Identical analyses were performed examining the association between specific physician behaviors and patient satisfaction following the enrollment visit. All physician behaviors were more highly correlated with patient satisfaction than with patient trust, ranging from 0.59 to 0.75 for satisfaction. In general, the pattern of correlation between behaviors and satisfaction was very similar to the pattern for trust. For the total sample, the 4 behaviors most strongly associated with trust were among the 5 behaviors most strongly associated with satisfaction. As with trust, there was relatively little variation in the associations with behaviors by patient subgroups.
Discussion
The strength of the association between key physician behaviors during the office visit on subsequent patient trust in the physician was assessed. The behaviors assessed were previously identified as affecting patient trust in a study using patient focus groups.1 This study found that the behaviors assessed were predictive of patient trust up to 6 months after the initial visit, though the strength of the association decreased over time. There were relatively modest differences in the strength of the associations between behaviors and trust among the patient subgroups examined. Being comforting and caring, demonstrating competency, and explaining and listening were most strongly associated with trust in all, or virtually all, the subgroups. For women, referral to a specialist if needed and checking progress were also strongly associated with trust. The relative importance of referrals among women may reflect a concern for seeing a specialist for reproductive-related conditions. Referral was also more strongly associated with trust among more established patients, perhaps because these patients were more likely to have experienced a need for referral from their current physician at some time. For younger patients, willingness to refer and respect for feelings, opinions, and self-knowledge were among the most important behaviors, possibly reflecting differences in expectations for physician behaviors among younger versus older patients.
Interestingly, treating the patient as being on the same level and asking the patient’s opinion, while significantly associated with trust, were among the physician behaviors least associated with trust. This finding does not mean that equality and partnership are unimportant. The degree to which patients want to be involved in making decisions about their care varies,14 and patients may choose to stay with physicians whose practice style fits their preferences for involvement in their care. Bedside manners, such as gentleness during the examination, greeting warmly, and making eye contact, while significantly associated with trust, were also among the least strongly associated. These behaviors, while desirable, may be less important to establishing trust.
It was also found that to a large extent the same physician behaviors most associated with trust are also most associated with satisfaction, though the associations are stronger with satisfaction. A previous paper has reported data indicating that patient trust is somewhat separate from satisfaction, predicting continuity and self-reported adherence to treatment independently of satisfaction.6 One possible interpretation of this finding is that physician behaviors that lead to satisfaction in a single visit also help build trust, but trust is more dependent on factors in addition to physician behaviors during the office visit. No previous studies could be located that reported on the association of physician behaviors with patient trust. However studies of physician behaviors and patient satisfaction, have found that interpersonal competence (similar to comforting and caring in this study), communication, and technical competency were all significantly associated with satisfaction, a result confirmed in our study.15-17
Limitations
Patients’ ratings of physician behaviors may reflect their overall positive feelings toward the physician. Thus it is not possible to conclude that differences in the specific physician behaviors cause differences in trust. However, identifying the behaviors most strongly associated with trust may help to focus future intervention studies on these behaviors.
Conclusions
The results suggest that caring and comfort are as important as technical competency in predicting patient trust. Also, expressive and receptive communication skills, which have been shown as strongly related to patient satisfaction, are also important predictors of trust. Although the relative importance of a few other behaviors differed between subgroups, these differences were relatively modest, suggesting that the listed behaviors are of general importance to patient trust. Further work is needed to test the hypothesis that changes in identified physician behaviors can modify levels of patient trust.
Acknowledgements
This study was supported in part by grants from the Picker/Commonwealth Fund (#94-130) and the Bayer Institute for Health Care Communication (#94-181). The author thanks Barbara Elspas, MPH, for her fine work as study coordinator. The participating Stanford Trust Study Physicians were: William G. Broad, MD, (Palo Alto, Calif); Lawrence J. Bruguera, MD, (Half Moon Bay, Calif); David R. Ehrenberger, MD, (Mountain View, Calif); Larry A. Freeman, MD, (Palo Alto, Calif); Robert J. Fuss, MD, (Milpitas, Calif); H. Wallace Greig, MD, (San Jose, Calif); Mary P. Hufty, MD, (Palo Alto, Calif); Carlos F. Inocencio, MD, (Los Altos, Calif); Steven R. Lane, MD, MPH, (Palo Alto, Calif), Jas P. Lockhart, MD, (Menlo Park, Calif); Jeffrey S. McClanahan, MD, (Cupertino, Calif); Catherine A. Owen, MD, (Half Moon Bay, Calif); William E. Page, MD, (Palo Alto, Calif); Kuljeet S. Rai, MD, (San Jose, Calif); Daljeet S. Rai, MD, (San Jose, Calif); Paulita R. Ramos, MD, (San Jose, Calif); William E. Straw, MD, (Los Altos, Calif); William S. Warshal, MD, (Campbell, Calif); Roger W. Washington, MD, (Mountain View, Calif); and Andrew W. White, MD, (Menlo Park, Calif).