The Quality of Physician-Patient Relationships

,

Original Research

The Quality of Physician-Patient Relationships

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

By

Julia Murphy, MD, MPH

Patients’ Experiences 1996-1999

References

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BACKGROUND: Our objective was to examine how patients of primary care physicians are responding to a changing health care environment. The quality of their relationship with their primary care physicians and their experience with organizational features of care were monitored over a 3-year period.

METHODS: This was a longitudinal observational study (1996-1999). Participants completed a self-administered questionnaire at baseline and at follow-up. The questionnaires included measures of primary care quality from the Primary Care Assessment Survey (PCAS).

RESULTS: There were significant declines in 3 of the 4 relationship scales: communication (effect size [ES] = -0.095), interpersonal treatment (ES = -0.115), and trust (ES = -0.046). Improvement was observed in physician’s knowledge of the patient (ES = 0.051). There was a significant decline in organizational access (ES = -0.165) and an increase in visit-based continuity (ES = 0.060). There were no significant changes in financial access and integration of care indexes.

CONCLUSIONS: The declines in access and 3 of the 4 indexes of physician-patient relationship quality are of concern, especially if they signify a trend.

The quality of physician-patient relationships alters health outcomes,^1-3 affects patients’ willingness to comply with medical advice or treatment,^4,5 and influences patients’ pursuit of malpractice suits.^6,7 Changes that reflect a decline in patients’ experience of structural and organizational aspects of care are important, because these areas are strong determinants of patient satisfaction.⁸

There is little question that health care delivery systems have undergone tremendous change over the past decade and a half. These changes have affected multiple aspects of medical practice, including financial incentives faced by individual clinicians, the organization of medical practices, and the corporate relationships among provider organizations. Primary care and its position within the health care delivery system has been a focal point for much of the change. Under most forms of insurance primary care physicians now hold a central role in patient care, responsible for coordinating and integrating all aspects of the care provided to their panel of patients and in some cases sharing in the financial risk associated with providing care under a capitated budget arrangement. As changes in the organization and financing of health care have unfolded (most notably over the past several years) they have almost always had direct implications for the primary care physician’s role in interacting with patients. During our study period of 1996 to 1999, these changes in the Commonwealth of Massachusetts have included the restructuring or merging of plans and their member practices, publicly reported financial difficulties, and the departure of plans from the market region. Even within stable plans, primary care physicians have experienced pressures to increase productivity, decrease costs, and attend to patient satisfaction.

We measured changes in patients’ experience of primary care with their primary care physicians over a 3-year study period in the Commonwealth of Massachusetts. We used indices of primary care quality and studied a panel of insured adults who provided detailed information about their care. Both the quality of their relationships with their primary care physicians and their experience with organizational features of care (access, continuity, integration) were monitored during the study period.

Methods

A sample of insured employees who responded to a mailed questionnaire at baseline (1996) and again 3 years later (1999) comprised the population of this longitudinal observational study. The participants belonged to 1 of 12 insurance plans. These were representative of the major health plans in the state. The questionnaire included the Primary Care Assessment Survey (PCAS),⁹ a validated patient-completed questionnaire that measures 7 essential characteristics of primary care, defined by the Institute of Medicine Committee on the Future of Primary Care.¹⁰ All PCAS scales are measured in the context of a specific physician-patient relationship and reference the entirety of that relationship (ie, they are not visit specific).⁹ In these analyses, we examined changes in the 8 PCAS scales over a 3-year study period. The scales that we examined cover 2 broad aspects of the patient’s primary care experience: the quality of the primary care relationship (4 scales: quality of communication, interpersonal treatment, physician’s knowledge of the patient, patient trust) and organizational features of care (4 scales: financial access, organizational access, visit-based continuity, integration of care). Table 1shows the item content of each scale.

Baseline data were obtained between January and April 1996. Using a 3-stage mail survey that included an initial mailing and 2 additional mailings to nonrespondents and limited telephone follow-up of randomly selected nonrespondents,¹¹ the PCAS was administered to a random sample of 10,733 Commonwealth of Massachusetts employees stratified by age, health plan, and ZIP code. Of the original sample, 221 were excluded as either unable to be located by mail (n=184), deceased (n=11), or no longer a Commonwealth of Massachusetts employee (n=26). In total, 6810 adults completed the baseline questionnaire by mail, and 394 completed it by telephone (response rate=68.5%).