial for medical residents to reach a patient-centered care . Originally we have been focused on this suggestion that development of doctor-patient communication skills will improve dissatisfaction among the patients, but results of our present study and fact of gradual increase of patients’ complaints against medical care providers in Kazakhstan show that probably communication skills is not the only reason of overall problem and require further detailed investigation . The Ministry of Health reported that most of the complaints were based on problems with the organization of medical care and poor quality of medical services, including medicinal provision, qualification and communication provided by medical personnel . From these perspectives we would like to discuss different possible reasons resulted in conflicts between patients and medical providers. Ministry of Health reports about arrangement of commission, which take over control of all medical providers through assessment of their knowledge and medical skills .
Some studies suggested that managerial vertical power of overall political system might affect health care organizations reflecting on quality of the medical care . It was revealed that power is all around us, affecting patients, professionals, and health institutions, and power plays have an important role in all relationships. This was observed in the lack of teamwork due to the interprofessional relationships in a hierarchical structure with vertical power and ineffective communication flows. Considerable evidence supports the idea that interdisciplinarity in the health care system is a fallacy that pervades the institutional discourse but is not practiced in reality [17, 18, 19]. This explains the paradox of teamwork reported in studies by Björkdahl  and Ehnfors et al. , where a cultural conception of “we work better together” is not efficient in the clinical setting. .
On the way from Ministry of Health to the medical practitioner we have endless departments of middle management including administration of the hospitals which responsible for basic organization of work, implementation of facilities, training and etc., which should set up the environment for comfortable interaction between doctors and patients. It is interesting to investigate the efficiency of each hierarchical level of local healthcare management: how good all these levels of organizations and departments are connected, how far they are effective and functional, since their mission is to make medical service processes comfortable and productive.
In most of the cases medical providers are not satisfied with environment developed without taking into account their real needs and problems which they experience during their work. Such discomfort might reflect on the interaction of doctors with their patients which usually come with extremely high expectations of high quality without understanding the above mentioned matters which leads to miscommunication and disappointment in medical care . Such patients can suppress their medical providers expecting doctor-centered approach by receiving medical prescription and cure . For most of the patients it is easier to find solution of their problem through punishment of their doctor rather than to have a discussion or negotiation. This kind of judgment widely practiced at each level of management in any field of our country, which has communistic background and it probably has been reflected on attitude of our population. Some authors discuss about similar issues common among post-communistic countries . All of them describe issues related to paternalism among the doctors and patients followed by punishment which was common during the communist regime. Researchers from post-communists countries describe different ways of their transition from old traditional format of paternalism into patient-centered approach through promotion of autonomy among the patients. Therefore, the widespread introduction of measures aimed at improving doctors and patient safety is of particular scientific and practical interest.
Also, some authors mention that less attention payed to the importance of risk management for orientation of healthcare providers in case of clinical incidence oriented not only on safety of patients but also legal protection of medical providers .
Nowadays the healthcare issues are arising in the medical organizations of Kazakhstan. One of the targeted moments for improving safety among the patients and medical providers is the provision of medical care within the framework of the national health care system, focused on international standards, but operating in the legal field of the country. Meanwhile, there are no works in the Republic of Kazakhstan summarizing international experience in managing health care risks. In practice, risk management of US health system today processes such as mandatory registration of incidents and clinical incidents with further screening procedures. Nowadays in Kazakhstan this model was implemented in the hospitals of University Medical Center and successfully underwent accreditation process for JCI international standard. But this is a single case of such experience in Kazakhstan which also requires long term of realization. Some authors identified that quality of medical care should comply with principles of safety, adequacy, high scientific, technological and professional level of providing with economic efficiency for medical facilities .
Our study showed high prevalence of doctor-oriented medical providers and doctor- oriented patients compare to patient-centered medical providers and patients.
Traditional and common way of doctor-patient relationship in Kazakhstan is based on paternalistic attitudes which common among the post-communist countries . Patient-centered approach consider patients autonomy defined as the patient’s right to make treatment decisions independently, which is widely known but only in theory [23,24]. Nowadays we are on the way to be changed and learn patients’ autonomy on practice which is not easy and need to be publicly clarified and promoted. This way of interaction between patients and doctors takes years to be changed .
In the previous study we discussed that doctor-patient miscommunication affects overall medical care, but in case of our country we have revealed that miscommunication is just one of the instrument which can fulfil the gap affecting overall doctor-patients interaction. Communication skills between doctor and patients used to be just a part of some clinical subjects in the medical curriculum of all medical schools of our country. From 2017–2018 all medical schools in the Republic of Kazakhstan implemented Communication as a separate and mandatory course in the medical curriculum. Further development of patient-centered communication Guideline based on cultural and local communicative specificities will be essential to be used by practitioners along with as a treatment protocols which help to improve their skills to communicate with patients as important part of treatment rather than emotional communication which always affect overall interaction.
Life satisfaction Scale can become a social determinant of health in our study as one of the major reason of shift from perception of patient-centered care among our respondents into doctor-centered health care. This study has demonstrated that younger health care providers and those with lower life satisfaction are more patient-centered. Older respondents and those with higher life satisfaction, in contrast, reported doctor-centered attitudes. The majority of younger patients have a stronger belief in good health associated with patient-centered care whereas the older population preferred a more doctor-centered care. In all patients, the preference of patient-centered care was associated with higher satisfaction in life.
In our study we manipulated that at the beginning of career younger health care providers are more enthusiastic with their newly gained skills and helpfulness in society and more patient-oriented due to high expectations from job reward but with years and negative experience in the life due economical instability along with extremely slow progress of salary increase finally leads to emotional distress and low motivation among health care providers and make them less patient-centered even after getting their stability and good salary when they get aged.
Current finding that senior health care providers which were satisfied with life remained to be not patient-centered suggested an area for more detailed investigation and improvement. We suspect that above mentioned tendency might gradually decrease motivation to work in spite of extensive experience. Aged care givers follow the rules and regulations developed by higher hierarchical level of healthcare management which doesn’t consider a feedback or direct communication due to the multiple intermediate hierarchical levels of executers so called “middle management”. There is no direct exchange and delivery of information about real needs of medical practitioners which could report about existing problems necessary to be solved. It originates from vertical power of local political system reducing motivation at each level coming down due to increased disconnection of upper level management with those which perform their regular work and deliver this regulations to medical practitioners. The best thing about being on the middle of this managerial hierarchical levels is lower responsibility since they are not original developers and neither medical practitioner, they can be considered as transmitters of information but in most of the cases absolutely useless and ineffective . This is one of the reasons why miscommunication will always take a place among our healthcare providers and patients and why patient-orientation will be less possible.
Vertical power and disconnection of workflow due to complex organization of healthcare management leads to reduction of motivation among healthcare providers to be a patient-centered.
Our study showed high prevalence of doctor-oriented medical providers and patients as well. Traditional and common way of doctor-patient relationship in Kazakhstan is based on ethical paternalism widely described in the literature.