As others have proposed, we concur that interaction style is not a dichotomy or even a continuum of patient versus physician control, but is multidimensional, cutting across the main functions of the patient encounter (ie, information gathering, relationship building, and making and implementing decisions). These data provide some confirmation for the original scheme proposed by Szasz and Hollander,10 with the Mutual Participation model most represented by the person-focused approach and the Activity-Passivity model most represented by the high-physician-control group. The biopsychosocial and biomedical approaches represent different versions of the Guidance and Cooperative model.
The 4 types of physician style empirically derived from our data are similar to communication pattern types found by Roter et al,27 in a study with similar aims but different methods. Of the 5 types reported, narrowly biomedical and expanded biomedical accounted for 65% of visits, and biopsychosocial accounted for 20%. Psychosocial and consumerist (distinguished by a high degree of patient questions) accounted for only 8% each. It is interesting that in our data, we found the person-focused style was by far the most common approach (49%) among this group of family physicians. These differences in use of particular interaction styles may have several explanations. First, these data were collected more recently.27 Thus our data may reflect trends in a movement away from a paternalistic style and toward an increased patient participatory style. Second, our sample consisted entirely of family physicians practicing in the community, where the model of person-focused care may have a longer history of support and endorsement or be of greater importance to community family physicians, whose emphasis is on a breadth of care based on patient needs.6,7,18
Physicians with a person-focused style granted the longest visits, while high-control-physicians granted the shortest—a difference of more than 2 minutes per visit on average. The associations were not explained away by accounting for patient or physician characteristics, suggesting that a person-focused style may require more time. However, others have found that physicians engaging in a patient participatory style had office visits that were of similar duration as found with other approaches,23, 27 although the average duration of visit for both of these studies were considerably longer than the office visits among our sample.
This study has several strengths. The use of community practicing physicians in real world conditions for whom visits were similar in content to the visits reported by NAMCS34 adds to the generalizability of the findings. We have used an integration of qualitative and quantitative approaches to empirically derive categories of physician interaction style. Our data are based on nurse observation of an average of 32 encounters per physician and documented in rich and comprehensive qualitative fieldnotes. And finally, by using multilevel modeling, we have reported an honest estimate of the association of physician style and patient report of primary care by appropriately modeling the nested data structure.
The findings must be interpreted in light of potential study limitations. First, the patients who did not complete the patient questionnaire are somewhat different demographically than those patients who did complete it. However, non-completion of the questionnaire was not associated with physician style; therefore, it is unlikely that the associations would change, had these individuals been included. Second, because the study was cross-sectional we cannot control for patient self-selection of physicians. Nonetheless, since patients dissatisfied with the quality of care are likely to seek another physician, we would expect patient self-selection of physicians to bias the study toward the null, thus making our results even more remarkable.
These findings, in combination with the literature on the person-focused,24 patient-centered5,17,19,20,41 and relationship-centered approaches,42 provide strong evidence to support the widespread implementation of this physician-patient interaction approach. Further investigation in community practice may lead to identification of ways to support and encourage person-focused care and the time needed to provide such care.
· Acknowledgments ·
The authors are indebted to the physicians, office staff members, and patients without whose participation this study would not have been possible. This paper was improved by helpful suggestions on an earlier draft by Kurt C. Stange, MD, PhD. This study was supported by a grant from the National Cancer Institute (1R01 CA60862) and in part by the Center for Research in Family Practice and Primary Care and the American Academy of Family Practice.