An observational and descriptive study was carried out in four provinces of Andalusia (Almeria, Granada, Huelva and Jaen), in February 2011 and May 2012.

The target population was family physicians of Andalusia; qualified preceptors and resident 4th year physicians.

The sample size needed was calculated for an accuracy of 1.5 points with an standard deviation of 7.2 in the final score of the CICAA survey12 (level of reliability 95%). Using the Epidat computer programme, the necessary number of physicians was 89, increased by 20% due to possible losses (107 in total). 119 professionals participated voluntarily, carrying out 436 valid videorecordings.

The main dependent variable was the score obtained in the CICAA survey13 (following the instructions of the user manual),14 which measures communication and establishes the interviewer's communication profile. It is composed of 29 items structured as a Likert-type scale with three grades: 0 points (unability to carry out the scheduled tasks), 1 point (ability to carry out the scheduled tasks sufficiently) and 2 points (ability to completely or almost completely carry out all the scheduled tasks). The items are grouped into tasks:

• •

  Task 1. Communicate well with the patient/family (items 1–6)

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  Task 2. Identify and understand the patient's/family's healthcare problems (items 7–20)

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  Tasks 3 and 4. Reach an agreement with the patient/family surrounding the problem/s, possible solutions and actions, and help the patient/family to understand and decide how to deal with the issues (items 21–29).

The total score was calculated along with the successful or non successful completion of each item. It was considered non successful when the item scored 0.

Independent variables included; personal and professional characteristics of physicians (age, gender, marital status and health centre), characteristics of their patients (rural or urban environment, population was higher or lower than 10,000, number of assigned patients, number of assigned patients over 65 years of age, patient load and time dedicated to each patient) and characteristics of single consultations (patient's gender, accompanied by someone, type of problem, first visit and number of reasons they had/motives for needing a medical consultation).

The time allowed for the interview was divided into intervals; exploratory phase (from the beginning of the interview until the physical examination), time spent on the physical examination and resolution phase (from the end of the physical examination until the end of the interview).

The physicians recorded themselves independently during their standard working day. The main researcher selected randomly 4 video recordings of each professional (excluding their first consultation and bureaucratic or internal consultations), which were subsequently analysed by two people alien to the research and trained in the use and management of videorecordings using the CICAA survey.14

The research protocol was approved by the Scientific Research Ethics Committee of Jaen Hospital. Informed consent from healthcare professionals and patients was obtained through written or verbal means as demonstrated in the videorecordings. The confidentiality of the information was guaranteed.

Descriptive and bivariate analysis were carried out, using Chi-square test, Student's t-test and ANOVA.

Characteristics associated with an improved level of communication were identified with a multiple linear regression analysis, with the total score on the scale as dependent variable. The variables were selected in two models, one backwards and other forwards, with p values of entry and exit of 0.05 and 0.1 respectively. A saturated model was built with the variables included in both models, and a heuristic approach was applied to retain in the final model those variables which changed the coefficient of the main explicative variable (type of professional) in more than 10%.

The intra-observer agreement was verified through the analysis of 40 video recordings with a 2 month interval using an Intraclass Correlation Coefficient. Their values were 0.89 (IC95%: 0.79–0.94) for the first observer and 0.91 (IC95%: 0.84–0.95) for the second one. The inter-observer agreement was 0.94 (IC95%: 0.89–0.96).

The statistical analysis was carried out using the SPSS (15.0) programme. The significance level was established in p≤0.05.

The average physician studied excelled in welcoming the patient, bringing the consultation to an appropriate close and employing a good use of non-verbal language. This could have a positive effect on the patient's willingness to divulge information, helping the interview to progress.5 Similar results were obtained by Ruiz-Moral et al.6 in medical hospitals, although they found that 3rd year resident physicians tried very little to welcome the patient, missing potential opportunities that could have been explored.

As other authors have noted,6 empathy is scarcely expressed (60%). There is also indication of a decline in empathy from the university.16,17 Distress, due to physicians being away from their families, working night shifts and unsociable hours, could explain why resident physicians are less empathetic than preceptors.16 In relation to gender, we have not found differences, which other studies have confirmed.17

Non-verbal language is more evident in resident physicians, female physicians, urban centres and in some Teaching Units. Differences in gender between professionals has been previously aforementioned and described.18 It has been proved that the use of these skills helps to increase the patient's ability to understand and cope with his/her illness,19 as well as being understanding when medical errors occur, which helps to preserve and maintain the physician–patient relationship.20

Excluding our study, in which 90% of cases were successful, bringing the interview to an appropriate close is still one of the main difficulties, along with the verification of information, clarity in the action plan or taking precautions.5,21

Active listening skills, a suitable level of reactivity, facilitating dialogue with the patient, understanding and answering their questions and ascertaining their expectations of the consultation are among the strengths demonstrated by the physicians in this task of the interview. However, near a third of the professionals asked open questions, with resident physicians obtaining particularly low scores in this task.

Likewise, they do not attempt to explore the emotional state of the patient, his/her state of mind or family situation. Asking about accidents, stressful life events or potential risk/preventative factors was rare. Nevertheless female professionals were more likely to ask these kind of questions than their male colleages.4,6,21 Unfortunately, professionals rarely summarised information obtained from the patient.

Without considerably increasing the amount of time dedicated to each consultation (30–50s), open questions can help to evaluate the patient's agenda,22 to actively involve him/her, and to obtain more answers and information; which in turn have an effect on the satisfaction of the patient,23 improving the physician–patient relationship and their quality of life.22 Whereas a high level of reactivity and closed questions, inhibits the interview from developing adequately because of interruptions and additional questions.5

The final part of the interview, which consists of informing the patient of the process and the stage that is to follow, verifying that they have understood and obtaining compromises surrounding the action plan are all carried out in 80% of cases. Combined with the fact that in all cases patients were allowed to express their doubts, this could lead us towards consultations based around the patient. However, decision-making is scarcely shared (55%), and cases in which negotiation is required rarely exceed 50%, thus it is clearly an approach in which the doctor is the focal point.

Despite the change in style of consultations that has occurred in the last few years, shared decision-making during consultations is rare,6,7 indeed many patients believe that the physician should make decisions for them, despite the fact that they would like the physician to include them in the process.7 In general, women, young people, those with greater socio-economic means and education, and those with mild illnesses, prefer a method which is centred around the patient, with decision-making being shared.22,23

The scores obtained from our study are higher than the scores found by Gavilán Moral et al.12 (21.4 and 12.8), possibly because of the patients and physicians, considering also that the physicians of family medicine include hospital physicians, who seem to have a larger focus on the physician.6

Being a preceptor can result in a better level of communication with the patient. This could possibly be due to better interview training for preceptors,4 since age4,24 (reversed in this study) and experience8,9,25 do not necessarily guarantee better communication skills.

However, the differences are not relevant as they only scored 2 points out of 58. In fact, other studies have noted that the communication skills of 4th year resident physicians and of preceptors are similar.8,24 Also a longer consultation, as other authors have noted4,24 results in an improved level of communication. It has also been proved that there is a link between the length of consultations and a better understanding, above all psychosocial from the patient.26 Longer consultations are also linked to consultation styles centred more around the patient,7,22,23 although there still could be an improvement in communication skills without having to necessarily increase the duration of the consultation.9,24

In our study we have not noted any differences in results between the gender of the professionals, however there are occasions in which female professionals allowed the consultation to go on for two minutes longer.18

According to the results aforementioned, Andalusian family physicians excel in terms of creating a friendly and trusting environment, possessing good listening skills and providing the patient with information. Skills to improve include; empathy, asking open questions, exploring the psychosocial sphere of the patient, summarising information and carrying out shared decision-making. Generally speaking, no differences were found between gender or age of the professional nor type of health centre. However, being a preceptor, dedicating more time to each consultation and being younger, are all factors which are associated with a higher level of communication with the patient.

To improve medical practice it is necessary to establish and maintain a good communicative profile and complement it with a practice which is centred more around the patient. To do this, it will be necessary to reassess the postgraduate and specialisation education and training plans, which will put a greater emphasis on the importance of focusing more on the expectations and worries of the patient.

Once again it has been demonstrated that dedicating an adequate amount of time to each consultation is one of the key factors in the physician–patient relationship.

It would be wise to incorporate the patient's personal perceptions, as well as the point of view of the professionals for future research that may help to better define this relationship.