DISCUSSION

It has been established in recent times that the roles and responsibilities of clinicians and patients are shifting, and patients must assume greater responsibility for their own health through primary prevention. (1) This is one of the major conclusions reached in the report of the United States Preventive Services Task Force (USPSTF). However, for clinicians to empower the latter to take charge of their own health, and at the same time better serve patient needs, a good understanding of social problems that could negatively color the clinical presentation of illnesses and diseases should always be at hand. In this study, such social problems have been brought to the lime light for all to see. The personal aspects of primary care also include the important area of self care. Most symptoms are self-evaluated and self-treated without the help of health professionals (2) and a vital function of primary care is to increase self-care competence so that patients can become active partners in health care. By providing information, answering questions, and helping patients find other resources for help, primary care clinicians can foster knowledgeable and confident self care.
On issues relating to psychosocial problems, doctor-patient decisional conflict is a factor that should be considered. It is influenced by inadequate knowledge, unclear values, inadequate support, and the perception that an ineffective decision has been made. Until recently, it has been studied at the individual level, which ignores the interpersonal system between patients and physicians.(3) With this study considering social problems under the domains of the patients' factors and the physicians' factors, the interpersonal dynamics are duly considered.

In this environment, patients are more likely to conceal any social problem that they are undergoing, mainly because of cultural unacceptability of disclosure to unfamiliar persons. In a UK study by Maginin et al (4), ethnicity did not independently predict detection of psychosocial problems, but it was observed that Black Africans were less likely to say that they would talk to their General Practitioner (GP) about psychological problems. It may however be that generally, Black Africans in the UK with psychological problems are less likely to attend their GP as compared with their Caribbean and English counterparts, and as such less willing to speak to them about these problems when they do attend the GP's clinic.

Patient satisfaction with GP care in general is largely determined by their perceptions of the GP-patient relationship and GPs' interpersonal skills. Patients often report that they feel unable to discuss personal problems, (5) discouraged from asking questions, (6) and that their opinions are undervalued or disregarded. Many also report receiving inadequate information (4) and complain about structural limitations such as lack of time in the consultation. The two aspects of doctor-patient communication which were significantly associated with feeling helped were: 'Doctor tells me all I want to know about my illness' and 'Doctor gives me a chance to say what is really on my mind'. Both factors reflect care which is oriented to patient concerns. In the light of the above, this study result provides support for importance a patient-centred approach to care (6).

Workplace conditions are a major determinant of physician well-being. Poor practice conditions can result in poor outcomes, which can erode quality of care and prove costly to the physician and health care organization .Our study revealed that physician's mental and physical stress constitute perceived problems that can influence patient care in over half of the respondents (54%).

Fortunately, these conditions are manageable. Organizational settings that are both "physician friendly" and "family friendly" seem to result in greater wellness for all (7).

In the baseline survey of Women's Health in Australia (WHA), there was a relatively high degree of satisfaction with referral, counseling and relaxation advice amongst those who received these treatments. In contrast, 20% of women who received a prescription or were listened to by their physicians found these treatments unhelpful. Thematic analysis highlighted three main concerns for women, namely structural limitations of the GP-patient consultation, GPs' limited interpersonal skills and GPs' limited interest, knowledge and skills in mental health(8).

Patients' agendas are complex and multifarious. Only few patients voice out all their agenda in consultations. Agenda items most commonly voiced are symptoms and requests for diagnoses and prescriptions. The most common unvoiced agenda items are: worries about possible diagnosis and what the future holds, patients' ideas about what is wrong, side effects', not wanting a prescription and information relating to social context. Agenda items that were not raised in the consultation often led to specific problem outcomes (for example, major misunderstandings), unwanted prescriptions, non-use of prescriptions, and non-adherence to treatment. In all of the 18 consultations with social problem outcomes, at least one of the problems was related to an unvoiced agenda item.

Decision making and participation are concerned with the collaboration between professional and patient. These two stakeholders in the consultation process are required to develop a list of options, from which the most suitable is chosen. (9) Engaging patients effectively in that process avoids the problems of disempowerment and 'personal identity threat' that underlie patients' dissatisfaction with health care.

As many as 90 million Americans have difficulty understanding and acting on health information. This health literacy epidemic is increasingly recognized as a problem that influences health care quality and cost. Yet many physicians do not recognize the problem or lack the skills and confidence to approach the subject with patients. (10) Further research is required to identify effective interventions that will strengthen the skills and coping strategies of both patients and providers and also prevent and limit poor reading and numeracy ability in the next generation.

CONCLUSION

The study revealed that in this environment, perceived social problems of both doctors and patients do significantly influence choice of management in 9 out of every 10 doctors in their consultations and clinical management. Doctors with more than 10 years clinical experience were less likely to be influenced by mental and physical stress. Also, more male doctors perceived loneliness as a consultation -interfering social problem as against female doctors.

Limitations: Patients' opinion of how their own perceived social problems could influence doctor's decision making was not put into cognizance.

REFERENCES

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