Each physician’s interaction style was determined through a 2-step process. In the first step, ethnographic field notes were used to gather information that helps define core features of physician style. The field notes from 4 days of observation of 138 family physicians in 84 practices were transcribed and imported into FolioVIEWS37 for data management and coding. Analysis was conducted with an immersion-crystallization approach38 involving repetitive reading and summarization of the text data. Case summaries were constructed from a sample of practices selected to maximize variation among practice characteristics such as size, physician sex, and practice location. The case summaries were independently reviewed, and important features were identified. These features were cross-checked against the original data. This process, and the resulting 30 features, are described in detail elsewhere.32
Six of the features that emerged from the qualitative analyses pertain to physician style and are listed in Table 1. Each of the 3 primary interview functions30 is represented by at least 1 feature, ensuring good coverage of the core aspects of the interaction. Gathering information is shaped by physician orientation and the clinical information allowed or elicited in the visits. Enhancing healing relationships is realized in part through affective connection with patients. The final function, making and implementing decisions, is influenced by the level of control or shared power with patients, the physician’s openness to patients’ agendas, and the physician’s willingness to negotiate options with patients.
The second step involved a cluster analysis of the 6 variables. First a hierarchical approach was used to estimate the number of clusters. Then a non-hierarchical clustering approach was used to determine physician classification among the clusters and the features that distinguish the clusters.39 Analysis of variance was used to confirm that variables included in the cluster analysis significantly differed between at least 2 of the identified clusters, and thus were contributing to defining interaction style.
TABLE 1
Physician style variables
| Physician orientation: |
| Problem focused—physician focuses on the patient’s presenting complaint |
| Patient-focused—physician is open to a broader health care agenda with the patient and explores other possible issues |
| Scope of clinical information: |
| Biomedical—talk focuses on the biological information, diagnoses and treatments |
| Biopsychosocial—explores both the biological and social and psychological issues |
| Affective connection with patients: |
| Physician personable and friendly, connects with person on a personal level |
| Physician not personable and friendly, maintains professional distance |
| Openness to patient agenda: |
| Physician open to patient’s agenda |
| Physician sets and maintains the agenda |
| Sharing of control in interaction: |
| Physician shares control of the interaction |
| Physician controls the interaction |
| Negotiation of options with patient: |
| Physician negotiates options with patients |
| Physician does not negotiate options with patients |
Analyses
The association of physician and patient characteristics with interaction style was assessed by chi square for categorical variables and by analysis of variance for continuous variables. The association of physician style with each of the 5 attributes of primary care measured by the CPCI, the indicators of patient satisfaction, and duration of the visit were tested using multilevel modeling,40 to account for the hierarchical nature of data (ie, patients nested within physicians).
Results
Of the 4994 patients presenting for care by their family physicians, 4454 (89%) agreed to participate in the DOPC study. Physicians participating in the DOPC study were similar in age to national samples of family physicians, but over-represented female and residency-trained physicians.34 Patient age, sex, and race were similar to the population of patients seeing family physicians and general practitioners nationally as reported in the National Ambulatory Medical Care Survey.34 Patient questionnaires were returned by 3283 (74%) of the patients. Of those respondents, 2881 satisfactorily completed the CPCI, representing 88% of those returning a patient questionnaire and 65% of the total sample. The patients who completed the CPCI were more likely to be white, have private health care insurance, and be somewhat older than patients who did not complete the CPCI.35
The cluster analysis identified 4 distinct groups of physicians. Each of the 138 physicians was classified into 1 group. Each of the 6 variables in the analysis contributed to defining the 4 groups by significantly (P
Forty-nine percent of physicians were classified as person focused. These physicians were more focused on the person than the disease, were perceived as personable and friendly, were open to the patient’s agenda, and frequently negotiated options with the patient. Physicians classified as biopsychosocial (16%) were more focused on the patient’s disease, but elicited psychosocial clinical information. Physicians classified as biomedical (20%) were also more focused on the patient’s disease and were unlikely to elicit psychosocial information. These physicians also demonstrated a low level of friendliness and were unlikely to negotiate options with the patient. The high physician control group’s major characteristics were domination of the encounter and disregard of the patient’s agenda (14%).