Patient’s perception of the communication of clinical doctors and surgeons in a university hospital

Introduction: The way information is transmitted is of crucial importance in the doctor-patient relationship, as good communication reduces complaints about inadequate practices and patient concerns and improves treatment adherence and health recovery. However, patient dissatisfaction on this subject is not unusual. Objectives: The objective of this work was to evaluate the perception of patients admitted to a Hospital Complex about the communication of clinical doctors and surgeons during the hospitalization period. Method: Cross-sectional, descriptive, analytical inquiry study, with the application of a questionnaire with questions about physicians’ general communication. The instrument was built by the researchers and was answered by 120 adult patients. The sample was defined by convenience and stratified by medical and surgical clinic. Frequency and statistical analyses were performed on the obtained results. Results: Of 120 patients, 53.33%(n=64) were admitted to the Surgical Clinic and 46.67%(n=56) to the Medical Clinic. Of this total, 57.5%(n=69) had high school to college/university education. Patients reported more negative than positive responses to the following questions: information about the side effects of medications (66%), advice on post-surgical procedures (68.75%) and information on health promotion and prevention in the hospital environment (63.33%). The surgical clinic had significantly lower proportions of positive responses for: The doctor said their name (p <0.01; crude OR: 0.33; 95% CI 0.15-0.76); The patient was informed about how their treatment would be conducted (p=0.02; crude OR: 0.38; 95% CI 0.17-0.87); and the patient was informed about the need to undergo tests (p=0.02; crude OR 0.40; 95% CI 0.18-0.90), which remained significant after adjustment for certain confounding factors. There were no significant differences regarding the other questions. When analyzing the question: “What grade would you give to the doctor’s general communication?” a significantly higher value (p=0.007) was given to the Medical Clinic (average 4.46±0.76) when compared to the Surgical Clinic (average 4±1.19). Conclusion: The doctor-patient communication showed significant deficits. Therefore, it is necessary for medical schools to offer students the development of this competence. Additionally, for an adequate generalization of the obtained results, new studies need to be carried out at different levels of medical care.


INTRODUCTION
The Curricular Guidelines for Undergraduate Health Courses in Brazil aim to build an academic and professional profile of doctors with skills that fit the approach of the Brazilian Unified Health System (SUS, Sistema Único de Saúde). Therefore, the professional must be able to perform their activities with quality, efficiency and problem-solving capacity 1 . In this context, the physician's language must be accessible to patients, coworkers and family members, through adequate communication with each group. The way information is transmitted is essential for the doctor-patient relationship, as good communication reduces complaints about inadequate practices and patient concerns, improves adherence to treatments and improves health recovery, both physical and mental 2 .
Also, in the world scenario, the ability to communicate with the patient is essential, being part of mandatory programs for residents in the United States, such as in the US Medical Licensing Examination 3 .
However, patient dissatisfaction regarding their communication with medical professionals is not unusual. Patients complain about the use of overly technical and poorly understood medical jargon, the inability to receive enough information to draw conclusions from the clinical condition, the cold attitude shown by the medical professional about the patient's situation, among others, which are reasons that can lead to complaints in medical councils and lawsuits 4 .
In this sense, a study by Loge (1996) observed that the way information was transmitted limited the understanding of health issues in 497 patients with breast cancer. Just as a Cochrane review concluded that many people, upon receiving a diagnosis of their pathology, have difficulty remembering the information provided to them during the consultation 5,6 , a meta-analysis showed that medical communication has a positive impact for greater patient adherence to treatment 7 .
Therefore, identifying the characteristics of communication, especially in hospitalized patients, is essential to strengthen the importance of the topic to members of this professional environment.
Objective: To evaluate patients' perception of the communication with clinical doctors and surgeons during the hospitalization period, specifically: 1. professional's introduction: knowledge of their name and specialty; 2. clarification on diagnoses, exams, therapy, evolution and conduct; 3. application of the Informed Consent form; 4. information on therapeutic and diagnostic actions during hospitalization; 5. surgical patients: information related to preoperative (such as anesthesia and medications) and postoperative care (such as side effects and personal care); 6. advice on preventive and health-promoting measures in the hospital environment; 7. general quality of medical communication. This was a cross-sectional, descriptive, analytical and  inquiry study, with the application of a questionnaire built by

Sample
The sample was defined by convenience, stratified by medical and surgical clinic, with an expected total of 120 patients to be interviewed. There was no sample calculation.
The patients were invited to participate in the study when the interviewer entered random rooms and explained verbally about the project. It was decided not to approach visibly severe patients, who were under sedative medications and had an altered level of consciousness. This assessment was carried out quickly, through questions about the patient's orientation, both auto-and alopsychically.
Patients hospitalized for at least two days at the Medical Clinic and Surgical Clinic, regardless of the specialty, were interviewed and signed the Free and Informed Consent Form (ICF). Patients must be 18 years of age or older and have the mental and emotional capacity to participate.
Patients under 18 years, those who did not have the mental capacity to respond, those who did not provide true information about their overall condition and sociodemographic data, those who had been admitted to the hospital for less than two days and those who were not interested in participating in the study were excluded. The patients' medical records were not analyzed.

Questionnaire
The questionnaire was built for the present study with interval questions, according to the Likert scale, and

Variables and Categories
The collected sociodemographic data were divided

Data Collection Procedure
The questionnaire was applied according to the following steps: the researcher explained about the research, awaiting confirmation of the interviewee's participation, read the questionnaire and asked each patient to sign the Free and Informed Consent Form, who gave their opinion about each question, in addition to informing on sociodemographic data.
The answers were recorded in writing by the researcher, after verbally asking the questions to the patient, to prevent missing data. Data collection took place from March to November/2018, at the patient's bedside.

Data Analysis Procedure
The collected data were tabulated in an Excel spreadsheet and hypothesis tests -Chi-square, from the STATA 16.0 programwere performed, followed by assessment of the significance of the raised hypotheses 11 .
An analysis of the distribution of absolute and relative frequencies of the assessed variables was carried out, in addition to Association tests (chi2) between the questionnaire/ sociodemographic answers with the specialty.
Univariate and multivariate logistic regression was performed using the Odds Ratio and respective 95% Confidence Intervals. In addition, adjustments were made for potential confounding variables. Student's t test was performed for the score assigned to the doctor's general communication.
A sensitivity analysis was indirectly performed by adjusting for variables associated with the patient's perception of medical communication, which are shown in Table 2.    Abbreviations: 1=location 2=age 3=ethnicity 4=level of schooling 5=hospital length of stay. Source: Research data. Table 3. Description of answers to specific questions applied to patients at the Surgical Clinic (N = 64).

Question YES/NO
Have you been informed about the type of anesthesia and medications? 25/39 Have you been informed about the risks and benefits of undergoing the surgery? 24/40 Have you been you informed about special care of the surgical wound and post-surgical hygiene issues? 27/37 Have you been informed about the side effects of the procedures? 44/20 Source: Research data. A meta-analysis on the impact of medical communication on the health care process concluded that better informed patients show better treatment adherence, understand their pathology better and are more involved in the decision-making process, with an increase of more than 19% in adherence to therapeutic proposals 7 .

Medical professional introduction
Regarding the medical professional introduction, informing their name and specialty, although most patients reported that the doctor gave the patient their name, the hypothesis test found a statistically significant association between the lack of information about the health professional's name and specialty and the area of expertise (p <0.01). Similarly, Ruberton et al. (2015) and Schaller (2008) demonstrated an association between the quality of medical communication and patient satisfaction with the received care.
Doctors defined as being less arrogant obtained better scores, according to patient satisfaction 15,25 .

Free and Informed Consent Form
The application of the Free and Informed Consent Form by medical professionals, although verbal, did not take place for almost half of the interviewed patients, but there is a tendency of non-application by the different medical specialties.
In a study conducted at Hospital Universitário,

Limitations
When assessing the presence of a selection bias, it was observed that there was a significant difference only in the distribution of intervening variables between medical and surgical clinic for the gender (p = 0.04).
Positively, the questionnaire was pre-tested with 15 patients, to eliminate possible confounding questions, despite the fact that no validation procedure was performed (analysis of the construct and of the discriminating power).
Two points that could possibly generate bias was the lack of data recording of patients who refused to participate in the research and the fact that the applied questionnaire was dichotomous, which may have limited the definition of the hospital sample at that time and a more accurate analysis of the patients' opinion, respectively. However, it was necessary for the questionnaire to have yes/no answers to almost all questions to facilitate the application, as it is more practical and less timeconsuming, which was a stimulus for the patient to participate in the study. Additionally, it prevented greater doubts about which answer to give, as it does not have several options to choose from.
Regarding the type of specialty, some patients had difficulty defining which would be the best option, since they received treatment from a varied team, undergoing both clinical and surgical procedures. In these cases, the patient was asked to evaluate the doctor with whom they had the longest contact to evaluate medical communication.

Sensitivity analysis
To annul the differences observed in the questions - interviewers' impression is that the sample was homogeneous between the participants and non-participants, since they were patients at the same age group as most of the study patients, using the same health system, attended by the same medical team and undergoing procedures similar to the other patients' .

Generalization
CHS is a university hospital, with highly qualified medical professionals (teachers, preceptors and assistants), in addition to residents and interns, with a strong presence in the services.
It is also a teaching hospital for other health professions.
However, despite being a teaching hospital, it is also a public hospital, which restricts its possibilities when compared to high-complexity private hospitals. This can have a stronger impact on procedures that are highly dependent on these resources, such as the Surgical Clinic.
Since the data collection field is a hospital with more complex cases and already screened by the Health Services Offering Regulation Center (CROSS, Central de Regulação de Ofertas de Serviços de Saúde) or Mobile Emergency Care Service (SAMU, Serviço de Atendimento Móvel de Urgência) systems, the obtained data may not be generalizable to all levels of health and do not represent the population of the region, since the CHS is a referral hospital for certain specialties, and not all of them.
When assessing the level of complexity of the treatments offered at CHS, studies indicate that the majority of health team professionals are uncomfortable and unprepared for the moment when they must talk to the patient when dealing with severe and life-threatening diseases 27,28 . Moreover, it is necessary to consider the individual tolerance capacity of each person when relaying bad news, both in relation to the diagnosis, prognosis and cure, as well as therapeutics 29 .
Therefore, for an adequate generalization of the obtained results, new studies need to be carried out at different levels of medical care, aiming to assess the patients' perception of medical communication, which can have a more comprehensive view of the interviewed groups, sample size and elimination of possible biases.

CONCLUSION
Considering the relevance of the assessed subject and the deficits still present in medical communication, it is essential to address the issue with professionals in the health area, especially during undergraduate school, emphasizing the importance of communication, aiming at developing a good relationship between doctor and patient and its impact factor on the individual's quality of life during hospitalization.
Therefore, it is necessary to invest in interventions aimed at developing communication skills in medical education.