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Analyzing the Medical and Non-medical aspects of Medical Consultation in the city of Visakhapatnam
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Supriti Agarwal , Sonia Singh

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April/May 2015 - Volume 13 Issue 3
Analyzing the Medical and Non-medical aspects of Medical Consultation in the city of Visakhapatnam

Supriti Agarwal
Sonia Singh

(1) Dr Supriti Agarwal, Assistant Professor,
Amity University, Noida, India
(2) Dr. Sonia Singh, Assistant Professor
Al Dar University College
Dubai, United Arab Emirates

Dr Supriti Agarwal
Assistant Professor,
Amity University, Noida, India
Zip- 201313


The Indian healthcare industry has the potential to reach $ 280 billion by 2020 (KPMG Report) reflecting a compounded growth of 17-18%. Indian health care is witnessing a huge change in the form of disease profile. Currently, 34% of death is happening due to infectious disease and 53% of death is due to lifestyle diseases. In spite of the technological advancement in medical sciences, diseases are engulfing human life. It creates a perplexed situation. The patient enters a medical practitioners' chamber with a high hope at the appointed time, but this consultation session is both a meaningful or superficial interaction. It is indeed a situation of dilemma
This case highlights the dilemma that exists in the medical practitioner's chamber related to patient interaction. Basically, consultation session in the medical practitioners' chamber varies from one patient to another. There are various reasons for this variation. Maybe the patient is a first timer or the patient is accompanied by an attendant or the presence of a pharmaceutical manager in medical practitioner's chamber is creating the difference. It can be also due to change in disease profile (infectious or lifestyle related). The public sector is keenly participating in the treatment of communicable diseases and the private sector is trying for lifestyle related diseases.

This case study is an observational study conducted at Visakhapatnam (port city in Andhra Pradesh). Visakhapatnam has been a centre of pharmaceutical companies from the last one decade. Three specialties (Cardiologist, diabetologist and Oncologist) were selected. Different situations were recorded and analyzed in these consulting sessions through observational schedule. Results indicated there are many reasons for the uniqueness. It can be used as training materials to the medical representatives as they get to know what exactly is happening in the chamber and helps them in preparing for their meeting with the doctors.

Key words: Medical consultation session, Doctor-patient interaction, Pharmaceutical marketing strategies, medical practitioners.


The patient
I had taken two hour break from my office for routine sugar check up. Although my reports were ok, still I am little bit worried. Two days back I lost my colleague, who was only 34 year old. He was also diabetic and succumbed to fatal heart attack. I started to enquire about the extent of diabetes from my fellow patients. Some were very hopeful and some were depressed. I was really very much in a dilemma. What is my future? This question had perturbed me so much, that I started viewing my watch. Now, this waiting time was troubling me a lot. Just then the receptionist called my name. Finally, I entered the doctor's clinic…….I showed him my reports. Doctor congratulated me for my good control on sugar level and enquired about exercise schedule. I assured him about the regularity of exercise schedule. He listened and started writing prescriptions. I thought I should ask about a few more doubts, but his speed of writing the prescription was a clear cut signal that my time is up. Or perhaps I'll ask next time.

The doctor
I'm a leading Endocrinologist consulting in a leading hospital… yet another busy day. It's 12.00 pm. Seventh patient comes in, clearly upset and angry, as he was waiting for more than one hour after his appointment time. I am aware they book multiple patients at the same time, but what can I do about that? Anyway, I felt sorry for him but really can't do much, as consultation time will be over by 1.00 pm and nine more patients are in the queue. I started enquiring about his sugar level and gave a few general instructions in a hurry. He didn't get himself diagnosed as he required a few tests; therefore I didn't change any medicine and asked him to visit me again with the test reports. The patient seemed to be in gloomy state which made me think that he wouldn't comply with my instructions. I tried to make him cheerful at the end , but it was in vain.

Epilogue: This was a typical situation happening during medical consultation. Nobody wants to fall ill, but, still one had to visit a doctor's clinic. Thankfully, nowadays a doctor's consultation chambers infuse a feel good factor in the patient's mind. Still! Illness had a negative impact on both the physical and mental status of the patient. Certainly, modern lifestyles have resulted in a variety of ailments. A recent report of WHO highlighted that lifestyle diseases accounted for 5.2 million (50.5%) of the 10.3 million deaths in India (2005) compared to 35 million (60.3%) of 58 million deaths worldwide. By 2050, people over 60 years will increase from 76.6 million (7.4% of total population in 2001) to 300 million (17% of the population). A great amount of money is being spent on medicine marketing by pharmaceutical companies in various ways, but they have not assessed the potential of the medical consultation. A study by world bank economist Jishnu (Hindustan times) found that in India, average consultation time per patient both at government and private hospitals was 5.3 minutes and the rate of correct diagnosis was just 21.8 %.

Generally, pharmaceutical marketing expenditure is incurred on analyzing and understanding the prescribing behaviour of medical practitioners only, but if they start analyzing the quality of doctor- patient interaction during medical consultation, it will definitely add more value in pharmaceutical interaction with medical fraternity.

The case: This case study is based on the medical consultation belonging to three types of chronic ailments, i.e. (Diabetes, Cardio-vascular disease and Cancer) conducted at Visakhapatnam, a port city in Andhra Pradesh. Visakhapatnam has a 5 million Telugu speaking population displaying a cosmopolitan nature. Visakhapatnam has many hospitals ranging from the King George Hospital to multi specialty hospitals like Care hospitals, Apollo hospital, etc. These hospitals are catering to the demand of diseases ranging from the smallest flu to the biggest death causing infections.

The study is qualitative in nature. Observation method was adopted for collecting data. Consultation observation tool was prepared. Questions were based on medical as well as nonmedical (psychosocial) perspectives of medical consultation. This study was carried out in the 7 hospitals at Vishakhapatnam city. The consultation observation tool was filled in by doctors. An observer was present in the medical consultation session for noting down the details of the medical consultation session.

There are various numbers of consultation models in existence, but most influential model is the Calgary-Cambridge approach. This model identifies five main stages (Figure 1) in the medical consultation session.

Figure 1: Calgary-Cambridge Approach


This framework provides structure and emphasizes the importance of building a good doctor- patient relationship. It is patient-centred and emphasizes effective communication and gives the direction for recording information from the consultation session. But it gives little consideration for the social, psychological and behavioural dimensions of illness. In order to understand the process of medical consultation, the consultation session can be real or simulated. They can be observed or recorded in a number of ways, such as:

1. An observer 'sits in' on real consultation session.
2. An observer may watch through a one-way glass so that they are not physically present in the consultation.
3. Consultations can be recorded and analyzed by using appropriate rules and guidelines.
4. Consultations can be described and discussed after the consultation by doctors, doctor and patient or more widely with others.
5. Mock consultations can be planned with participants playing the role of doctor or patient.

This case study is developed through the first method (presence of observer in the real consultation session) and revolving around the stages mentioned in the Calgary-Cambridge model.


Lifestyle diseases such as diabetes and hypertension are commonly found associated with rural and tribal areas of Vishakhapatnam. The findings are the result of a six-month pilot study on non-communicable diseases (NCDs) being undertaken by the Public Health Foundation of India (PHFI) in collaboration with the Union health ministry's directorate of NCD and Nature NGO. The main causes of these diseases are changes in lifestyle and diet pattern, besides genetic predisposition and weak immunity system.

This case study analyzes the nuances of the consultation session. The table below depicts a summary of the patient details which have been used for analyzing the medical consultation session.

Table 1: Patient Details

This case study is developed for three types of patients, i.e. those suffering from lifestyle diseases such as Diabetes, Cardio-vascular problems and Cancer. Observations derived through the medical consultation sessions for 7 different patients are illustrated as follows:

Ramakrishna agony of Cancer…..

Ramakrishna, 38, works as a drawing teacher in a local private school for the past 10 years. One morning, he observed some unwanted growth on his throat which was very disturbing. On his meeting with the doctor, it was confirmed that it is an unwanted growth which has to be removed by chemotherapy. Chemotherapy cycles were planned and everything was going well. On his completion of the 4th cycle out of 6 cycles, Ramakrishna came to visit the doctor to give a report of his health condition. Ramakrishna was escorted by his wife who stood supportive all through the treatment. The doctor started the conversation and asked about the well being of Ramakrishna for which the response was good.

Ramakrishna came up with several doubts regarding the necessity of PET scan. The doctor explained the relevance of the scan as it supports the normal CT (Computer tomography). Hence it helps in understanding the condition of the patient better. Ramakrishna also complained about the insomnia he is suffering from for which the doctor prescribed some sedatives that will help the patient to have a sound sleep. Ramakrishna was completely relieved of the tension and greeted the doctor while leaving the chamber.

This case indicates that consultation session (15 minutes) was not only filled with the biomedical (technical) investigations, but filled with the real sharing of the patient's concern and fear (psychosocial session). This doctor-patient communication process has been widely researched in the context of medical teaching and training in many studies conducted by Kurtz et al (1998) & Silverman et al (2005).

Now, another case is about a low profile village farmer, who is shocked at hearing about his diagnosis of cancer.

Ramana was shocked………
Ramana, 36, is a farmer who lives in a village, 150 km away from the city, and leads a common life. Ramana suddenly started facing some problems in the stomach which made him feel sick. Ramana came to know that he was suffering from advanced rectum tumour which he earlier believed was some sort of stomach problem. Treatment included radiation therapy which had to be completed in 6 cycles. The 1st cycle was successful and he arrived to be admitted to hospital for the 2nd cycle to commence. Ramana was completely preoccupied with the tensions regarding his family, children and work.

The doctor grasped the situation of Ramana and greeted him in a comforting manner. He made the patient comfortable in the chamber by enquiring about his family condition, financial status and about the consequences of the first chemotherapy cycle. Ramana gave one word answers all the time. The doctor also checked the reports and previous prescriptions which helped him to get an idea of the treatment and the stage which he needed to continue. Ramana was examined physically for about a minute. "The second cycle will start from tomorrow and the whole process will be completed within 3 months. You should be prepared to get admitted to the hospital and you have to stay for the entire period of chemotherapy" remarked the doctor. "Yes" is the answer from Ramana. Meanwhile, Ramana also pointed towards his wife who had accompanied him with all the requirements for his 3 months. The doctor asked the nurse to take care.

Here the session lasted only for ten minutes and covered the biomedical aspect as the doctor tried his level best in reducing the shock level of Ramana. Then, patient became stronger in accepting the mode of treatment. This aspect was similarly seen in the study of Maguire P et al 1996, as they established key tasks of the consultation while conducting research into doctor-patient communications. It includes patients' problems and concerns, giving information, discussing treatment options and unconditional support of the medical fraternity. Studies (Balint M; 1964) reveal that doctor make patients feel better when they listen to the patients attentively. Another study by Jenkins et al (2001) found that 87% of hospitalized cancer patients interviewed desired all the information about their disease, good and bad, and 98% preferred to know whether or not their illness was cancer. Numerous studies have also examined the relationship between cancer pain and various forms of psychological distress, including mood disturbance, anxiety, depression, emotional distress, fear, and worry (Francis et al. 2004).

Now-a-days, diabetes is also becoming a major problem and is considered as the 'long-term sickness' in people over the age of 50 years (Waddell & Aylward 2005). Globally 366 million people are suffering from diabetes as per 2011 statistics. By 2030 it is expected to double. While China is leading in diabetic population with about 97 million, India is second only to China with about 77 million diabetic patients, said Dr. Saxena, Chief advisor, Kareus Therapeutics, SA, during a symposium at DRILS in Hyderabad Central University. Next observation is of a government worker, who has been suffering from diabetes for the last four years.

Bujji appearing for routine check-up for Diabetes ……….
Bujji, 36, works in the government sector, and has been suffering from diabetes for the past four years. He only consulted a general physician for the treatment. The doctor examined the previous prescriptions and reports "There is nothing much to worry about regarding the diabetes in your case, as the sugar levels are under good control and you only have to take precautions in terms of diet and lifestyle" he continued ."Get your sugar level's checked and show me the reports after 3 months", replied the doctor. A sympathetic gesture of the doctor brought a smile to Bujji's face.

This 8 minute consultation session highlighted the psychosocial aspects. Here observation is displaying strong emotional bond between doctor and patient. It was seen here that the doctor tries to teach Bujji the basics of self-management for diabetes. Definitely these self-management sessions had strengthened the doctor and patient relationship over time. This case justified the study of Mishler 1984 that came up with a disease centred model where the doctors talk in terms of medicine only. Their main aim and objective depends on the explanation of physical symptoms to the patient and thus the doctor listens to the 'voice of the patient', and encourages the patient's active involvement in the consultation. Thus, a positive reply from the patient drafts a positive impact on health care and status (Esterling B et al 1990).

Another case is of Prasad, who thought that his eye infection was due to his diabetes. But the medical consultation unfolded a different story.

Prasad is confused by the eye infection………..

A case of Doctor-patient exchanging information

M.S.N Prasad, male, aged 49 works as a conductor in a government corporation arrived to the clinic. Doctor greeted the patient with a smile and Prasad occupied the seat in front of the table. The session started with formal greetings from both of them as they knew each other, belonging to the same department. And the conversation begins.

Prasad: "Doctor, I have infection in my eyes and they are hurting a lot."

Doctor: "Let me observe your eyes first."

After a keen observation into the cornea, doctor came up with some questions, "Did you eat anything which is not in your regular diet?"

Prasad: "Doctor, I had mangoes which literally started irritation in my eyes. Can eating mangoes affect a person?"

Doctor: "See, it's not like that. It depends on various reasons. Did you have this problem before or did it show after you had this diet?"

Patient was a little confused at this answer. Immediately the doctor came up with some more questions. "Do you smoke?"

Prasad: "Yes" was the answer after some seconds of silence.

Doctor: "Anybody in your family suffered from blood sugar or any hereditary disease?"

Prasad: "Yes doctor. My mother has a diabetic history and she has been treated for the past ten years. Is this blood sugar doctor?" asked the patient with some state of tension in his mind.

Doctor: "No, I can't come to a conclusion right now. I have to perform some basic tests. I am prescribing some medicines which will reduce irritation and also some tests to be performed" and continued "Please meet me next time with all your reports"

Prasad: "Yes doctor, I will be quitting smoking as soon as possible".

Doctor: "Remember, it's better to quit smoking, it will certainly help you a lot" the doctor ended the consultation session.

In this consultation, it was observed that doctor was very much pleased to hear the positive reply from the Prasad and therefore session ended with the positive note. This medical consultation session covered purely biomedical aspects.

Psychological stress in the workplace is generally regarded by the public as an important cause of coronary heart disease. While epidemiological studies have amply demonstrated a strong, consistent relation between coronary disease and cigarette smoking, high blood cholesterol, hypertension, diabetes, and family history (Kannel et al.1976; Kannel et al 1986). In India, three out of every 1,000 people suffer a stroke. The number of deaths due to heart attack was projected as 1.2 million to two million in 2010. Studies (Ford et al 1997) found that doctor feel that satisfied patients follow the treatments more religiously.

Now analyzing the medical consultation session for patients suffering from cardiovascular problem, the first patient is V.Saikanth, who is trying to figure out the cause of chest pain in his consultation with the doctor.

Saikanth presented due to severe pain in chest……………

V Saikanth, 44, is from a middle class family and he suffered some unbearable pain that rose from his chest and made him to fall tothe ground. Hence Saikanth visited a specialist doctor as recommended by his friends.

Saikanth was escorted by his wife. The doctor examined Saikanth by making him to perform some breathing patterns. The doctor also examined the pulse, blood pressure and the patterns of heart beats. The doctor started explaining the case, "There is nothing to worry much. Your reports show that you are fit and fine. The main problem is there is a blockage in your blood vessel which resulted in unbearable pain. The solution for this problem is to insert stents which will clear the blockage. Stents are in the shape of small tubes which free the blood vessels from blockages and help in the free flow of blood. The operation can be scheduled in the next week once all matters are settled".

Saikanth replied, "Yes doctor! I will be ready with the arrangements as soon as possible". "Don't worry!! Everything will be fine" assured the doctor which made the patient feel comfortable and walk out from the consultation chamber with a cool mind.

This session highlighted both perspectives (psychosocial & biomedical) of the consultation session and lasted up to 13-15 minutes. Hence the medical practitioner was trying to make the patient feel satisfied and comfortable in the entire session. If the outlook of the medical practitioner provides a credible self help approach to the patient, definitely the medical consultation session will necessary move from a 'disease model' to a 'bio psychosocial model' (Waddell & Aylward 2010). Further Maguire & Pitceathly (2002) also emphasized that the usage of more open ended questions should be adopted in dealing with psychosocial and complex emotional issues and then only will patients be more involved in the session.

The last case is of Mrs. Ramani. She is trying hard to manage high blood pressure and increased level of cholesterol.

Although Mrs Ramani is vigilant about her illness, still, there is a long way to go…………….

Mrs. Ramani, 50, is a school teacher. She had increased level of cholesterol and elevated blood pressure for which medications have been prescribed. For the past few weeks, she has been suffering from aches and pains in the legs which is disturbing her dailyroutine. She enters the chamber with her son as an escort.

"How are you Mrs. Ramani? Is everything going fine?" questioned the doctor.

"Doctor, I am fine but, I had severe ache and pains in my legs for the last few weeks. I am a school teacher; therefore, I have to stand throughout the day. This is not new to me but pain has started suddenly and is disturbing my entire work schedule"
replied the patient.

"Do you have anything new in your diet?
" asked the doctor.

"Yes, I have started taking fresh grapefruit juice that makes me energetic and improves my energy levels also, so that I can get on with my work perfectly"
replied the patient.

"Yes, this is the main reason for your aches and pains in the legs. Grapefruit juice is contraindicated to the medications which you are taking. The main side effect is myopathy or muscular weakness and it is the main reason for your pain" explained the doctor patiently.

"So, Should I stop grapefruit juice doctor? Is there anything more I have to modify in my diet?"
asked the patient.

"Yes, of course! Stop having grapefruit juice; I am also prescribing some new medications which will relieve you from pain or muscular weakness. Next time, please consult me before trying anything new in the diet" replied the doctor.


Medical consultation is indeed a very important phenomenon, as it initiates the rapport between doctor and patients. Medical consultation is not only about doctor-patient relationship but it also includes doctor and pharmaceutical representative relationship. Thus, these skills are of great benefit to doctors, patients and pharmaceutical representatives, as they are a direct or indirect link to consultation phenomenon.


According to Pendleton (1984), consultation is 'the central act of medicine' which 'deserves to be understood.' It is focal to the transaction between doctors and patients and plays a crucial role in the relationship between doctors and patients (Smith R 2003). It influences the precision of diagnosis and treatment, and studies have indicated that over 80% of diagnoses in general medical clinics are based on the medical history. There are three main aspects of medical consultation session. They are: Preparation, Establishing initial rapport, and Identifying the problems and concern.

Click here for Picture 1: Consultation Session

Preparation: In preparing for a consultation, an optimal setting is required. It includes the setting of consultation room and waiting lounge. It should be neat and tidy. Time management is a very important aspect in medical consultation session, as it not only includes quality of the consultation session but also waiting time.

Establishing initial rapport: During the consultation session, it is essential to develop a comfortable bonding between doctor and patient. Generally the doctor sees at least 10 -15 patients in their consultation hour, therefore it becomes pertinent for the medical practitioners to understand the patient's history and illness. Only then does the real diagnosis happen.

Identification of problems and concern: Once the patient finishes the discussion of symptoms, he/she wants to know the mode of treatment. If the session has gone well, then it leads to successful identification of the illness and the treatment regime will be considered by the patient.

Thus, more recent approaches to medical consultation is not just assessment of medical anomaly but also assessing non-medical (psychosocial) issues along with the history of illness (See Diagram-1). Broadly, a medical consultation session should cover two aspects, i.e. Medical (Biomedical aspects) and Non-medical (Psychosocial aspects). Medical aspects include the pathophysiology of disease that is assessed through symptoms of the disease, analyzing the diagnostic report and the history of illness. Non-medical aspects include the true emotional trauma of patients behind their illness. Basically, a good consultation should follow a set schedule which starts with the formal interaction and goes into the depth of concern areas. Gask and Usherwood identified three major features of the consultation. They are as follows

(a) Style with which a doctor listens to a patient will influence what they say.
(b) Effective communication between doctor and patient leads to improved outcome for many common diseases.
(c) Patients' compliance will be improved if the management plan has been negotiated jointly.

Once these features are met in the consultation session, only then are they effective and fruitful. Many-a-times, doctors often fail in covering all these tasks. They cannot get the correct information regarding the patient's agony and this effects quality of consultation. They do not check how well the patient has opened up with their problems and thereby rapport cannot be established. Henceforth, doctors should be competent in maintaining fruitful interaction with patients.

It is estimated that a doctor might perform 200,000 medical consultations in his/her lifetime but the success of the medical consultation depends on the doctor's clinical knowledge, interview skills and doctor-patient relationship. A study by Roter and colleagues (1998) concluded that those physicians who are trained in non-verbal communication skills, ask more open-ended questions, and use greater emotional talk and are more likely to receive greater personal- and disease-related information from their patients. It leads to more satisfied patients and their chances to follow the treatment prescribed more strenuously (Ford, Bach, and Fottler 1997; Parente, Pinto, and Barber 2005; Zandbeh et al. 2007).

Consultation time also plays a crucial role in assessing the quality of medical consultation session. Generally, medical consultations last about 6 minutes, although this can vary from about 2 minutes to over 20 minutes. This time pressure results in tightly controlled doctor-centred (or 'paternalistic') consultation with less attention paid to the social and psychological aspects of a patient's illness. Therefore, less psychological problems are identified and more prescriptions are issued (Howie et al 1992). Average consultation time was found to be 8 minutes in a UK study. Other studies conducted by Ridsdale and his colleagues (1992) conclude that the time available for consultations was increased to 10 minutes. Patients' satisfaction would have increased by improving the way time is spent within the consultation (Ogden J 2004). Satisfaction can be infused only when the doctor increases the time of consultation and explains the patient's concerns clearly (Tuckett et al 1985).

Another qualitative study by Barry et al (2000) that was based on 35 patients (18 years plus) and 20 general practitioner consultants, found that only four of 35 patients voiced their concerns during the consultation. Again this data also puts a serious question mark on the psycho-social perspective of the consultation session. Thus, it becomes imperative to analyze the nitty-gritty of consultation session. How it can be done effectively? Are the consultation sessions really covering the biomedical as well as psychosocial perspective also? Can it be used in training medical representatives for making their interaction with doctors more fruitful? Maybe the findings can bring some fruitful changes in the consultation session. This case study is an attempt to address these intriguing situations.

As shown in the study done by Fottler et al (2011) some patients also believe or feel that hospitals and health care systems go so far as to regard them as guests as stated. Another study conducted by Agnieszka (2012) also stated that permanent improvement in quality of health care can be enhanced through interpersonal communication and it simultaneously shapes the attitudes and behaviours of health (medical) staff as well as consumers of health services (patients).

Epilogue: These cases of medical consultation tried to unravel the role of doctors. These can also be used as training materials for medical representatives as they get to know what exactly is happening in the chamber and helps them in preparing themselves for their meeting with the doctors. All these different observationa derived from medical consultation sessions resulted in an amazing perspective:

Medical consultations are really meeting the criteria of fruitful interaction level or they are only depictions of routine doctor-patient interaction.

Doctors are really practising the non-medical (behavioural/ psychosocial pattern) as well as medical (biomedical) perspectives of medical consultation or are busy in calculating the number of patients.

Doctors effectively utilize the time span of whole medical consultation session or they are simply keeping track of the number of patients who have visited them.

Patient involvement in the medical consultation session is required especially when the disease falls into the category of life style diseases such as Cancer, Diabetes, Cardiac diseases.

Patient's outlook is to be a treatment seeker or is an active participant in the treatment schedule.

This case study dealt with all the phases mentioned in the Calgary-Cambridge model and also analyzed the biomedical (medical) and psychosocial (non-medical) aspects of medical consultation sessions but a few issues are not covered. Details of clinical assessment and safety netting (ability of the doctor to consider good or bad outcome of the consultation and be ready with plan 'B') are the issues that have to be explored more in future studies.


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