Interpretation of results
Our study shows that the overwhelming majority of health care providers and even patients are doctor-centered. The patient-centred orientation of health care providers is negatively correlated with age (P=0.000218) and life satisfaction (P=0.000001). In patients, contrarily, patient-centredness is enhanced by higher life satisfaction (P=0.040), although negatively correlated with age (P=2.659E-21).
Our data show that only 10,6 % of overall medical providers identify themselves as patient-centred, but this proportion was smaller among doctors (8,7%) compared to that of nurses (15,7%) with no difference between males and females. This finding suggests that more nurses scored as patient-centred than doctors, and this may be in part due to different aspects of standard interactions with patients. Nurses spend more time with patients during regular medical visits and procedures in the hospital or outpatient clinics, and these interactions require more attentive care and communication skills in order to instruct patients and reduce their anxiety (28). However, the results of the PPOS still showed that significantly more nurses scored as doctor-centred rather than patient-centred (7).
The proportion of patient-centred providers is higher among the ages of 31-40 years old (16,2%) and 41-50 years old (10,4%) than among the ages of 25- 30 years old (5,1%) and older than 50 years old (5,3%). The proportion of patients who identify as patient-centred is 13,8%. The proportion of patient-centred patients was higher among the ages ≤ 40 years old (34,6%) and ≥60 years old (35,3%).
This study found that more of the younger health care providers and those with lower life satisfaction are patient-centred. More older participants and those with higher life satisfaction, in contrast, reported doctor-centred attitudes. The majority of younger patients have a stronger belief in good health associated with patient-centred care whereas the majority of older population preferred a more doctor-centred approach. In all patients, the preference of patient-centred care was associated with higher satisfaction in life. Overall, this study shows the high prevalence of doctor-centred medical providers and doctor-centred patients compared to patient-centred medical providers and patients.
The Life Satisfaction Scale (25) in this context appears to be a relevant measure in identifying additional factors in patient satisfaction beyond what happens in clinics. Life satisfaction is related to the preference of patient-centred care among our respondents rather than doctor-centered health care. However, it is different for providers, depending on their age group, and different for patients. Younger health care providers and those with lower life satisfaction are more patient-centred. Older respondents and those with higher life satisfaction, in contrast, reported doctor-centred attitudes. The majority of younger patients have a stronger belief in good health associated with patient-centred care whereas the older population preferred a more doctor-centred approach. In all patients, the preference of patient-centred care was associated with higher satisfaction in life.
Current healthcare policies that focus on punishing organizations for high complaint ratings instead of encouraging the examination of underlying causes for possible solutions were identified as facilitating factors in doctor orientation (3, 14). A punitive environment can encourage an adversarial relationship with patients rather than a cooperative one. The Ministry of Health recently revealed policies to regulate provider performance through commission which applies to all medical providers. These commissions would be based on an assessment of provider knowledge and medical skills, the purpose of which is to increase the quality of medical care by encouraging professional development in these areas. However, such incentives are being rolled out without any preliminary investigation of current challenges and successes of medical services and existing personnel(3, 14). An incentive for development of medical but not clinical (i.e. patient-centered) skills will only exacerbate the problem.
National policies establish rules and regulations which are then enacted by healthcare management, and little to no feedback or communication from medical professionals about difficulties they face makes its way back to policy makers. We suspect that this top-down management of the health system has contributed to the current environment and will continue to decrease the motivation of providers to work towards patient-centredness, regardless of years of experience(3, 20). In most cases, medical providers are not satisfied with the working environment because their expressed needs and problems are not taken into account. Such neglect and frustration likely affects provider attitudes and influences their interactions with patients who typically come with high expectations of quality without understanding contextual factors which lead to miscommunication and disappointment in medical care(29). This is one of the driving forces of miscommunication and different expectations which continue to have a place among healthcare providers and patients in Kazakhstan, making patient-centeredness less possible.
In our study we found that at the beginning of their careers, the younger healthcare providers are more patient-centred, possibly due to their newly gained skills and perceived role in serving society(11). Younger doctors have high expectations in job reward. Years of negative life experience, economic instability and a punitive working environment likely will lead to emotional distress and decreased motivation or burnout, as described by Reith et al.
(20). Even after establishing themselves as professionals and achieving a higher salary, these other environmental factors may cause them to become less motivated to update their professional skills that serve patient needs (11, 20, 29).
Most patients in this study, regardless of social status, still expect the doctor to be authoritative, not only prescribing the solution but curing the patient’s illness (30). Many doctors tend to overestimate their ability to communicate with patients, especially when that communication requires explanation of complex medical concepts and relationship building for greater trust (31). Furthermore, a treatment prescribed by a provider may not bring anticipated results, and not in an anticipated timeframe. In this study, doctor-centred patients visit doctor-centred doctors which still results in dissatisfaction. The finding that experienced health care providers which were satisfied with life remained doctor-centred suggested an area for more detailed investigation and improvement. Traditional doctor-patient relationships in Kazakhstan are based on paternalistic attitudes, common among post-communist countries (32). The patient-centred approach considers patient autonomy, defined as the patient’s right to make treatment decisions independently, which is widely known but not always practiced (32, 33). Today these approaches are gaining acceptance, and patient autonomy in practice, which is not easy to implement, needs to be publicly clarified and promoted. Improving doctor-patient communication is possible, but it takes time and a supportive environment (30).
Poor doctor-patient communication affects overall medical care (4, 5, 22, 30), but in the case of Kazakhstan we have revealed that miscommunication is just one of the factors affecting doctor-patient interactions. From 2017 to 2018, all medical schools in Kazakhstan implemented “Communication skills” as a separate and mandatory course in the medical curriculum (34). Further development of a patient-centred communication guideline, based on cultural and local communicative specificities, will be essential if it is to be used by practitioners in their daily medical practice. The skills, along with valuing the importance of understanding the environmental influences on interacting with patients, is needed to improve provider communication with patients.
Limitations of the study
Limited time and resources constrained the number and representativeness of the participants. To have access to a more representative and diverse group of participants, more formal arrangements with hospital administrations will be necessary. Additionally, the duration of hospitalized patients typically lasts no longer than 3-6 days, giving us a limited window to approach patients and secure their participation. Hospital administration allowed the research team to approach patients in a stable condition with predominantly chronic diseases which were able to complete provided questioners without assistance.
An additional challenge in this study is the lack of published data covering this research area of patient dissatisfaction with health care and providers, as well as the convoluted official information about the exact number and types of patient complaints in the Republic of Kazakhstan. The available information is from scattered newspaper and news website articles, and some articles published as official reports for the World Health Organization (1, 3, 34, 35).