The Quality of Physician-Patient Relationships

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Original Research

The Quality of Physician-Patient Relationships

J Fam Pract. 2001 February;50(2):123-129

References

1 Greenfield S, Kaplan SH, Ware JE, Yano EM, Frank HJL. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3:448-57.

2. Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med 1985;102:520-28.

3. Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27 (suppl):S110-27.

4. DiMatteo MR. Enhancing patient adherence to medical recommondations. JAMA 1994;271:79-83.

5. Francis V, Korsch BM, Morris MJ. Gaps in doctor-patient communication: patients’ response to medical advice. N Engl J Med 1969;280:535-40.

6. Penchansky R, Macnee C. Initiation of medical malpractice suits: a conceptualization and test. Med Care 1994;32:813-31.

7. Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice: lessons from plaintiff depositions. Arch Intern Med 1994;154:1365-70.

8. Harpole LH, Orav J, Hickey M, Posther KE, Brennan TA. Patient satisfaction in the ambulatory setting: influence of data collection methods and sociodemographic factors. J Gen Intern Med 1996;11:431-34.

9. Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care 1998;36:728-39.

10. Institute of Medicine Primary care: America’s health in a new era. Washington, DC: National Academy Press; 1996.

11. Dillman DA. Mail and telephone surveys: the total design method. New York, NY: John Wiley; 1978.

12. Ware JE, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability. Med Care 1996;34:220-33.

13. National Center for Health Statistics. Current estimates from the National Health Interview Survey. Washington, DC: US Government; 1993.

14. Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA 1995;273:323-29.

15. Emanuel EJ, Brett AS. Managed competition and the patient-physician relationship. N Engl J Med 1993;329:879-82.

16. Ettner S. The relationship between continuity of care and the health behaviors of patients: does having a usual physician make a difference? Med Care 1999;37:547-55.

17. Kao AC, Green DC, Davis NA, Koplan JP, Cleary PD. Patients’ trust in their physicians: effects of choice, continuity, and payment method. J Gen Intern Med 1998;13:681-86.

18. Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract 1997;45:129-35.

19. Weiss LJ, Blustein J. Faithful patients: the effect of long-term physician-patient relationships on the costs and use of health care by older Americans. Am J Public Health 1996;86:1742-47.

20. Hjortadahl P. Continuity of care: general practitioners’ knowledge about, and sense of responsibiltiy toward their patients. Fam Pract 1992;9:3-8.

21. Weiss GL. Patient satisfaction with primary medical care. Med Care 1988;26:383-92.

22. Becker MH, Drachman RH, Kirscht JP. A field experiment to evaluate various outcomes of continuity of physician care. Am J Public Health 1974;64:1062-70.

23. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: manual and interpretation guide. Boston, Mass: New England Medical Center; 1993.

24. DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol 1993;12:93-102.

25. Marquis MS, Davies AR, Ware JE. Patient satisfaction and change in medical care provider: a longitudinal study. Med Care 1983;21:821-29.

26. Grumbach K, Selby JV, Damberg C, et al. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. JAMA 1999;282:261-66.

27. Safran DG, Murray A, Chang H, Montgomery J, Murphy J, Rogers WH. Linking doctor-patient relationship quality to outcomes. J Gen Intern Med 2000;15(suppl):116.-

28. Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality of care. Inquiry 1988;25:25-36.

29. Robbins JA, Bertakis KD, Helms LJ, Azari R, Callahan EJ, Creten DA. The influence of physician practice behaviors on patient satisfaction. Fam Med 1993;25:17-20.

30. Thom DH, Campbell B. Patient-physician trust: an exploratory study. J Fam Pract 1997;44:169-76.

31. Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’ interviewing skills and reducing patients’ emotional distress: a randomized clinical trial. Arch Intern Med 1995;155:1877-84.

32. Carney QA, Eliassen MS, Wolford GL, Owen M, Badger LW, Dietrich AJ. How physician communication influences recognition of depression in primary care. J Fam Pract 1999;48:958-64.

33. Wagner EH, Barrett P, Barry MJ, Barlow W, Fowler FJ. The effect of a shared decisionmaking program on rates of surgery for benign prostatic hyperplasia. Med Care 1995;33:765-70.

34. Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JE. Characteristics of physicians with participatory decision-making styles. Ann Intern Med 1996;124:497-504.

35. Palmer RH. Considerations in defining quality of health care. Part I. In: Palmer RH, Donabedian A, Povar GJ, eds. Striving for quality in health care: an inquiry into policy and practice. Ann Arbor, Mich: Health Administration Press; 1991:1-54.

36. Harris LE, Swindle RW, Mungai SM, Weinberger M, Tierney WM. Measuring patient satisfaction for quality improvement. Med Care 1999;37:1207-13.

37. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA 1999;282:583-89.

38. Fox SA, Stein JA. The effect of physician-patient communication on mammography utilization by different ethnic groups. Med Care 1991;29:1065-82.

39. Taira DA, Safran DG, Seto TB, Rogers WH, Tarlov AR. The relationship between patient income and physician discussion of health risk behaviors. JAMA 1997;278:1412-17.

40. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Mahwah, NJ: Lawrence Earlbaum; 1988.

Results

The sociodemographic characteristics and health status of the analytic sample are presented in Table 2. Study participants ranged in age from 20 to 88 years, with a mean of 50.2 years. The majority were women and white, with some college education. On average they began our study with 2.8 chronic conditions. Physical and mental health status (as measured by the SF-12) was consistent with those observed nationally in adults in this age group.²³

Table 3 shows the unadjusted PCAS scores at baseline and follow-up and provides the 3-year score differences for the analytic sample. Two scales showed significant improvements (physician’s knowledge of the patient and visit-based continuity). Four scales showed significant declines (communication quality, interpersonal treatment, patient trust, and organizational access). The standardized measure of change (effect size [ES]) reveals that the largest changes occurred in organization access (ES=0.165), interpersonal treatment (ES=0.115), and communication quality (ES=0.095). The effect sizes for the other scales ranged from 0.016 (integration of care) to 0.060 (visit-based continuity).

For the 4 indicators of relationship quality, the observed (or unadjusted) change and change adjusted for the length of the physician-patient relationship are depicted in the Figure 1. The adjusted change scores from 1996 to 1999 show significant declines in all 4 indicators of relationship quality, ranging from -1.72 (physician’s knowledge of the patient) to -3.28 (interpersonal treatment).

Discussion

This observational study of patients under the continuing care of a primary physician from 1996 to 1999 found significant declines in 3 of the 4 indicators of relationship quality between 1996 and 1999. The largest declines were observed in interpersonal treatment, followed by declines in the quality of communication and trust. The fourth measure of relationship quality—the physician’s whole-person knowledge of the patient—increased, but this increase could not be demonstrated when adjusting for increased relationship duration. The adjusted figures demonstrate the concept that if expected increases in relationship quality due to increased relationship length are controlled for (ie, taken into account), then even larger decreases in relationship quality are demonstrated Figure 1.

Primary care is predicated on sustained physician-patient relationships, as recently noted by the Institute of Medicine Committee on the Future of Primary Care.¹⁰ The importance of relationship quality in health care is underscored by a research literature that links it to important outcomes of care. The quality of the physician-patient relationship in primary care has been associated with outcomes that include patients’ compliance with medical advice,^4,5,24 clinical outcomes of care,^1,3 patients’ willingness to initiate malpractice suits,^6,7 and patients’ decisions to change physicians.^25-27 Interpersonal treatment is a correlate of patient satisfaction,^28,29 which is important to individual patient well-being and as a factor that results in patient disenrollment. Research literature establishes that effective communication builds trust, reduces patients’ emotional stress, facilitates the process of diagnosing medical conditions, affects medical management decisions, and creates positive health outcomes.^1,3,30-34 In this context the observed decline in some of the indicators of quality of primary care relationships across the 3-year study period is concerning. We do not know from our study whether the quality of relationships was already declining before 1996 and, more important, whether declines are continuing at this rate.

Previous analyses employing baseline PCAS indicators of relationship quality as predictors of outcomes of care in this study population²⁷ enable us to estimate with some caution the effects of the observed declines in relationship quality over time. On the basis of this previous evidence, had the observed declines in interpersonal treatment and communication not occurred, an estimated 5% of the rate of patients’ voluntary disenrollment from their physicians’ practices could have been avoided. The observed decline in interpersonal treatment could translate into a measurable decline in patients’ attempts to adhere to their physicians’ counseling about smoking cessation, reducing alcohol consumption, and increasing exercise.

Our study included 4 indicators of organizational/structure features of care, 2 of which were observed to change significantly during the study period. Visit-based continuity between patients and their primary physicians (the ability of patients to see their regular physician for routine care and appointments when sick) increased. Patients’ organizational access to care (which includes patients’ ability to reach their physician’s office by phone and to obtain timely appointments when sick) declined substantially—more so than any other scale in the study. Still, patients in this study sample were better able to see their own physician, and having done so they go on to report that the quality of the encounters is declining. Access to care is a defining feature of primary care^10,35 and an important correlate of patient satisfaction.^8,36 The observed decline in organizational access to care raises concerns about the quality of primary care.