Physicians’ Code of Conduct and Further Requirements for a Productive Patient Physician Relationship Exemplified in the Area of Orthognathic Surgery

The precise amount of information and appropriate kind of communication is known to be one of the most important factors for patients in treatment in order to maintain a positive outcome [1]. Characteristically, only patients can determine the adequateness of information and communication. Physicians need to tell them “everything” in order to prevent unexpected encounters. On the other hand, physicians should not go into unnecessary detail in order to prevent them to panic. Finally, physicians should have the ability to take patients’ positions and find the right word and tone (sensible, warm, but not schoolmasterly or patronizing). Physicians find it often challenging to do justice to the individual patients need due to time restrictions and the time requirement in hospitals. Especially patients who are confronted with a drastic surgery are reliant on a sensitive and well-elaborated treatment. Orthognathic surgery is e.g. one kind of a very intensive and radically treatment. Patients with jaw modulation often suffer from functional problems such as chewing or swallowing. Additionally, psychological side effects such as emotional instability or low-self esteem because of “abnormal” appearance are very common and portray just a few of associated psychological difficulties [2, 3]. The main purpose of orthognathic surgery is finally to correct these functional and aesthetic problems due to underlying jaw deformities. However, psychological consequences of such a surgery and its treatment tend to be neglected. The result of an aesthetic improvement does not always correspond with the patients´ self-concept [4]. To integrate one’s facial appearance into the individual self-concept requires a well elaborated support. Therefore, the main research purpose and question is with what kind of expectation patients enter the treatment, how far they deal with such a decisive medical treatment, how they inform themselves and experience the process. Besides, in order to improve the common physician-patient relationship and way of communication, the question occurs in which way physician should act with their patient. The study will represent a potentially code of conduct for physicians. Furthermore, a first approach of possible app content guidelines as a further electronic support service for improving the physician patient communication will be described.

1.1 Clinical Picture

A malocclusion (jaw modulation) is an incorrect relation between the teeth of the two dental arches when they approach to each other. The term “bad bite” is also in common use. People with this deformity are often not able to close their mouth properly due to the misalignment of teeth. The misalignment may be due to the misplacement of some teeth or to an abnormality of the position of the jaws. This physical appearance may imply functional and social consequences [5]. Ability to eat or to speak may be affected as well as comorbid disorders such as headache may appear. Furthermore, social side effects such as dissatisfaction with the facial appearance lead to a lower self-esteem and may affect people’s life from childhood to adulthood.

1.2 Medical Treatment

Orthognathic surgery is recommended for people who suffer from severe functional problems such as not being able to chew properly among others. The malocclusion is restructured by cutting the specific bone and repositioning the bone segments thus the upper and the lower jaw match with each other again. This intervention requires a long recovery period of at least 6 months. Common problems after surgery which might appear are numbness of the upper or lower lip or other risks such as infection, swelling or muscle spasm among others. Besides, psychological consequences also belong to problems after surgery. The change of the familiar facial appearance often causes adaption disorders or a general negative psychological well-being [6–8]. In a first consultation with the physician possible treatment procedures are discussed. Once the patient has agreed on a surgery, X-ray images and plaster models are manufactured. With the help of plaster models, the patient receives medical education by the physician. The physician explains the exact procedure, describes all possible risks and answers all questions which remain on the patient side. The patient will stay at hospital at least 7 days. After 10 days, 1 month, 3 months and 6 months follow-up cares are offered. After 6 months a second surgery is done to remove the metal brace.

1.3 Psychological Requirements and Communication

The communication and relationship between patient and physician can be seen as the main component in medical care. This topic has been popular over decades in research. The phenomenon has been divided into distinct aspects by different authors, such as the (1) different purposes of medical communication, (2) the analysis of physician-patient communication, (3) the specific communicative behaviors displayed during consultations and (4) the influence of communicative behaviors on certain patient outcomes [9, 10]. It has also been reported that the specific phyiscians behavior has an influence on certain patient outcomes, namely: satisfaction, compliance/adherence to treatment, recall and understanding of information and health status/psychiatric morbidity. Moreover, the physician-patient relationship has been shifted from a predominantly physician-dominant, one-sided relationship to a proactive one from both sides. This is mainly attributed to the amount of information available to patients via the Internet. Nowadays, a patient-centered approach is practised and describes a new alliance between physician and patient, based on a co-operation rather than a confrontation [11]. Taking this theoretical research findings into account the physician´s challenge in this patient-centered model is “(…) to bridge the gap between the world of medicine and the personal experiences and needs of his patients” [11]. Even though, theoretically this model is comprehensible, the reality often lacks of the implementation of these findings in the daily practical work. Correcting a jaw modulation involves further changes in the face, such as the position of the nose, cheeks, etc. which might imply a kind of identity change. The face, as being one of the most complex part of the body, reflects the individuality and social identity [12]. Therefore, this intervention has to be handled with sensitivity and with a good psychological support in order to support patients in an optimal way. Physicians challenge is to find the right balance between explaining risks and in the same way not to scare patients but still deliver the adequate dose of necessary information. Further more, explanation with the help of the plaster model are hard to understand which also cause uncertainty of comprehension among patients.

1.4 Requirements for Electronic Support

The usage of smartphone applications –so called apps- is nowadays very common. Among the huge range of app purposes, the number of healthcare apps is growing [13]. The area of use is diverse. Mosa et al. [14] stated in their review of healthcare applications areas, such as e.g. disease diagnosis, drug reference, medical calculators, clinical communication. Communication between patient and physician via an application is still rarely common in daily medical work. However, the benefits of integrating smartphones into the practice of medicine and one’s personal life are numerous [15]. Since the main focus of this study is placed on patient and physician communication and how it can be improved, the application approach also considers this fact. Therefore, a possible app solution in the area of patient-physician communication should support and not hinder aspects of the face-to-face dialogue between patient and physician. It could support the information process on both sides. For physicians, information about patients such as character traits could be provided. Patients would answer specific questions prior the medical education. On the other hand, patients could e.g. use the app to keep a pain diary. Physicians would be able to intervene directly in case of emergency. More over, the app could easily be used when the patient is already at home. Occurring questions dealing with the recovery e.g. could be directly leaded to the physician. Besides, the app could offer a patient network that provides the possibility for patients to exchange experience, support, encourage and advise other affected patients. Finally, general information material as well as FAQ’s could be included.

1.5 Question Addressed and Logic of Procedure

The study aims to explore the individually experienced process of treatment of each patient as well as to sense the patient´s needs. Since every patient has its own way of handling such a decisive experience, first insights into the patients’ way of dealing with it are collected. Thus, four main research questions are guiding the study: (1) What are the expectations (cognitive and affective) regarding consequences of surgery? (2) How far and in what ways do patient inform themselves and which attitudes do they recommend a physician to be?, (3) What kind of impact has the surgery on quality of life?, (4) How far does the patient´s mood change due to the surgery?

In order to understand the individual experience of such a decisive intervention, a longitudinal study design over a time period of 6 months was chosen. The study accompanied patients while they were going through treatment. Thus, it was possible to collect data at each important state of treatment. In order to conduct the study as economically as possible for patients as well as physicians, the questionnaire method was selected. Patients who were going to receive surgery participated and assessed on five different periods of time the treatment; one day before surgery, 10 days after, 1 month after, 3 and 6 months after surgery. Therefore, five different questionnaires were designed, collecting qualitative and quantitative data (Fig. 1).

Structural figure of current longitudinal study design

Full size image

2.1 Survey Structure

The survey contains five questionnaires, one for each period of time. In order to compare questionnaires individually for each patient and still provide anonymity, patients had to create an individual code which they had to provide for each investigation.

Demographic data. The questionnaire before surgery measured demographical data such as gender, age, educational level as well as the reason for undergoing surgery.

Information type. Participants were asked to state their source of information seeking for the upcoming surgery. Multiple replies were possible (Internet, research literature, etc.). During the treatment patients were again asked where they inform themselves with three items which had to be answered on a 6-point-likert scale.

Advice to physician. Participants were asked to give advice to physician by finishing following sentences: (1) “The physician should be…” (2) “It would be helpful for treatment, if.…” (3) “For future patient it would be helpful,…” (4) “The physician should avoid…” Multiple replies were possible.

Affective and cognitive expectations. Before surgery, patients were requested to describe their positive and negative expectations of the intervention. The question was stated in an open way. Multiple answers were permitted.

Quality of life. To assess the level of life satisfaction, the standardized questionnaire by Fahrenberg et al. [16] was included in the questionnaire at two times of the investigation: before surgery and 6 months after surgery. This instrument measures the following areas of life satisfaction: health, job and profession, finances, leisure, spouse/partner, friends and relatives, and home. All of the items were formulated as followed: “How satisfied are you with your (health, etc.)?” and had to be rated from 1 (very dissatisfied) to 5 (very satisfied). High scores indicate high satisfaction with the areas of life.

Emotional condition. The adjective mood scale, developed by Zerssen [17], represents 24 bipolar item meanings such as e.g. happy versus unhappy, irritated versus calm, etc.. Patients are requested to select the most appropriate alternative or if they can not decide the “neither nor” alternative. The emotional condition was assessed before, 10 days after, 1 month and 3 months after surgery.

2.2 Procedure

In the beginning of each treatment, the patient was informed about the study and its purpose. The participation of the study was optional. Most of the patient undergoing surgery, decided to take part into the study. To each period of time (one day before surgery, 10 days after, 1 month after, 3 months and 6 months after) patients were asked to fill out the questionnaire via a tablet or computer.

2.3 Sample

Data was collected from patients undergoing orthognathic surgery at the RWTH clinic, Aachen University. Participants were invited to participate in the study via the attending physician. Completion of the questionnaire took approximately 30–40 min. 22 patients fulfilled the study from its beginning to its end. The mean age of the participants was M = 24.95 years (SD = 9.89, 17–48 range years). 19 participants were female and 3 were male. The profession of patients compasses a wide range of activities (student, employees, free-lancer, etc.). Asked for the reason of surgery, the most mentioned was the functional one (58 %; problems when chewing), followed by reasons of pain (25 %; jaw pain, headache) and recommendation by ambulant physician (17 %).

Results were analysed by frequencies, qualitative data analysis by Mayring [18] and with non-parametric tests due to the small sample size. Friedman test was calculated.

Cognitive and affective expectations. Patients stated various hopes and worries. Multiple responses were possible by each patient with an open stated question. Answers were differentiated by cognitive (beliefs and thoughts towards surgery) and affective (feelings and emotional reaction towards surgery) meanings following the guidelines of the qualitative data analysis by Mayring. Cognitive hopes were described as “general improvement of appearance”, such as the improvement of the face and smile (11 namings) and “general functional improvement” such as jaw position, speech and less pain (22 namings). Affective hopes were described with the category “process of treatment” (17 namings).

Patients stated hopes such as to recover totally, to have no complication and pain during treatment, receiving a socially accepted appearance as well as hoping to have a lifelong solution. Worries were divided into “worsening of appearance” as the cognitive component with 10 namings (e.g. worry about functional decline). As affective worries, two categories were developed: “complication in recovery process” (19 namings e.g. pain during recovery, restriction in life, inflammation during recovery, etc.) and “negative consequences of surgery” (22 namings; e.g. neural damage, numbness, other remaining pain, weightloss, death, no recognition because of facial change) (see Fig. 2).

Reported expectations (affectiv worries and hopes; cognitive worries and hopes). Multiple responses possible (∑ = 101 responses; N = 22).

Full size image

Information. Asked about where patients inform themselves about surgery and treatment over 55 % stated to receive their information from the Internet, followed with 36 % by questioning the attending physician. 32 % also stated to ask other experienced patients (multiple replies were possible). During the process of treatment patients were asked where they inform themselves when having questions. On a 6-point rating scale from 1 = I do not agree at all to 6 = I agree at all, patients rated to ask the attending physician over the whole period of time rather the nurse staff, other patients or even the Internet (see Fig. 3 left).

Information source during treatment (response scale from 1 = do not agree at all – 6 = do agree at all).

Full size image

Advice to physician. Since the physicians’ behaviour has a main influence on certain patient outcomes such as satisfaction among others, patients were asked to give advice to physician regarding four different aspects: physicians’ character, helpful information for treatment, advice for future patients, information which should not be mentioned. Multiple replies were possible on the open question. Figure 4 (left) protrays the results on the physicians’ character. Being “friendly” (12 namings), followed by “being open-minded” (8 namings) and being “honest” (6 namings) seem to be the most important character traits, a physician should have. The outstanding advice regarding behaviour a physician should avoid, were the “usage of medical language” (10 namings) as well as fearing the patient (4 namings) among others (see Fig. 4 right).

Reported advice; left multiple responses possible (∑ = 44 responses; N = 22); right multiple responses possible (∑ = 23 responses; N = 22).

Full size image

Regarding the question what would be helpful for treatment, the most important advice were (Fig. 5): “receive detailed information” (5 namings), “have attention” (4 namings) and “to show models which portray the future face” (4 namings).

Reported advice; multiple responses possible (∑ = 44 responses; N = 22)

Full size image

Asked about what current patients would wish for future patients, the following aspects were mentioned (multiple answers were possible): “Future patients should have their questions and concerns discussed in detail” (7 namings), “(…) should be patient” (3 namings), “(…) should meet a competent physician” (2 namings), and as one time mentions “(…) should see a better visualisation model of future face”, “(…) should have courage” and “(…) should meet a physician who explains comprehensible”.

Quality of life. An overall mean score was computed with all the items before surgery and a second one 6 months after surgery. The overall mean value before surgery was M = 3.4 and SD = 0.7 on an answering scale of 5 points max. A similiar responsiveness was found 6 months after surgery with M = 3.65 and SD = 0.6. No statistically significant difference could be found from the first assessment before surgery and the last after 6 months.

Emotional condition. The emotional condition was assessed at four different periods of time (before, 10 days after, 1 month after and 3 months after). The positive attribute of the bipolar word pair carried the higher value 3, the negative 1 and neither nor the value 2. Considering the overall mean values before, 10 days, 1 month and 3 month after surgery a slight but non significant deviation of response behaviour can be registered (pre M = 2.3, SD = 0.3; post 10 days M = 2.4, SD = 0.4; post 1 month M = 2.3, SD = 0.6; post 3 months M = 2.3, SD = 0.5).

Figure 6 shows the assessment of each word pair to each time of investigation. Taking a general look at the figure, the assessment of attributes is rated throughout positively. However, a few deviations are noticeable during the course of time. Before surgery patients feel rather “tired” and “hesitant” in comparison with further times of treatment. 10 days after surgery patients feel outstanding useless. 1 month after surgery a very homogenous picture appears. 3 months after surgery two emotional conditions are more outstanding. The feeling of “safety” is rated as being very strong. The emotional condition of feeling “weak” is remarkably negatively attributed in comparison with the other times of investigation.

Emotional condition; response pattern before, 10 days, 1 months and 3 months after surgery (1 = negative attribute; 2 = neither nor; 3 = positive attribute; N = 22).

Full size image

In this paper a longitudinal study is represented as an empirical approach to an improvement of the patient and physician relationship of patients undergoing orthognathic surgery. The overall purpose of the current study is the development of a data base for an information and communication concept. Thus, 22 patients were accompanied over six months during treatment. Patients who were going to receive surgery participated and assessed on five different periods of time the treatment. The main research aims were to identify expectations of patients entering the treatment, coping strategies, information behaviour and recommended physician behaviour stated by patients. The data portrays that patients with jaw malposition suffer from psychological and physical difficulties. Patients mainly decided to undergo surgery in order to improve the function of chewing, as being a basic necessity. The expectation to receive an improvement of general functions such as chewing and biting is obvious and can also be seen in the data of patient´s reported expectations. Having divided the stated expectations into cognitive and affective hopes and worries, it turns out that the reported affective worries outnumber the hopes and seem to be of special importance. Main topics are complication in recovery process and negative consequences of surgery. Information about treatment before surgery was mainly collected in the medical education by the attending physician as well as in the Internet. A similar behaviour pattern occurs in information seeking during treatment. The attending physician is the most contacted person followed by other experienced patients and the Web. Therefore, medical education and especially the physician as a person is among the whole treatment the essential source for patients receiving answers on their questions and needs special focus regarding an information communication concept. Even though essential necessities as e.g. being able to chew properly were reported as a main reason for surgery with the intention to improve it, no effects on the patient´s quality of life especially before and after surgery could be detected. It seems that generally the group of patients has a well rated quality of life and does not show any remarkable losses due to their jaw deformity, at least not in the experimental time frame of 6 months. However, the opposite has been discovered in studies [19] and still needs to be focused on in further studies. The course of emotional conditions was also throughout positive which leads to the assumption that patients who have decided on such a severe treatment are likely to be highly motivated to make changes to their facial appearance and quality of life.

As a code of conduct patients of this underlying study recommended the physician to be friendly, to be open-minded, and honest. The physician should use comprehensible words in his explanations, calm patients and inform in detail. Furthermore, a model with the facial result in advance would be appreciated as well as to have an attentive physician who takes patients’ concerns serious. Now, the question occurs during what time of treatment the patient needs special support. The scale of emotional conditions provides first insights into the patient´s well-being and delivers hints at which point an intervention could take place in order to maintain a positive emotional condition. It is known that the better the emotional well-being the better the treatment outcome [20]. Before treatment the emotional condition of patients is described as being tired and hesitant. Psychological support and motivation for doing this decisive step needs to be offered to the patient thus the patient does not need to be hesitant. Also 10 days after surgery the emotional condition, described as feeling rather useless, needs special focus. The feeling may originate from medication and physical limitations due to the recent surgery but still encouraging attention is necessary. Taking all this results into account, a first approach to app content guidelines is to offer more information about complication in recovery process and negative consequences of surgery in detail. It is important to describe possible consequences in comprehensible language. An included medical dictionary needs to be integrated at this point. Experience reports of patients who have already undergone surgery should be provided. As results show, many patients inform themselves via Internet besides the dialogue with physician. However, to receive emotional support, get encouraged especially in severe times right before and after surgery a patient-network needs to be generated. Generally, risks need to be mentioned however in a calming way. Regarding information about surgery, information about the different treatment steps and possible psychologically and physically recovery stages should be offered as well as recommendation what to do for well-being. Thus, a patient could wonder at which time the swelling declines. The app would offer the information of recovery at four times of assessment as executed in this study (before, 10 days, 1 month, 3 months and 6 months after surgery). Since the app is supposed to be a communication tool between patient and physician, the physician could easily intervene and encourage or calm the patient. Additionally, motivational support before and directly after surgery needs to be offered.

So far the study only describes possible contents for an app guideline. The assessment of such an idea, specific contents and its structure necessarily has to be investigated in a first step. In a further study, a real prototype should be developed and tested regarding the (TAM Model by Davis [21]) attitude towards using it, the perceived usefulness, the perceived ease of use and intention to use it. A further aspect is the size of our sample. In order to report representative data, the sample has to be enlarged. On a long term, the question appears how far an information and communication strategy in the field of jaw malposition under regard of technical devices for patient information is transferable to other medical fields. An interesting research question could be how far this kind of electronic support has an impact on the patient´s well-being and a positive outcome of treatment. Finally, the question appears, if this kind of information and communication concept is transferable to other medical fields.