PROBLEMS OF GENERAL PRACTITIONER-PA-TIENT COMMUNICATION IN BULGARIA

professionals in primary care


INTRODUCTION:
Communication effectiveness in primary care typically focuses on assessing the generally applicable, welldefined communication skills of a general practitioner (GP).However, in everyday practice, communication is determined by specific factors, such as knowledge of the patient and/or the presenting problem.Hence, the need for high level-communication culture arises in the process of medi-cal practice and GPs' training process [1,2,3,4].
Communication is an essential factor in the quality of medical care offered.Its complex nature directly correlates with patient satisfaction, professional medical ethics, and a patient's trust in the doctor.Communication can be recognized as an essential component of medical care.During medical encounters, it can be evaluated by using various interaction analysis systems.
The new model of collaboration and partnership (mutual or empathetic model) is gaining ground in modern healthcare.This model implies continuous communication, interaction, and trust between doctor and patient, based on the principle of patient-centered communication.This means that the patient is an active participant involved in his or her healing process.A patient is expected to have a sense of responsibility and control over it, and be convinced that his or her lifestyle will influence the healing process.It should be acknowledged, however, that in Bulgarian healthcare this principle remains mainly in the field of theory, and can be rarely seen in primary healthcare practices [ 4,5,6].
Informed consent in primary care is part of the communication process, which helps achieve good patient outcomes.In addition, an individualized approach appropriate for a patient's level of education is necessary to accomplish proper and effective communication.[7,8]

MATERIAL AND METHODS:
The data collected through an empirical study of doctor-patient communication are presented and analyzed based on a general analysis of the phenomenon of communication.An anonymous survey was conducted among 1053 respondents in the period 1-30 September 2018 in the Pleven region, Bulgaria.A questionnaire was developed including questions to assess the following characteristics: patients' satisfaction with the information received from the GP; the time spent talking to the patient; obtaining informed consent from the patient, as well as whether the degree of focus of the GP on listening during the act of communication.The respondents were patients who visited their GPs during the period.The results were processed with Microsoft Office Excel 2007.Quantitative analysis was performed with SPSS 17.0.

RESULTS:
In the survey we conducted in the Pleven region, special emphasis was given to the questions related to the patient's satisfaction with the activities of their GPs.
Data from Fig. 1 show that patient satisfaction was low in terms of time spent talking to patients: 481 (46%) of respondents were dissatisfied.This is an extremely unfavorable level of specific patient satisfaction.Patients' views on the opportunity to share their concerns and whether they were listened to are summarised in Fig. 2. Regarding the extent of focused listening by the doctor, respondents gave a negative response in half of the cases -481 (46%).This reveals the poor communication culture and skills of the GPs, though these skills are important not only in professional ethics but also in organizational aspects.

Fig. 2. Degree of focused listening to the doctor about the patient's problems
The physician's ability to listen to a patient is an important step in their communication and is mostly a qualitative component of this interaction.A quantitative expression of listening is the time spent while talking with each patient.The survey demonstrated (Figure 3) a significantly high level of dissatisfaction among the patients: 470 (45%).
Because a modern patient has a higher level of culture and higher expectations, the problem of the GP's communication skills becomes particularly important.
In this regard, the data in Fig. 4 is noteworthy, showing that the approach of a coordinated opinion and informed consent of the patient is rarely used in the activities of the GP.Positive answers regarding this approach were rarely seen.The answers showed it did not occur (32%) or was rarely seen (30.2%), i.e., the phenomenon of a partnership between the doctor and the patient did not exist.

Fig. 4. Agreed opinion with the patient and his/her informed consent
In summary, the data indicated wide and fundamental gaps in the doctor-patient relationship and communication.

DISCUSSION:
In doctor-patient communication, it is crucial for a doctor to provide enough time for a discussion with a patient, to listen carefully, to discuss upcoming tests and procedures, and to understand the patient's attitudes and expectations by establishing trust and a good relationship.Patients want to be assured that they are taken good care of in the outpatient practice.They expect to see warmth and friendliness in their physicians.A GP's communication skills should be recognized and acknowledged as a prior-ity in his or her professional evaluation.This depends on three major factors.
Doctor-patient communication directly depends on the organization of a GP's activities.Safe organizational conditions should be there to provide enough time for effective communication between doctor and patient, careful listening and history taking, and clear instructions regarding medications and treatment regimens, etc. [9, 10,11,12].Poor organization and lack of a nurse in GP offices lead to many gaps in doctor-patient communication and are reasons for patients to change their choice of GPs.Some authors believe that for good communication the general practitioners should understands the emotions and worries of the patient, shows willingness to answer the patient's questions, avoids all other activities during the communication, checks the patient's, understands for the given explanations, uses words and expressions according to the cultural and educational levels of the patient, ect.According to others the mistakes that doctors make when listening include poor eye contact with the patient (wandering gaze, gaze directed at other objects), incorrect position of the doctor's body (not facing the patient, too close to the patient, etc.), disturbed attention (telephone conversations, performing written work unrelated to the patient, etc.); neglectful or ironic facial expression and rude interruption with inadequate intonation, among others [10,11].
Explaining is part of the communicative technique to convey information from the doctor to the patient.Overlooking it very often compromises the whole examination, leading to a second visit or seeking medical help from another doctor.In addition, the explanation must be comprehensible to the patient [13,14,15].
Today, patients have a considerably higher general and medical awareness, hence their higher expectations and claims for medical care, placing new and higher re-sponsibilities on physicians to provide effective physician-patient partnerships, based on mutual respect and trust.The patient's expectations of primary care are based on good communication and the provision of adequate health care [16,17,18].
Patients' expectations in primary healthcare imply good communication and adequate healthcare.The lack of understanding of the patient's needs and lack of skills to properly communicate with patients may result in dissatisfaction with the visit for both physician and patient.Patients need to be sure that they are taken good care of and expect to see responsiveness, friendliness, and empathy in their physicians in resolving their health problems [17,18].
Communication skills play a primary preventive and curative role.These skills determine the degree of trust patients have in physicians and medicine in general.Low degrees of trust encourage self-medication and seeking help from self-proclaimed healers.It is therefore imperative that communication skills are regulated as a mandatory element in the professional assessment and licensing of primary care physicians [9,10].

CONCLUSION:
GP -patient communication is an issue in general medical practice.It is a factor and a criterion of the quality of the medical care provided.
Literature data, as well as our empirical study, indicate the existence of many unresolved communication problems.
The need for more comprehensive training of medical staff in communication skills is evident.With this in mind, important tasks lie ahead for undergraduate and postgraduate training of primary health care providers.GPs could further improve their communication skills by paying more attention to psychosocial examination, the structure of consultation, and patient-centered communication.

Fig. 1 .Fig. 3 .
Fig. 1.Evaluation of the time spent talking with the patient