December 2001 · Vol. 50, No. 12
When Physicians and Patients Think Alike: Patient-Centered Beliefs and Their Impact on Satisfaction and TrustRahman Azari, PhD
Submitted, revised, May 17, 2001.
From the Health Psychology Program, Massachusetts College of Pharmacy and Health Sciences, Boston (E.K.); the departments of Communication (R.A.B.) and Statistics (R.A.), University of California, Davis (R.A.B.); the University of California, Davis, Center for Health Services Research in Primary Care, Sacramento (R.L.K., R.A.); and the Division of Family and Community Medicine, Stanford University Medical School, Palo Alto (D.T.). Reprint requests should be addressed to Edward Krupat, PhD, Health Psychology Program, Massachusetts College of Pharmacy and Health Sciences, 179 Longwood Ave, Boston, MA 02115. E-mail: firstname.lastname@example.org.
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 affect patients’ evaluations.
Study Design: Physicians provided demographic information and completed a scale assessing their beliefs about sharing information and power with their patients. 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 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: We measured trust in the physician pre-visit, and visit satisfaction and physician endorsement immediately post-visit.
Results: Among patients, patient-centered beliefs (a preference for information and control) were associated with being female, 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 them, 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.
trust [non-MESH]. (J Fam Pract 2001; 50:1057-1062)
A patient-centered approach to care has been widely advocated1-5 Although there are several dimensions to patient-centeredness, one key element involves patient participation and the sharing of power and information between the patient and physician. Physicians who take a patient-centered orientation approach are more likely to treat them as partners, and assist them in making informed choices among several options. This approach has been associated with a range of positive outcomes, such as heightened patient satisfaction, better adherence, and improved health outcomes.6-10
Yet in spite of the general effectiveness of patient-centeredness, it is reasonable to ask whether a one-size-fits-all approach to patient care is the best one. Some patients—such as the elderly, or patients of certain ethnic backgrounds, for example—may desire a physician whose style is more structured and who provides more guidance.11-14 Patients who are sick or have serious health concerns may also want their physicians to provide more direction.15,16 Therefore, while accepting the overall value of patient-centeredness, some physicians and researchers have advocated that the degree of “fit” between patients and physicians, (the extent to which the physician holds attitudes and beliefs that are congruent with those of the patient17,21) should have an independent effect upon patients’ reactions to their health care providers.
Our study involves the measurement of patient-centeredness among both physicians and patients, in particular beliefs about the sharing of power and information. We asked what personal characteristics were associated with patient-centered beliefs among physicians and patients, and investigated the extent to which patients felt positively about clinicians who hold matching opinions about power and information sharing.
The data we report come from the Physician Patient Communication Project, a large observational study conducted in the Sacramento, California, metropolitan area. Patients in the study were surveyed before and immediately after a target outpatient visit. The physicians provided data before and immediately after the same visits.
Physician Sampling and Data Collection
All physicians and patients in the study were affiliated with one of the 2 major health care systems in the region, the University of California, Davis, Medical Group (UCDMG) or Kaiser Permanente (KP). All physicians were involved in direct patient care at least 20 hours per week in family medicine, internal medicine, or cardiology. Forty-five physicians took part in the study (22 from UCDMG, 23 from KP). Eighteen practiced general internal medicine; 16 were family physicians; and 11 were cardiologists. The UCDMG and KP physicians did not differ significantly with regard to age or sex.
All participating physicians filled out the Clinician Background Questionnaire, which contained basic demographic questions, a 15-item work satisfaction scale,22 and the 9-item Sharing subscale of the Patient-Practitioner Orientation Scale (PPOS).23-25The PPOS, which has been shown to have good reliability and validity, measures the beliefs of patients and physicians along a dimension that ranges from patient-centered to physician-centered. The sharing subscale of the PPOS assesses beliefs toward sharing information (eg, “It is often best for patients if they do not have a full explanation of their medical condition.”) and power and control (eg, “The doctor is the one who should decide what gets talked about during a visit.”) on a 6-point Likert scale from strongly agree to strongly disagree. A higher score indicates an orientation that is more patient-centered (ie, more approving of sharing power and information sharing).
Patient Sampling and Data Collection
We identified the English-speaking adult patients of the participating physicians who could complete the questionnaires with minimal assistance. Because of the larger study’s interest in patient expectations and requests, selected patients had all indicated that they had a new or worsening problem, or that they were at least “somewhat concerned” about a serious undiagnosed condition. Contact with randomly selected patients was made through the physicians’ appointment lists 1 to -2 days in advance of the visit. During the 11- month patient enrollment period, 2606 telephone contacts were made; 677 patients declined to participate, and another 737 were deemed ineligible (69% of these because they had no significant health concern). Of the 1332 eligible consenting patients, 1071 completed screening forms, and 909 completed questionnaires at the scheduled visit.
Eligible patients filled out the Sharing subscale of the PPOS at the end of the screening interview. The instructions for the patients were the same as those for the physicians, and the items and response scale were identical to those filled out by the physicians. Immediately before their office visits, patients filled out the Trust in Physician Scale26 a 9-item instrument asking patients how much confidence they have in their physicians about specific issues (eg, to always tell the truth, to put your medical needs above all other considerations, including cost). This scale could only be completed by patients who had seen the physician at least once before (n=714).
At the end of the visit, patients provided basic demographic and personal information and evaluated the physician and their visit. Visit evaluation was measured using the sum of 5 items assessing satisfaction with care received (ie, amount of time the doctor spent with you today, explanation of what was done for you, personal manner of the doctor, technical skill of the doctor, and overall satisfaction; a=.88). Using a 5-point Likert scale (from strongly agree to strongly disagree), patients additionally evaluated their physician on 3 items (ie, I would make a special effort to see this doctor in the future; I intend to follow the advice of this doctor; and I would highly recommend this doctor to a friend). These were summed to form an Endorsement of Physician Scale a=0.90). All of the evaluative instruments were scored so that a higher score indicated a more positive evaluation.
We first analyzed the data separately for patients and physicians using 1-way analysis of variance to determine the relationship between patient-centered beliefs and personal characteristics. Then analyses were conducted to determine the relationship of (1) the patient’s beliefs, (2) the physician’s beliefs, and (3) the difference between patient’s and physician’s beliefs (“belief congruence”) to patients’ evaluations. Because patients were clustered within-physicians, these analyses were conducted using multivariate generalized estimating equations (GEE) analysis using the Stata 6.0 software (Stata Corporation; College Station, Tex) xtgee procedure. This procedure accounts for within-physician correlation, thereby ensuring that standard errors are not overestimated. In those cases where the GEE analyses indicated significant relationships, analysis of covariance was conducted to determine whether the results remained significant after controlling for potential confounding variables.
Since physicians’ and patients’ attitudes toward sharing power and information were both measured using the Sharing subscale of the PPOS, we were able to compare the scores of each group. Patients’ scores covered the full possible range of the scale, while the range for the 45 physicians was somewhat more constricted (from 2.7 to 5.7). Physicians’ mean scores were significantly higher than those of the patients (4.5 vs 4.2, P <.04), indicating a stronger belief in sharing power and information. The correlation between the score of a given patient with his or her physician scores was extremely small (r = 0.03), and the observed difference scores for each pair (patient score minus physician score) ranged from 3.33 to -3.78.
Patient Characteristics and Beliefs in Sharing
The patient sample contained somewhat more women than men (56% women) and had a mean age of 57 years. More than three fourths (77%) of the sample had completed at least some college, and 30.2% had at least a bachelor’s degree; median income was in the $40,000 to $60,000 range. The vast majority of the patients were white (81.4%), with a small representation of Latinos (6.6%), African Americans (5.4%), Asian/Pacific Islanders (3.1%), and Native Americans/Alaskans (1.9%). Of the patients, 40% were being seen in internal medicine, 37% by family physicians, and 23% in cardiology.
Women were significantly more patient-centered in their beliefs, as were patients who were younger, more educated, and had a higher income Table 1. The scores of patients aged 18 to 39 years, 40 to 49 years, and 50 to 59 years were homogeneous, and as a whole they were significantly more patient-centered than those of patients between ages 60 and 69, and those 70 years and older (using post hoc-tests, the Student-Newman-Keuls statistic). Similarly, those who had completed high school or less were less patient centered than those with some college, who differed from those with at least a bachelor’s degree. Income differences were noted between those who reported $20,000 or less versus compared with those in the $40,000 to $80,000 range compared with those of $80,000 or more. Overall, white patients were more patient-centered than nonwhites; and although the numbers of Latinos, African Americans, Asians, and Native Americans were too small for meaningful statistical comparisons, the scores of African Americans were almost identical to those of the white patients, while Latinos’ and Asian/Pacific Islanders’ scores were somewhat lower and closer to one another. The cardiology patients were less patient centered than those who were being seen in internal medicine or family practice; however, these differences may be explained by the fact that the cardiology patients were significantly older than the other 2 patient groups (mean age = 64.2 years vs 56.2 years for internal medicine and 53.4 years for family practice; F=35.80, df=2, P <.001).
Physician Characteristics and Beliefs in Sharing
Seventy percent of the study physicians were men, and 71% were white (the largest group of nonwhites were Asian/Pacific Islanders [n=6]). Their mean age was 43.9 years, with a median of 13 years since graduation from medical school. They had been affiliated with their current system for a mean of 8.3 years. Ninety-six percent of the physicians were board certified in their primary specialty, and they spent a mean of 39.1 hours in patient care weekly.
Although the physician sample was limited in size, we also explored the relationship of physicians’ PPOS scores to their demographic and personal characteristics. In contrast to the patients, the scores of men and women were very similar (4.52 and 4.45, respectively), and no significant differences were found according to ethnicity, specialty, time spent in patient care, or workplace satisfaction. Also, beliefs in power and information sharing did not differ according to experience, either by splitting physicians at the median on age or the time since their graduation from medical school.
Attitudes Toward Sharing and Patient Evaluations
Patients’ evaluations of their physicians and their visits were measured in 3 different ways: trust (pre-visit), visit satisfaction, and endorsement of physician (both post-visit). Although these measures were themselves highly intercorrelated (between 0.45 and 0.48), separate GEE analyses were performed for each. For each measure, the analysis was run 3 times, each using a different predictor. First, we entered the patients’ PPOS scores as the only predictor, then the physicians’ PPOS scores, and then the difference between the patients’ and physicians’ scores (patient minus physician). As indicated in Table 2, visit satisfaction was not significantly related to any of the predictors. However, patient-centered patients and those whose attitudes were discrepant from their physicians, were both significantly less trusting and less likely to endorse their physicians. Physicians who were patient-centered were marginally more likely to be trusted (P=.09).
Since patients’ PPOS scores were related to several other variables, the GEE analyses for those variables showing significant (P <.05) associations between beliefs and belief congruence as predictors and patient evaluations as outcomes were run a second time, controlling this time for sex, age, education, income, and ethnicity. The results of these analyses did not weaken any of the relationships. Patient PPOS and degree of congruity were each found to be stronger independent predictors of the trust and endorsement than any of the potentially confounding variables.
The results of our study provide us with information about where patient-centered beliefs reside. Among patients, a belief that power and information should be shared appears to be a cultural phenomenon; younger age, female sex, white ethnicity, higher income, and more education were all closely associated with a desire for sharing. Yet we found a somewhat unexpected pattern for age: There was little difference among the 3 youngest categories (18-39, 40-49, and 50-59 years), and then relatively sharp drops among those in their 60s and older. These findings suggest that if there is a generation gap in patients’ beliefs about empowerment, it exists not so much between younger and middle-aged patients as it does between those older than 60 years and those younger than 60 years.
Although the comparable physician data have to be interpreted with extreme caution because of the small sample size, we found that physicians are apparently less affected by those same societal factors that shape patients’ attitudes about sharing of power and information. Consistent with previous administrations of the scale to other physician samples,24 male and female physicians did not differ in their patient-centered beliefs, nor did we find significant relationships between patient-centeredness and physician experience. Contrary to the stereotype that older physicians take a more authoritarian orientation toward patient relationships, the data suggest that patients seeking a physician who values information and power sharing are likely to be disappointed if they merely use physician age as a proxy for patient-centeredness.
Perhaps the most significant finding of this study was that the degree to which patients and physicians held similar orientations was a strong predictor of 2 of the 3 patient evaluation measures. Patients whose beliefs were congruent with their physicians’ beliefs trusted them more, as indicated before they completed the target visit. After the visit, they were also more likely to recommend to others, follow the advice of, and make a special effort to see their physicians (the 3 components of the endorsement index).
Generalizations from our data are limited not only by the small sample size of physicians, and by the fact that the patients and physicians all came from managed care systems in one region of the country. Another limiting factor may be that the visits studied represented a targeted subsample of patients who had an ongoing or worsening problem that concerned them. Nonetheless, the most surprising finding was that physicians who held patient-centered beliefs about power and information sharing were rated no more positively on measures of satisfaction, trust, and endorsement. One possible explanation for this may have to do with the study sample of patients, all of whom had a significant problem or concern. Previous research15,16 has indicated that physicians act differently toward their patients who are more ill or more emotionally distressed, showing greater signs of conflict or tension. It is therefore possible that the power-sharing beliefs of the patient-centered physicians were not translated as directly into action in the course of treating these patients. A second possible explanation is that patients who have strong health concerns may actually want their physicians to revert to ways that are more authoritarian and to take greater control during the course of the visit.
In the light of the demonstrated relationship of congruence to trust and endorsement, it is striking that visit satisfaction did not reflect the same strength of relationship with congruence, even though the outcome measures were themselves highly correlated. We suggest that this pattern reflects the manner in which belief congruence operates within the physician-patient relationship. That is, even when patient and physician have a shared sense of how much control makes them both feel comfortable, this may not be reflected in the success of any single encounter. Attempts to meet a patient’s expectation do not always result in visit satisfaction.27 Yet when physicians and patients begin with similar world views about medical practice or when they negotiate a meeting of the minds in the course of their relationship, it is likely that this is reflected in patients’ global positive sentiments, the kind that are indicated by endorsement and trust.
This research was funded by a grant from the Robert Woods Johnson Foundation (#034384). The authors gratefully acknowledge the assistance of the 45 participating physicians and their patients. Thanks also go to Sara Lu Vorhes, Steven Kelly-Reif, and David Omerod for assistance with physician recruitment and data collection; to Christine Harlan for budgetary management; and to the staff of the Patient-Provider Relationship Initiative (Bernard Lo, Director) for technical assistance. No conflict of interest.
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