COMMUNICATION SKILLS USED BY BULGAR-IAN GENERAL PRACTITIONERS DURING THE MEDICAL CONSULTATION

Background: The concept of doctor-patient communication develops from the idea that its main function is to gather information to the idea that it is an interpersonal relationship and interaction. Aim: To evaluate and analyze the opinion of general practitioners on the application of basic communication skills in medical practice in the therapeutic process and in the process of health education of the patient. Material/Methods: An empirical sociological representative survey was conducted among 190 randomly selected family physicians from two regions of the country. Results : Half of the GPs try to motivate patients, and significant differences were found regarding their sex, age and work experience (p=0.004). For chronically ill patients, 96% GPs discuss and offer advice related to healthy life style, daily activities (toilet, nutrition, mobility) or social activities. The doctors often give advice on nutrition (77%) and physical activity (71%). The majority of GPs (90%) report that they can motivate their patients to maintain a healthy lifestyle if there is even a small interest to do it. However, general practitioners still make insufficient use of active listening techniques, maintain poor eye contact during the interview, and perform other activities during the patient’s hearing. In addition, physicians rarely involved the patientin discussions for therapy anddecision making. Conclusion : Surveyed physicians report to a significant extent that they are committed to the health education of their patients in the form of advice on a healthy life style. They manage to deal with many of the difficult communication situations in general practice.

• Primary care physician's (PCP's) demographic data and practice characteristics • PCP's communication for examination and planning of the treatment • PCP's communication and motivation skills for increasing of health literacy of the patient The collection of information was carried out through anonymous surveys among 190 family doctors in Bulgaria, selected randomly in the period: 1. 02. 2020 -31. 12. 2020. They represent 4.6% of the general population of GPs for the whole country. The study was conducted in compliance with the principle of autonomy, ethical principles and rules for conducting research and after obtaining permission to conduct research on the committee of ethics at the Medical University of Pleven.
The methods of parametric and non-parametric analysis were used for data processing, the statistical significance of the differences was assessed with chi-square and t Student-Fisher test. The data from the survey were processed with the software statistical packages Excel v.10.0 and SPSS.
In total, 190 physicians from the country took part in the survey. The majority of participants are women, given the fact that women predominate as a gender among GPs in the country. Physicians with longer work experience also predominate, given the high average age of doctors working in primary health care in Bulgaria. Some of the physicians have practices located in urban cities, others work in small settlements and villages, some of the GPs have mixed practices. More of them work in individual practices for primary health care. The structure of the surveyed persons from this group is presented in Table 1.

RESULTS:
Given the described various effects of doctor-patient communication on the results of the doctor's work as a whole, information was collected and systematized from the responses of general practitioners about the importance of good communication with the patient and the use of some basic communication skills in medical consultation. All participants in the study praised the impact of physician communication on the diagnostic, promotional, and therapeutic processes, on the quality of physician-patient relationships, and on increasing patient satisfaction with health care. The data are presented in Figure 1: In communicating with the patient, doctors appreciate a lot the right beginning of the consultation and the meaning of body language. For most of the respondents, it is important to inform the patient about the upcoming tests. Feedback from the patient is also well-represented. It was found that doctors still do not sufficiently apply the methods of active listening -the use of paraphrases and summaries. Maintaining eye contact with the patient during the interview is short. Doctors take into account the fact that they often engage in other activities during the patient's hearing. In addition, physicians rarely discuss therapy and its side effects with the patient. The use of basic communication skills by GPs in their practice is described in Table 2.
The style of physicians' communication shows the influence of some characteristics such are sex, experience, and training. For example, physicians who have been trained in communication skills during or after their student education are more likely to facilitate the patient's story and use paraphrases, summaries, and explanations (p=0.01). These physicians commented more on the therapy and its side effects with the patient (p=0.02). The way of the respondents communicate also is influenced by gender. Women are much more inclined to predispose the patient to talk at the beginning of the consultation (p=0.01), more inclined to answer the patient's questions (p=0.02), to give more explanations (p=0.03) and to take into account the patient's preferences for therapy (p=0.01). This fact is observed in other studies and is explained by the differences in the approach to communication in general between men and women [4,16]. Work experience also influences the way of physicians communicate Physicians with more professional experience -over 15 years are more likely to discuss with the patient the various options for therapy (p=0.01) and possible side effects (p=0.01). The youngest physicians -the ones with less than 5 years of experience, are more likely to predispose the patient at the beginning of the conversation with an appropriate welcome (p=0.005), to answer the patient's questions in detail (p=0.02) and to comply with the wishes of the patient in determining the treatment plan (p=0.05).
The surveyed physicians report to a significant ex- tent that they are committed to the health education of their patients in the form of advice on a healthy lifestyle. The highest share of physicians is engaged in advice and training related to reducing bad habits in patients. The following are tips on proper nutrition and physical activity. The positive fact is that the majority of doctors use an individual approach for health literacy, consistent with the lifestyle and understanding of the patient. They understand that this approach is the most effective way of learning and implementing it in their daily practice. Thus, a very large part of GPs successfully changes the lifestyle of their patients. There are a few doctors who fail or do not try to change the harmful habits of their patients. Physicians who have longer professional experience -the ones with over 15 years of experience, are easier to persuade and motivate the patient to change (p=0.01). Women in general medical practice also find it easier to motivate patientsto change (p=0.02). GPs are well aware of the living conditions of their chronically ill patients due to frequent and prolonged meetings with them. The issues that are most often discussed with them are related to the difficulties in the daily activities and social life of the patients. Firstly, this includes dealing with the toilet and eating, secondly, the problems of moving patients are discussed, and thirdly, the problems related to the performance of daily household duties are discussed. Very few doctors are limited to the medical side of the disease. The GPs' communication and motivation skills for increasing of health literacy of patients are described in Table 3.

DISCUSSION
The communication model of Bulgarian GPs shows some improvement compared to our studies from 10 years ago. The initiation of the consultation, the process of giving the explanation, the feedback to the patient have improved. The pattern of communication observed in this study is similar to the models of GPs' communication from other European countries, described in the literature [10,14,16]. In them, the authors point out that the doctor is a leader in communication, and most of his consultation is dedicated to gathering information about the patient's medical problems, providing information and advice on therapy. As in other studies, the results still show insufficient involvement of the patient in the final decision [14,[16][17][18][19][20]. The communication style of Bulgarian GPs is influenced by gender, practical experience or communication skills training [4,13,15,16].
GPs have known their chronically ill patients, their peculiarities, problems and need for a longer period of time and successfully communicate with them. That's probably why the group of chronically ill patients does not cause difficulties in communication with GPs in Bulgaria. The questions that general practitioners discuss most often with this type of patient are related to both -the medical side of the disease and dealing with difficulties in the patients' daily and social life.
Good communication is an essential part of a patient's health education and is a necessary tool for health promotion.The GPs are in the best position to influence patients' bad habits and form a healthier lifestylePhysicians, by working with their patients for a long time and knowing more about their living conditions, their understandings and norms of behavior. A large number of GPs successfully change the lifestyle of their patients using an individualized approach based on the knowledge they have of the patient's characteristics.

CONCLUSIONS:
The surveyed physicians report that they are committed to the health education of their patients in the form of advice on healthy lifestyles and manage to deal with many of the difficult communication situations in general practice. The doctors do their best to involve actively the patients in health promotional activities This shows that they understand their role in the process of health education of patients, as well as the importance of skilful use of communication skills related to explaining, giving advice and motivating the patient. However, general practitioners still make insufficient use of active listening techniques and body language during medical consultations. There is still insufficient involvement of the patient in the final decision regarding the treatment plan.