Two physician styles of focusing on the family

BACKGROUND: Previous research has identified 2 styles of family physicians' focus on the patient's family: (1) using the family history as the context of care of the patient; and (2) maintaining a family orientation with the family as the unit of care. The purpose of our study was to determine whether these styles affect patient outcomes and time use during outpatient visits. METHODS: In a cross-sectional study, data on 4454 outpatient visits to 138 community family physicians were collected using direct observation, patient and physician questionnaires, and medical record review. We computed partial correlations between the physician's family practice style score and patient outcomes for delivery of preventive services, patient visit satisfaction, and patient-reported delivery of specific components of primary care. We controlled for relevant patient characteristics. RESULTS: The patients of the physicians using either practice style had similar levels of satisfaction with coordination of care and interpersonal communication, and their value of continuity of care was comparable. Patients of physicians with a family-history style, however, rated their physicians lower on a measure of in-depth knowledge of the patient and family but higher on preventive services delivery. Differences in time use during the visit reflected how these styles were manifested during the outpatient visit. CONCLUSIONS: The different styles physicians use to focus on the family affect the process and outcomes of patient care. This difference may be explained by the developmental life cycle of family physicians, as younger physicians may be more focused on family history and older physicians may have a more family-oriented focus. Physicians may need to find alternate ways of meeting those patient needs not well met by their predominant practice style.     

Relationship between outpatients' perceptions of physicians' communication styles and patients' anxiety levels in a Japanese oncology setting.

For life-threatening illnesses such as cancer that require a long-term treatment regimen, communication is particularly important between doctors and patients. While it is assumed that the more serious the illness, the greater the need to relieve patients' anxiety, physicians' communication styles can directly influence patients' anxiety levels. The purpose of this study was to examine the relationship between outpatients' perceptions of physicians' communication styles and the patients' anxiety levels in oncology settings. Patient anxiety level was measured using the State Trait Anxiety Inventory before and after the consultation. The Perceived Physician's Communication Style Scale was developed in this study. Analysis of responses to the scale resulted in four factors--"acceptive", "patient-centered", "attentive", and "facilitative"--of the physician's communication style and explained 63.7% of the variance. The inter-correlation for overall scale items was 0.95. Patient satisfaction with the medical encounter was also measured to validate the physician's communication style scale. Moderate correlation between the physician's communication style and satisfaction was observed and confirms the relationship between a favorable communication style and a patient's satisfaction. After the consultation, the patients' anxiety levels dropped 5.0 +/- 1.5 points (p<0.001), and the physician's communication style was shown in many cases to be linked to patient anxiety levels after the consultation. The effect of the physician's communication style on patients' post-consultation anxiety levels was small among the patients with an advanced disease status. Also, the findings showed that patients' post-consultation anxiety levels remained low even among those patients with unfavorable examination results if the patients evaluated their physician's communication style as high. This study suggested that the physician's communication style is important not only for moderating patients' anxiety, but could also be helpful for moderating physicians' own stress levels when communicating bad news to patients.     

Meeting patient's expectations in primary care consultations in Lithuania.

OBJECTIVE: Patient satisfaction with health care services is considered an important factor of health care. Although research on patient satisfaction has become standard in Western Europe, in countries such as Lithuania the concept of patient satisfaction is still a relatively new one. This study aimed to investigate how the meeting of patients' expectations is related to increased satisfaction with medical consultation. STUDY DESIGN: The methodology used by Williams et al. in the UK was applied to the Lithuanian health care setting. Forty physicians from 22 primary health care centres attending courses on general practice at Vilnius University were recruited for the study. Every third adult patient coming to a practice during a 5-day period was invited to participate in the study. In all, 609 patients coming to meet their physician regarding health problems were included in the study sample. The patients were asked to complete three standardized questionnaires: the Patient Intentions Questionnaire prior to the consultation, and the Expectations Met Questionnaire and Medical Interview Satisfaction Scale after the consultation. Cronbach's alpha statistic was used for the validation of the questionnaires and principal components analysis was used to determine the factors of patient expectations. RESULTS: The response rate was 78%. ANALYSIS: of 460 sets of questionnaires revealed that satisfaction with medical consultation is higher among patients who have a greater number of expectations met. Physicians' success in meeting different types of patient expectations also had different influences on patient satisfaction. The most important expectations to be met were "understanding and explanation", followed by expectations of "emotional support", while "getting information" was less important. CONCLUSIONS: The most frequently reported expectations on the Patient Intentions Questionnaire were for "getting information" and "understanding and explanation" of the patients' health problem items, and the least mentioned were for emotional support items. Patients with more expectations met were found to have significantly higher scores on the satisfaction index. Satisfaction with the consultation is best predicted by meeting the patient's expectations for understanding and explanation, and for emotional support. Providing desired information to the patient as well as meeting the patient's expectations for diagnostic procedures and treatment is less associated with patient satisfaction.     

Relation of patients' experiences with individual physicians to malpractice risk.

OBJECTIVE: Patient care experience survey data might be useful for managing individual physician malpractice risk, but available evidence is limited. This study assesses whether patients' experiences with individual physicians, as measured by a validated survey, are associated with patient complaints and malpractice lawsuits. DESIGN: Random samples of active patients in physicians' panels, with sample sizes adequate to provide highly reliable, stable information about patients' experiences with each physician (n = 19 202, average respondents per physician = 119) were used to assess the relation of patient survey measures to malpractice risk. SETTING: A large multi-specialty physician organization in eastern Massachusetts, USA. PARTICIPANTS: Physicians providing care for at least 5 years in adult primary care and select high-risk specialty departments between January 1996 and December 2005 (n = 161). MAIN OUTCOME MEASURES: Patient complaints (2001-05) and malpractice lawsuits (1996-2005). RESULTS: Compared to primary care physicians, high-risk specialists had a lower patient complaint rate (0.34 vs. 1.36 complaints per patient care full time equivalent; P < 0.001), but a higher lawsuit rate (0.09 vs. 0.05 lawsuits per patient care full time equivalent; P = 0.02). Irrespective of physician specialty, the quality of physician-patient interactions (IRR = 0.61; P < 0.001) and care coordination (IRR = 0.65; P < 0.001) were inversely associated with patient complaints. Patient survey measures were not associated with malpractice lawsuits. CONCLUSIONS: The results underscore the challenges organizations face when attempting to use patient survey data to manage individual physician medical malpractice risk. Because lawsuits are infrequent events, calibrating these validated patient survey measures to malpractice lawsuit risk will require large physician samples from diverse practices.     

Patients' perceptions of physicians communication and outcomes of the accrual to trial process

The purpose of this study was to examine the relations among patients' perceptions of their physicians' communicative behavior during the informed consent interview, the patient's feeling of being confirmed by the physician and satisfied with care delivered by the physician, and the patient's decision to participate in a clinical trial or not. Respondents included 130 cancer patients who were eligible for a clinical trial and who had recently discussed trial participation with their physicians. Results indicated that a linear combination of the variables physician affiliative style, physician dominant or controlling style, patient satisfaction, patient confirmation, patient preference for decision making, patient desire for information, and patient age discriminate between patients who agree to participate in clinical trials and patients who refuse to participate. Physicians' affiliative communicative behaviors and patient satisfaction were clearly important to patients who agreed to participate. Motivations for patients who declined to participate in trials were less clear. Implications for physicians who offer clinical trials to their patients are that specific communication skills may enhance their patients' satisfaction and may help increase enrollment in clinical trials.     

An interactional structure of medical activities during acute visits and its implications for patients' participation

Within the context of primary-care, physician-patient visits, researchers have documented both patients' low levels of communicative participation (e.g., question asking) and the advantages of such participation to healthcare (e.g., improved physical health and satisfaction). Prior research has offered a variety of partial, non-exclusive explanations for patients' low levels of participation. This article investigates one underdeveloped source of explanation: the organization of interaction itself. This article argues that the establishment of new medical problems in acute visits makes relevant an organized structure of social action that is composed of an ordered series of medical activities: establishing the reason for the visit, physicians gathering additional information (i.e., history taking and physical examination), physicians delivering diagnoses, and physicians providing treatment recommendations. This "project" of medical activity shapes physicians' and patients' understanding and production of communicative behavior. Using the method of conversation analysis, and analyzing transcribed audio- and videotape data of actual acute visits, this article describes and grounds this project and discusses its implications for research, theory, and improvement on patient participation.     

The impact of patient participation on physicians' information provision during a primary care medical interview

This study investigated the impact of patients' participation on physicians' information provision during a primary care medical interview. When communicating with high-participation patients, physicians provided significantly more information overall, more information in response to patients' questions, and volunteered more information than when interacting with low-participation patients. The most significant differences with respect to volunteered information involved communication about treatment and tests or procedures. These results were interpreted to suggest that high-participation patients' communication style promotes better alignment of patients' and physicians' goals and agendas. Overall, the results suggest that patients' style of participation during a medical interview significantly influenced the extent and type of information physicians provided. Given that patients' biggest complaint about physicians often is a lack of desired information, this study has important implications for physician-patient communication.     

Information-giving in medical consultations: the influence of patients' communicative styles and personal characteristics

Informing the patient is arguably the physician's most important communicative responsibility. Recognizing this researchers have long been interested in the question of why some patients receive more information from physicians than do others. In this paper, it is argued that the amount of information physicians provide patients during medical consultations may be influenced by two sets of factors, patients' personal characteristics (age, sex, education, and anxiety) and patients' communicative styles (question-asking, opinion-giving, and expression of concern). The analysis of audiovisual recordings of 41 physician-patient consultations in a family practice clinic revealed several notable findings: (a) information regarding diagnosis and health matters was primarily related to the patient's anxiety, education, and question-asking, (b) information regarding treatment was primarily a function of the patient's question-asking and expression of concerns, and (c) patients' assertiveness and expressiveness were strongly influenced by physicians' use of 'partnership-building' utterances that solicited the patient's questions, concerns, and opinions. The data suggest that, when attempting to explicate factors affecting physicians' informativeness, researchers must take into account features of the patients' communicative styles as well as physicians' perceptions of certain groups of patients.     

When physicians and patients think alike: patient-centered beliefs and their impact on satisfaction and trust.

OBJECTIVE: Our goal was to identify physician and patient characteristics associated with patient-centered beliefs about the sharing of information and power, and to determine how these beliefs and the congruence of beliefs between patients and physicians affect patients' evaluations. STUDY DESIGN: Physicians completed a scale assessing their beliefs about sharing information and power, and provided demographic information. A sample of their patients filled out the same scale and made evaluations of their physicians before and after a target visit. POPULATION: Physicians and patients in a large multispecialty group practice and a group model health maintenance organization were included. Forty-five physicians in internal medicine, family practice, and cardiology participated, as well as 909 of their patients who had a significant concern. OUTCOMES MEASURED: Trust in the physician was measured previsit, and visit satisfaction and physician endorsement were measured immediately postvisit. RESULTS: Among patients, patient-centered beliefs (a preference for information and control) were associated with being women, white, younger, more educated, and having a higher income; among physicians these beliefs were unrelated to sex, ethnicity, or experience. The patients of patient-centered physicians were no more trusting or endorsing of their physicians, and they were not more satisfied with the target visit. However, patients whose beliefs were congruent with their physicians' beliefs were more likely to trust and endorse their physicians, even though they were not more satisfied with the target visit. CONCLUSIONS: The extent of congruence between physicians' and patients' beliefs plays an important role in determining how patients evaluate their physicians, although satisfaction with a specific visit and overall trust may be determined differently.     

The effects of a mobile application for patient participation to improve patient safety

BackgroundPatient participation in patient safety activities in care processes is a fundamental element of safer care. Patients play an important role in preventing patient safety incidents and improving health outcomes. Therefore, healthcare providers need to develop and provide educational materials and actionable tools for patient participation.ObjectivesThis study aimed to develop a mobile application for health consumers'' participation and evaluate the effect of the mobile application on improving health consumers'' participation in patient safety.MethodsA quasi‐experimental design was adopted. We developed a mobile application on the basis of a needs assessment, literature review, compilation of patient safety topics, and validity testing of the application. The target population included Korean adults aged between 30 and 65 years who had visited a medical institution more than once within the most recent 6 months. The intervention group received patient participation training by using the mobile application, Application for Patient Participation in Safety Enhancement, for 2 months. The primary outcome variables were patient safety knowledge, self‐efficacy of participation, willingness to participate and experience of patient participation in patient safety activities. End‐user satisfaction was assessed using a questionnaire. To assess participants'' experiences with the intervention, qualitative data were collected through a focus group interview and open‐ended responses to an end‐user satisfaction survey.ResultsThe intervention group (n = 60) had significantly higher overall average scores than the control group (n = 37) with regard to patient safety knowledge (p < .001), self‐efficacy of participation (p = .001), willingness to participate (p = .010) and experience of participation (p = .038) in the post‐survey. The total mean end‐user satisfaction score was 3.56 ± 0.60. The participants expressed the realization that patients could play an important role in improving patient safety.ConclusionsThis study demonstrated that educating health consumers through a mobile application with useful information improves patient participation in patient safety activities. Educational materials and patient participation tools could motivate health consumers'' health‐related behaviours.Patient or Public ContributionPatients were involved during the programme development and evaluation.     

Measuring Patient Satisfaction in Primary Care: a Joint Project of Community Representatives, Clinic Staff Members and a Social Scientist

We describe the process of planning and developing a questionnaireand conducting a patient satisfaction survey in a neighbourhoodclinic in Beer-Sheva, Israel. The project was conducted by theclinic staff members, patient representatives and a medicalsociologist. The satisfaction survey was conducted in patients'homes, with a 67% response rate. General satisfaction and satisfactionwith specific components of service are described. Patient satisfactionwas higher among men than among women, and negatively correlatedwith family size. The strongest predictor of general satisfactionwas satisfaction with physicians' services. Implications ofthe survey results were decided upon by active collaborationbetween the clinic staff and the patient representatives. Theinferences drawn from the patients' replies and the changesintroduced as a result of them, are discussed. Health care consumersshould be active participants in carrying out surveys of satisfactionon a regular basis.     

The effect of patient race and socio-economic status on physicians' perceptions of patients

Despite its potential influence on quality of care, there has been little research on the way physicians perceptions of and beliefs about patients are affected by patient race or socio-economic status. The lack of research in this area creates a critical gap in our understanding of how patients' demographic characteristics influence encounter characteristics, diagnoses, treatment recommendations, and outcomes. This study uses survey data to examine the degree to which patient race and socio-economic status affected physicians' perceptions of patients during a post-angiogram encounter. A total of 842 patient encounters were sampled, out of which 193 physicians provided data on 618 (73%) of the encounters sampled. The results of analyses of the effect of patient race and SES on physician perceptions of and attitude towards patients, controlling for patient age, sex, race, frailty/sickness, depression, mastery, social assertiveness and physician characteristics, are presented. These results supported the hypothesis that physicians' perceptions of patients were influenced by patients' socio-demographic characteristics. Physicians tended to perceive African-Americans and members of low and middle SES groups more negatively on a number of dimensions than they did Whites and upper SES patients. Patient race was associated with physicians' assessment of patient intelligence, feelings of affiliation toward the patient, and beliefs about patient's likelihood of risk behavior and adherence with medical advice; patient SES was associated with physicians' perceptions of patients' personality, abilities, behavioral tendencies and role demands. Implications are discussed in terms of further studies and potential interventions.     

Physicians’ communication and perceptions of patients: Is it how they look,how they talk,or is it just the doctor?

Although physicians' communication style and perceptions affect outcomes, few studies have examined how these perceptions relate to the way physicians communicate with patients. Moreover, while any number of factors may affect the communication process, few studies have analyzed these effects collectively in order to identify the most powerful influences on physician communication and perceptions. Adopting an ecological approach, this investigation examined: (a) the relationships of physicians' patient-centered communication (informative, supportive, partnership-building) and affect (positive, contentious) on their perceptions of the patient, and (b) the degree to which communication and perceptions were affected by the physicians' characteristics, patients' demographic characteristics, physician-patient concordance, and the patient's communication. Physicians (N=29) and patients (N=207) from 10 outpatient settings in the United States participated in the study. From audio-recordings of these visits, coders rated the physicians' communication and affect as well as the patients' participation and affect. Doctors were more patient-centered with patients they perceived as better communicators, more satisfied, and more likely to adhere. Physicians displayed more patient-centered communication and more favorably perceived patients who expressed positive affect, were more involved, and who were less contentious. Physicians were more contentious with black patients, whom they also perceived as less effective communicators and less satisfied. Finally, physicians who reported a patient-centered orientation to the doctor-patient relationship also were more patient-centered in their communication. The results suggest that reciprocity and mutual influence have a strong effect on these interactions in that more positive (or negative) communication from one participant leads to similar responses from the other. Physicians' encounters with black patients revealed communicative difficulties that may lower quality of care for these patients.     

Comparison of patient satisfaction with ambulatory visits in competing health care delivery settings in Geneva, Switzerland.

OBJECTIVES: To measure satisfaction with medical visits in various health care settings and to assess the extent to which differences in satisfaction scores between health care settings can be attributed to patients' characteristics. DESIGN: This was a cross sectional survey to measure seven dimensions of patient satisfaction. SETTINGS: Ambulatory visits to 'gatekeepers' or specialists in a newly established managed care organisation, a private group practice, or a university hospital outpatient clinic in Geneva, Switzerland. PATIENTS: There were altogether 1027 adult patients (81% participation rate). RESULTS: Patients who consulted physicians in the private group practice reported higher levels of satisfaction (overall mean 83.2 on a scale between 0 and 100) than university clinic patients (79.7), patients of independent specialists within the managed plan (78.5), and patients of managed plan gatekeepers (69.8, intergroup differences p < 0.001). Differences between settings were reduced after adjustment for sex, age, country of origin, general practitioner versus specialist visit, and scheduled versus urgent visit (adjusted scores: 80.8, 78.8, 77.6, and 72.7 in the four settings, p < 0.001). Intergroup differences were largest for general satisfaction, but small and non-significant for satisfaction with explanations given by the physician and for time spent with the patient. CONCLUSIONS: Patient satisfaction varied widely between health care settings. Differences in satisfaction ratings could be ascribed only partly to disparities in patient populations. Patients of managed plan gatekeepers were least satisfied, presumably because they could not choose their physician freely. Comparison of patient satisfaction across health care settings can provide a basis for targeted quality improvement initiatives.     

Family physicians' perceptions of the family conference

Ninety-one of 127 graduates (72 percent) of one family practice residency returned a questionnaire in which they estimated the likelihood that their patients would want a physician-family conference for each of 21 clinical situations. For each situation the physicians also rated their own preferences regarding patients' interest in family conferences. Serious medical illnesses received the highest ratings for both sets of ratings. For all 21 situations, physicians' estimates of patients' responses were significantly lower than physicians' preferred response ratings. The physicians' estimates and preferences regarding patients' interest in family conferences were compared with actual patients' ratings obtained in a previous study. The patient ratings were significantly greater than the physicians' estimates of patient ratings for 14 of 21 situations; the physicians' preferences ratings were significantly higher than the actual patient ratings for 11 situations and lower for three situations. The mean number of actual family conferences conducted in the previous month was 2.6, and 66 percent of respondents had conducted at least one such conference during this time. These data indicate that physicians may be more interested in family conferences than their patients are, but that they may underestimate the degree to which patients do, in fact, want them. The implications of these data for teaching, practice, and research are discussed.     

Hospitalization style of physicians in Manitoba: the disturbing lack of logic in medical practice.

Variations in hospital admission rates across small areas are ubiquitous, and it is increasingly assumed that high rates result from physicians' discretionary decisions. Data for elderly patients from the health insurance system of Manitoba were used to construct an index that divided physicians into four groups based on their propensity to admit patients to the hospital. I then determined whether physicians who are more prone to admit patients use hospitals for more discretionary purposes and admit patients who are less ill. Although the differences between physicians with different practice styles were in the expected direction, the most compelling finding was the similarity in characteristics of patients admitted by physicians with markedly different practice styles. Such findings suggest a very wide latitude in physicians' decisions to admit patients; this latitude is not well captured by a model that posits a logical relationship between physician treatment patterns and patient need.     

Customer convergence: patients, physicians, and employees share in the experience and evaluation of healthcare quality

This article explores the interrelationships between three categories of service quality in healthcare delivery organizations: patient, employee, and physician satisfaction. Using the largest and most representative national databases available, the study compares the evaluations of hospital care by more than 2 million patients, 150,000 employees, and 40,000 physicians. The results confirm the relationship connecting employees' satisfaction and loyalty to their patients' satisfaction and loyalty. Patients' satisfaction and loyalty were also strongly associated with medical staff physicians' evaluations of overall satisfaction and loyalty to the hospital. Similarly, hospital employees' satisfaction and loyalty were related to the medical staff physicians' satisfaction with and loyalty to the hospital. Based upon the strength of the interrelationships, individual measures and subscales can serve as leverage points for improving linked outcomes. Patients, physicians, and employees, the three co-creators of health, agree on the evaluation of the quality of that service experience. The results demonstrate that promoting patient-centeredness, enhancing medical staff relations, and improving the satisfaction and loyalty of employees are not necessarily three separate activities in competition for hospital resources and marketing leadership attention.     

HMO penetration and the geographic mobility of practicing physicians

In this study, we assessed the influence of changes in health maintenance organization (HMO) penetration on the probability that established patient care physicians relocated their practices or left patient care altogether. For physicians who relocated their practices, we also assessed the impact of HMO penetration on their destination choices. We found that larger increases in HMO penetration decreased the probability that medical/surgical specialists in early career stayed in patient care in the same market, but had no impact on generalists, hospital-based specialists, or mid career medical/surgical specialists. We also found that physicians who relocated their practices were much more likely to choose destination markets with the same level of HMO penetration or lower HMO penetration compared with their origin markets than they were to choose destination markets with higher HMO penetration. The largely negligible impact of changes in HMO penetration on established physicians' decisions to relocate their practices or leave patient care is consistent with high relocation and switching costs. Relocating physicians' attraction to destination markets with the same level of HMO penetration as their origin markets suggests that, while physicians' styles of medical practice may adapt to changes in market conditions, learning new practice styles is costly.     

Patient satisfaction with prescribed medicines in community health services in China: A cross‐sectional survey 6 years after the implementation of the national essential medicines policy

The National essential medicines policy (NEMP) is promoted by the World Health Organization for affordable medicines that can meet the basic needs of communities. Patient acceptance is essential for achieving the policy goals of the NEMP. This study aimed to assess patient satisfaction with prescribed medicines in community health services under the NEMP context in China. A stratified random sampling strategy was adopted to select 1,037 participants in 40 community health centres from four provinces in China. Patient satisfaction was rated on a five‐point Likert scale (from 1 = “very dissatisfied” to 5 = “very satisfied”) covering four domains: availability, affordability, effectiveness and safety. The results showed that the participants expressed a moderate degree of satisfaction, with a rating in the range of 66–82 out of a total of 100. Older people, those covered by insurance and those with a lower level of education tended to have higher ratings. While eastern (wealthy) residents were more likely to be concerned with “effectiveness,” western (poor) residents were more likely to be concerned with “affordability.” Awareness of the NEMP was negatively associated with patient satisfaction after control for other factors.     

Patient expectations at a multicultural out-patient clinic in Switzerland

BACKGROUND: Recognizing patient expectation is considered as an important objective for primary care physicians. A number of studies suggest that failure to identify patient expectations can lead to patient dissatisfaction with care, lack of compliance and inappropriate use of medical resources. It has been suggested that identifying patient expectations in multicultural contexts can be especially challenging. OBJECTIVES: The aim of the study was to compare health care expectations of Swiss and immigrant patients attending the out-patient clinic of a Swiss university hospital and to assess physicians' ability to identify their patients' expectations. METHODS: Over a 3-month period, all patients attending the out-patient clinic at a Swiss university hospital were requested to complete pre-consultation surveys. Their physicians were requested to complete post-consultation surveys. Outcome measures were patients' self-rated health, resort to prior home treatment, patients' expectations of the consultation, physicians' perception of their patients' expectations and agreement between patients and physicians. RESULTS: We analysed 343 questionnaires completed by patients prior to their consultation (> 50% immigrants) and 333 questionnaires completed by their physicians after the consultation. Most expectations were shared by all patients. Physicians had inaccurate perceptions of their patients' expectations, regardless of patients' origin. CONCLUSIONS: Our study found no evidence that immigrant patients' expectations differed from those of Swiss patients, nor that physicians had more difficulty identifying expectations of immigrant patients. However, physicians in our study were generally poor at identifying patients' expectations, and therefore inter-group differences may be difficult to detect. Our results point to the need to strengthen physicians' general communication skills which should then serve as a foundation for more specific, cross-cultural communication training.