Our results showed that some patients and their families faced an unexpected type of interaction. Forms of interaction were unacceptable to them, which led to their disappointment. The main reason for their disappointment was a weakness in the DPI. They believed that the DPI was unacceptable due to the doctor’s position. They felt that doctors should consider patients feelings and problems, interact appropriately, exhibit punctuality, and be responsible. They wanted the doctor to communicate better with the patients and give them a progress report. Some doctors not only ignored these obligations but also suppressed the patients and their families. Therefore, patients were faced with uncertainty with the DPI. In this scenario, they were cautiously worried about future interactions with the doctor during his/her upcoming visits.
The unexpected interaction refers to ignoring patients’ rights. Even though patients know what is acceptable in a DPI, they seem powerless to claim this right. In this situation, patients can officially file a complaint, but it rarely happens. They often believe that if they complain and the doctor finds out, he/she may stop or reject their treatment. In this condition, having a good doctor with a good DPI is a random chance that it merely depends on a doctor’s personality. The unexpected interaction included four themes:
unequal, unprofessional, instrumental, and non-cooperative. 4.1. Unequal
In an unequal interaction, one side of the interaction is lower than the other. In this type of interaction, doctors are in a dominant position. This situation allows them to determine all processes of the interaction, including how the interaction should start, continue, and finish. Therefore, patients and their relatives do not have any opportunity in the interaction. Their only opportunity to interact is to carry out the orders given by the physician.
Due to the educational structure, interactions were merely between physicians and medical students. Hence, this form of interaction is very common on SFMs daily rounds. Patients and their relatives have many questions concerning their illness, but there is no clear response from SFMs. Even when they present their questions, the SFM’s reply is often inadequate and sometime ambiguous, which creates real crises for the people involved. Hence, because of the asymmetrical power relationship, their questions are ignored by physicians. In contrast, it seems that SFMs do not visit patients every day and sometimes not for more than a week. In this situation, patients complain to the on-duty supervisor or hospital manager, but they do not complain to the doctor directly, which illustrates the asymmetrical power interaction. Since an unequal power interaction is defined as a norm in the context of this study, even medical students allow themselves to have bad interactions with patients.
4.1.2. Specific Observation
Mahin is a 22-year-old female who had an appendectomy two days ago. She has a newborn child and breastfeeds. This morning, she was told that she was going to be discharged from hospital. However, the resident surgeon did not visit her until 8 p.m. Her husband asked the nurse in charge to follow-up on the problem, but when the doctor became aware, he ignored the patient and did not visit her at all. He told the nurse, “The patient cannot be discharged. If she wants to go, she should complete the release sheet. Then she is allowed to go.” Since the patient’s perception was that she would be released but she was instead kept in the hospital for an unknown reason, the problem was forwarded to the supervisor in charge. When the resident did not provide an adequate reply, the issue was referred to the SFM by the supervisor to resolve the issue. The SFM called the resident, and the resident convinced the SFM that the patient should not be discharged clinically. However, the patient was forced to leave the hospital against medical advice with her own consent.
4.1.3. Meaning Unit 1
The patient does not dare to speak with his/her doctor because he/she is powerless. The patient is afraid to complain because the doctor may stop the treatment treat him/her badly. Thus, the patient does not allow himself/herself to complain in the presence of the doctor. Here, the doctor-patient relationship is like a master-servant relationship. The issue is not being afraid of the master. It is worse; it seems that the servant does not know his/her rights and does not allow himself/herself to even talk. Patients here are not aware of their rights (the patient’s son has a renal problem).
4.1.4. Meaning Unit 2
The doctor-patient relationship in our country is a one-way street, and doctors do whatever they want.
Horizon Analysis; Possible Validity Claims of the Quality of DPI Titled Unequal
Claims Possible subjective claims Quite foregrounded, quite immediate The doctor orders and the patient should comply. The patient does not complain. Less foregrounded, less immediate The patient is a passive party. High foregrounded, high immediate Unequal interaction Possible objective validity Quite foregrounded, quite immediate The patient is afraid to complain to the doctor. The doctor does whatever he/she wants. Less foregrounded, less immediate Master-servant interaction Possible normative claims Less foregrounded, less immediate Doctor should consider patients’ rights. Less foregrounded, less immediate Unequal interaction is not appropriate.
As shown in Box 1, the doctor-patient interaction is completely unequal. In this situation, the patient cannot do anything even when he/she feels that he/she is being ignored. The doctor can easily reject the patient and does not feel any responsibility towards his/her professional obligation.
Unprofessional interaction refers to the passive interaction that takes place between doctors and patients in the same way that a medical student has inadequate information about the patients’ past medical history. In this situation, the patient feels that the doctor does not have proper information about him/her. Thus, the patient thinks his/her health is not important to the doctor. When a doctor does not have comprehensive information about the disease, how can he/she provide appropriate treatment? This type of unprofessional interaction is a one-dimensional approach to diagnosis and treatment. For example, when a surgeon student merely focuses on the surgical problems of a patient and ignores all other aspects.
The visits and consultations were conducted unprofessionally and were weak. The medical students obtained superficial information from the patients, and the SMFs solely relied on their reports. Specifically, during admission, the medical students focused on the part of the body that required treatment. For example, when a patient is admitted to the surgical ward, the doctor’s history-taking only focused on his/her surgical problem. In this situation, other organs are ignored, particularly in patients with multiple problems. The issue becomes even more complicated when SFMs depend solely on this form of evaluation and treatment, as in consultation No. 87, a patient with cardiovascular problems (
DPI in Clinical Daily Visit No. 87
Participants Statements SFM Does he not have bradycardia? Resident No, professor, he even had tachycardia. SFM Has he been out of bed? Resident Yes, professor. SFM When was this electrocardiogram taken? Resident It was taken last night. I saw it, and there was nothing. He is in good condition, and his lab report does not show any problems. Nurse Can he be discharged? SFM It is unsafe until we know for sure. Resident Only with your permission because he has been consuming Keflin for a long time. I have stopped the order.(Finish) Time of consultation 1:15 minutes
This consultation session revealed that the SFM and his resident did not have any conversation with the patient. Due to this unequal interaction, the patient did not have any opportunity to present his problem. Thus, only one organ was examined and treated, and the other organs were ignored. This method can lead to medical errors and malpractice as well as patient dissatisfaction.
4.2.2. Specific Observer Comment
Ali is a 25-year-old male who was admitted due to a renal stone diagnosis and was discharged from the urology ward after a few days because the lab data and ultrasound were normal. The patient was readmitted to an internal medicine ward due to general weakness with sepsis. He was afflicted with renal failure required dialysis.
4.2.3. Meaning Unit 1
Doctors admitted him with a renal stone problem. On his discharge sheet, they wrote that he did not have any problems. However, his problem was not related to renal stones. Now he needs surgery for the insertion of a double lumen. Who should I complain to? (The patient’s brother).
4.2.4. Specific Observer Comment 2
Hamid is a 32-year-old male who has been living with inflammatory bowel disease (IBD) and underwent a colostomy. He was referred to the hospital for an abscess. He expected that his surgeon would be an SFM, but the SFM forwarded the case to one of his residents. In the operating room, the resident asked Hamid, “Do you have a colostomy?”
4.2.5. Meaning Unit 2
“Why are you going to operate on me when you do not even know whether I have a colostomy or not? I have already told my doctor everything.”
Horizon Analysis: Possible Validity Claims of the Quality of DPI Titled Unprofessionalism
Claims Possible subjective claims Quite foregrounded, quite immediate The doctor does not spend time with the patient. The doctor does not obtain a sufficient past history. Less foregrounded, less immediate The patient was readmitted due to the doctor’s error. Possible objective validity Quite foregrounded, quite immediate His problem was not renal calculi. Just before the surgery, the resident asked Hamid “Do you have a colostomy?” Less foregrounded, less immediate To whom should I complain? Possible normative claims Less foregrounded, less immediate Doctors must also consider the patient’s past history. Less foregrounded, less immediate An unprofessional interaction is not right.
As Box 2 shows, patients and their families criticized the unprofessional interaction. An important point was that they understood the doctor had provided unprofessional care, which decreased their trust. This mistrust should be a warning sign for doctors. Due to the unequal power distribution, patients prefer not to complain.
Instrumental interaction refers to a form of interaction in which the doctor does not have any verbal or non-verbal communication with the patient. In this case, the doctor does not introduce himself/herself to the patient and does not participate in any dialogue with the patient; a physical examination is rarely performed. In this condition the base of diagnosis and treatment is based on paraclinical data. For example, if a patient is referred for abdominal pain, a complete blood count (CBC) and abdominal ultrasound should be ordered. Thus, this instrumental interaction generally refers to passive relationship between doctor and patient which only relays on the patients’ paraclinical data and not the physical exam or past history of illness.
It is a routine behavior for the doctor not to introduce him/herself to a patient. Daily visits involve conversations between SFMs and their medical students and residents about the pathology and treatment (Box 1). The diagnosis and treatment were carried out using paraclinical data, such as magnetic resonance imaging (MRI), computed tomography (CT), laboratory data, and radiographs. The diagnosis and treatment were performed with the least possible amount of human interaction between the doctor and the patient. Thus, the patient thinks that his treatment is extremely mechanical.
4.3.2. Meaning Unit 1
“The problem in this hospital is that rounds are done, but no one introduces him/herself to the patient. They do not even say, ‘I’m your doctor.’ Rounds are done, and all the patients’ problems were tended to, but there was no interaction that allowed the patients to understand what is being done for them.” (Maryam, a patient with a cardiac problem).
4.3.3. Meaning Unit 2
In the past three days, Dr. Fayez has visited our neighboring patient three times, but he did not introduce himself, and he did not communicate with the patient. He comes, reads a series of reports, gives a series of commands, and then leaves. Maybe the patient has a pain that needs to be reported? (The sister of a patient with a surgical problem).
4.3.4 Meaning Unit 3
“He comes and takes a look at the machine and then leaves. I mean, Dr. Farshad is not a doctor; he is an engineer, a mechanical engineer!”
Horizon Analysis: Possible Validity Claims of the Quality of DPI Titled Instrumental
Claims Possible subjective claims Quite foregrounded, quite immediate The doctor does not have a dialogue with the patient. There is no introduction by the doctor. The doctor does not do a physical exam. Less foregrounded, less immediate Only the doctor is physically present. The doctor relies on paraclinical data. Possible objective validity Quite foregrounded, quite immediate He did not introduce himself and did not communicate with the patient. He is not a doctor! He is an engineer, a mechanical engineer! Possible normative claims Less foregrounded, less immediate Doctors must have a dialogue with patients. Doctors must examine the patient. Less foregrounded, less immediate Instrumental interaction alone is not right.
As the horizon analysis shows, the doctor-patient interaction is carried in an instrumental and mechanical fashion. The doctor only reads some reports, such as vital signs or paraclinical data, and uses these documents to prescribe an order. Most patients expect doctors to interact with them like normal human beings, not a device.
Another feature of unexpected interaction is non-cooperativeness, where a doctor or medical team makes a decision without the participation of the patient. This type of interaction can increase the possibility of medical errors. Additionally, in a non-cooperative interaction, the patient does not know what will happen to him/her; the patient is in limbo. Therefore, patients have a clear right to know the process of his/her treatment.
Doctors do not communicate with the patient. They do not provide adequate information for their patients. Sometimes, if the patient has a question, they reply with short answers. It is a rare thing for a doctor to suggest various types of treatments to the patient or ask his/her opinion. In this situation, the patient is puzzled.
4.4.2. Meaning Unit 1
Doctors do not give us the right to participate in the treatment at all. We do not have any right to participate. I’m upset because I do not know what is going to happen to me. The doctor does not want us to present our opinion about our own treatment at all. (Zahra, a patient with a surgical problem).
4.4.3. Meaning Unit 2
If we have a question during the course of the disease, they do not provide a clear answer. For example, I asked my doctor what he was going to do. He just replied, ‘I have to wait for fifteen weeks, then I will think of something.’ I am completely confused!” (Maryam, who has multiple sclerosis and a surgical problem).
Horizon Analysis: Possible Validity Claims of the Quality of DPI Titled Non-Cooperative
Claims Possible subjective claims Quite foregrounded, quite immediate The doctor does not consider the patient’s opinion. Treatment is one way. Less foregrounded, less immediate The patient does not have any role. Possible objective validity Quite foregrounded, quite immediate The doctors do not give us the right to participate in the treatment at all. They do not provide an obvious answer. Possible normative claims Less foregrounded, less immediate Doctors must consider the patient’s opinion. The doctors should consult with their patients. Less foregrounded, less immediate Cooperative treatment is a right.
As the horizon analysis showed, the authoritarian model of interaction leads to patient dissatisfaction. They were upset about this type of interaction.