Family Practice Vol. 18, No. 1, 42-47
© Oxford University Press 2001
Doctor-patient relationships |
Patients' views on the professional behaviour of family physicians
Lazi-Banaszak
Department of Family Medicine, ‘Andrija 
tampar’, School of Public Health, Rockefellerova 4, 1000 Zagreb, Croatia.
Kati M, Budak A, Ivankovi D, Mastilica M, Lazi , Babi-Banaszak A and Matkovic V. Patients' views on the professional behaviour of family physicians. Family Practice 2001; 18: 42–47.
Received 7 January 2000; Revised 12 May 2000; Accepted 5 September 2000.
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Abstract |
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Background. Patient satisfaction is an important part and a measure of the quality of health care. Patient satisfaction with family physicians was studied within the project ‘Analysis of Transition of Health Care System in Croatia’.
Objectives. The aim of this study was to explore patient satisfaction with family physicians through evaluation of some characteristics of physician behaviour. The specific goals of this study were to determine whether there were differences in the evaluation of patient satisfaction with physician behaviour with regard to some sociodemographic characteristics of the respondents.
Methods. The study group consisted of 1217 respondents: 479 (39.4%) men and 738 (60.6%) women. Medical students interviewed the respondents ‘face-to-face’ immediately after their consultation with the physician. An anonymous questionnaire was created providing answers to 10 questions on patient satisfaction. Data on sociodemographic characteristics and the reason for encounter of the respondents were also collected.
Results. The average positive rating over 10 questions on patient satisfaction was 85.3%. There was a statistically significant difference in age distribution between geographic areas (P < 0.001). Differences in answers were found regarding sex, age, educational level (P < 0.001) and reason for encounter (P < 0.01). Two factors were obtained by factor analysis: the first could be called physician's competence/expertise estimated by respondents, and the other physician's empathy evaluated by respondents. The respondents were divided into two groups based on the reason for encounter as a criterion for discriminant analysis: acute (symptoms and complaints, injuries; n = 553) and other reasons (n = 664). The discriminant function obtained was statistically significant (P < 0.01). Younger respondents, regardless of sex, whose reason for encounter was an acute condition, were less satisfied with the physician's expertise, agreeableness during the consultation, physician's interest in what they were saying and physician's friendliness.
Conclusion. Considering the difficulties present in the health systems of countries in transition, the results of our study were surprisingly encouraging, showing that the respondents were satisfied with the physician's behaviour and that the physicians fulfilled the basic elements of professional behaviour.
Keywords. Family practice, patient satisfaction, physician behaviour.
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Introduction |
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Health care quality assurance and improvement has become a growing issue in health care systems of all countries. It is a systematic and permanent process that should be integrated and implemented effectively in the everyday work of all health care system members.1
Patient satisfaction is an important part of health care. It is defined as "an evaluation based on the fulfilment of expectations".2 It is also a measure of quality of health care.3 A successful doctor–patient relationship is one of the basic characteristics of work in family practice. The most productive relationship between the doctor and the patient is achieved when the doctor completely understands the patient's present complaints and his diagnosis.
Patients can make a useful contribution to health care system improvement. As participants, they can influence the quality of health care and it is important to know which aspects of health care are important for patients. Such knowledge helps those who provide health care to set out the priorities in their efforts to respond to patients' needs and desires.4
Satisfaction is a personal experience and it is influenced by the quality of the consultation and by the extent to which the physician manages to satisfy the patient's expectations. When the patient is satisfied with the consultation and actively involved in the decision-making process about the therapy, it is more likely that he will follow his physician's instructions and that their relationship will be successful.5 The doctor–patient relationship and the physician's professional competence have the greatest value for patients in the overall estimation of quality of health care.6
Changes in the health care system in Croatia, which started in 1990, affected all components of the system—delivery, financing, control and reimbursement structure. The ultimate goal of the reform is to rationalize health care expenses radically without jeopardizing the health status of the population, and a political decision was made that the government should take over the control of the previously disintegrated and uncontrolled health system.7 The aim of this study is to explore patient satisfaction with family physicians through evaluation of some characteristics of physician behaviour. The specific goals of this study are to determine whether there are differences in the evaluation of patient satisfaction with physician behaviour regarding some sociodemographic characteristics of the respondents.
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Methods |
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This study was conducted in selected family practices where patients were interviewed in waiting rooms immediately after the consultation with the physician. Randomly chosen patients were interviewed face-to-face in 10 minutes by trained interviewers—students of the Zagreb University Medical School. Randomization was performed at two levels. First, a working day was selected randomly within each selected practice. Secondly, family physicians were asked about their average daily number of consultations and, from the expected daily number of patients, 10% of patients were chosen randomly with respect to the order of consultations. Only patients aged 18 years and over were included in the study. If a younger patient appeared on the randomization list, the next patient on the list was interviewed. The rejection rate was <1%. The selected family physicians gave informed consent for the procedure 2–3 months before the event.
The questionnaire was developed partly on the basis of methodology from earlier work.8,9 Most of the questions were designed originally for the purpose of this study. In stage 1, open-ended explanatory interviews were carried out to collect the full range of patient views on personal and professional qualities of their chosen physician. A review of other questionnaires on patient opinion on physician behaviour was undertaken.10,11 In stage 2, a fixed closed questionnaire was designed. The applicability of the questionnaire was established by pilot testing. The questionnaire was anonymous, consisted of a series of statements, and the respondents were told to express the degree of their agreement or disagreement with the given statements. The answers were based on a five-point Likert scale ranking from "I completely disagree" to "I completely agree". The questionnaire was ‘episode specific’, i.e. the patients were evaluating the behaviour of their physician immediately after the consultation and not evaluating the health care system and physicians in general. The questions referred to physician behaviour during the consultation (10 statements):
- He explained everything about my illness in detail.
- He did his job very competently.
- I didn't understand a great deal of what he told me.
- He didn't have the time to talk to me.
- He showed interest in all of my problems, not just my illness.
- He was full of understanding.
- He wasn't interested in what I was telling him.
- He gave me useful instructions and advice.
- He was very unkind.
- It was pleasant talking to him.
Questions on nurse behaviour (five statements), and conditions and organization of work (six statements) were also included. The questionnaire also contained questions on sociodemographic characteristics (sex, age, education and employment) of the respondents. The last question in the questionnaire referred to the reason for encounter, and the respondents described this in their own words. In the analysis, the reasons for encounter were divided into seven groups: (i) symptoms and complaints; (ii) diagnostic and preventive procedures; (iii) therapeutic procedures; (iv) seeing the test results; (v) administrative reasons; (vi) referral to specialist consultations and tests; and (vii) injury, based on the International Classification of Primary Care (ICPC).12
When the respondents stated more than one reason for encounter, we entered the first stated reason only.
In this study, an analysis of the part of the questionnaire regarding patient satisfaction with physician behaviour was done.
Categorical data distributions were compared by chi-squared test. Factor analysis and discriminant analysis were applied to quantitative and semi-quantitative data. Variables consisting of questions on physician behaviour as well as questions regarding age and educational level of respondents were subjected to factor analysis. Discriminant analysis was performed among the groups of respondents regarding reason for encounter.13
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Results |
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A total of 1217 respondents were questioned: 479 (39.4%) men and 738 (60.6%) women. The survey included 573 respondents from 11 municipalities in the city of Zagreb, 343 from the municipality of Ivani
, 146 from the municipality of Samobor, 93 from the island of Bra
and 62 from the island of Korula. The distribution of respondents by sex and age groups is shown in Figure 1
.
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A statistically significant difference in age distribution between geographic areas was found. The respondents from Zagreb were on average older than the respondents from other areas (chi-squared = 41.27; d.f. = 8; P < 0.001). There was no statistically significant difference in age distribution regarding sex.
The respondents were divided into four groups with regard to their educational level. Out of 1217 respondents, 368 (30.2%) had no schooling at all, had not completed primary school or had only completed primary school. The second group, with completed trade, industrial or other secondary schooling, consisted of 651 (53.5%) respondents. In the third group, there were 96 (7.9%) respondents with completed 2-year higher degree education. A total of 102 (8.4%) respondents had university education, a masters degree, PhD or specialization. There was a statistically significant difference in educational level between male and female respondents: men were more educated (chi-squared = 36.07; d.f. = 3; P < 0.001).
For the description of the respondents' answers, a shortened distribution based on a Likert scale was used and the answers were divided up as follows: "I disagree", "I neither agree nor disagree" and "I agree". Table 1 shows the distribution of the respondents' answers to all 10 questions which describe the respondents' perceptions of physician behaviour.
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The first question was answered positively mainly by older respondents (P < 0.001). Respondents who had undergone secondary and higher education estimated the physician's competence less highly than other respondents (P < 0.001); they also estimated the physician's willingness to understand them less highly than others (P < 0.05).
A difference among respondents was also found regarding the question on understanding physician's explanations. Respondents with a lower level of education (P < 0.001) and younger respondents (P < 0.01) estimated that they did not understand the physician's explanations very well.
Older respondents rated more positively than others the physician's interest not only in their illness but in all their problems (P < 0.05).
A total of 631 out of the 1217 respondents lived in a town, 431 in a village and 155 on an island. Discriminant analysis regarding place of residence did not show a statistically significant difference in evaluating physician behaviour among the respondents.
The respondents were divided into two groups based on the reason for encounter as a criterion for discriminant analysis: acute (symptoms and complaints, injuries; n = 553) and other reasons (n = 664). The discriminant function obtained was statistically significant (chi-squared = 77.17; d.f. = 12; P < 0.01). The meaning of the obtained discriminant function is described by a structure matrix containing a Pearson correlation coefficient of obtained function and manifest variables. The function is defined predominantly by the first five items in Table 2.
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The function is evaluated at group centroids (discriminant function group averages), the centroid of the acute group being –0.27950, and the centroid of the group of others being 0.23889. The definition of the function and position of group centroids are presented in Figure 2
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Younger respondents, regardless of sex, whose reason for encounter was an acute illness, a complaint or an injury, were less satisfied with their physician's competence and with the lack of agreeableness in talking to the physician, but satisfied with the physician's interest in what they were saying, and with the physician's kindness.
In order to recognize the latent (underlying) dimensions in the patient satisfaction with physician behaviour, factor analysis was used. In addition to answers to the questions on physician behaviour during the consultation, patients' age and educational level were taken into account. Three derived latent dimensions with an eigenvalue above 1.0 were obtained by factor analysis. They accounted for 57% of the total variance (Table 3).
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It is evident that the first factor is described dominantly with positive perceptions of physician's understanding, competence, detailed information on illness, agreeableness during conversation, showing interest in all patient's problems and giving useful instructions and advice. This factor could be called the physician's competence as estimated by respondents.
The second factor is described dominantly with positive experiences: physician's willingness to spend time in talking to the patient, the physician's interest in what the patient was saying, the patient's understanding of what the physician was saying, and the physician's kindness. This factor could be called the physician's empathy as evaluated by respondents.
The third factor loadings are described predominantly by age and educational level: older respondents of lower educational level.
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Discussion |
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Sociodemographic characteristics of patients as an important factor in evaluating patient satisfaction with health care in general have been researched in many studies. Data from the literature regarding the correlation between patient satisfaction and sociodemographic characteristics of patients are controversial. Hall and Dornan performed a meta-analysis of studies on the correlation between sociodemographic characteristics of patients and patients' satisfaction with the health care system. They considered different points of view and concluded that the correlation between sociodemographic characteristics of patients and patients' satisfaction is relatively poor, inconsistent or does not even exist.14
A patient's age turned out to be a more consistently correlating variable than other sociodemographic variables, and many authors agree that older patients are more satisfied.15 In our research, older respondents gave statistically significant more positive answers to questions on the physician's willingness to explain everything about their illness in detail and to questions on the physician's interest in all their problems and not just the illness. This implies that the physician gives his patient sufficient attention, and this particular characteristic of physician behaviour had the best rating in research on the reason for the choice of physician in the work of Budak et al.16 In our research, there was no statistically significant difference in the respondents' satisfaction in terms of gender. The results of several studies have shown a correlation between gender and overall satisfaction with service.17 The results of the current research are consistent with those of previous quantitative research on patient satisfaction and communication where two key components that determine patient satisfaction arise. Those components are the technical competence of the physician and interpersonal characteristics. The patients accepted both of those factors as crucial for determining the quality of health care.
The results of factor analysis of the respondents' answers in our study have also shown that patients perceived physician behaviour in, so to speak, two dimensions: the physician's professional competence and the presence of empathy, which means successful communication and physicians' understanding. These results are similar to those found in other similar studies; Wensing concluded that patients found the physician's competence and knowledge of the patient's personality to be most important, and the results have shown that it is most important for the patient that his doctor hears him out, and defines and understands his problems well.4
Patient overall satisfaction with medical service is influenced by the extent to which the characteristics of physicians' professional behaviour are compatible with patient expectations. Patient dissatisfaction with the consultation may be the result partly of what professionals usually call ‘unrealistic’ patient expectations. Without diminishing the importance of clinical evaluation, physicians should, nevertheless, bear in mind the fact that the patient's knowledge is also based on experience and understanding of his condition, previous knowledge and information from previous visits. Patients expect from their physician an explanation of what is happening to them and what is wrong, and they want to feel that the physician understands their problem. They also expect to have the physician's support regarding their emotional condition.
In this interaction, the presence of a certain amount of disagreement between the physician and the patient due to their different expectations and their different experience is inevitable and it would be unrealistic to expect a total absence of conflict between those two interactive partner roles. Even though the behaviour of the physician and the staff is susceptible to change, dissatisfaction with the doctor–patient relationship is, for most of the patients, the main reason for changing their physician.18
Patients are more likely to be completely satisfied if they believe themselves to be in good health, when they do not wait too long and have health insurance. Patient dissatisfaction is connected with the time spent waiting and the belief that the physician did not pay enough attention. Knowing this, it is understandable why patients with acute conditions and complaints showed less satisfaction with physician behaviour in this study.
Data collected in this study have shown that there is a high total level of patient satisfaction with family physicians in all municipalities in the Republic of Croatia included in this research. The average level of satisfaction with physician behaviour for all 10 investigated characteristics was 85.3%. In Mastilica and Chen's research on health care users' views conducted in 1994, only 98 (17.8%) out of 562 respondents from Split and Zagreb expressed satisfaction with the health care system. However, when researching particular components of the health care system, 37.3% of the respondents expressed satisfaction because of the kindness of medical staff and quality and professional level of health care.7
The reasons for these controversial results lie in the fact that our research was conducted in waiting rooms of family physicians' offices among patients who were interviewed immediately after their visits and the only parameter investigated was patient satisfaction with the physician's behaviour. In contrast, the research by Mastilica and Chen was conducted in an unselected group of all health care users and their satisfaction with the health care system in general and the understanding of its changes were researched.
With respect to the fact that the way of interviewing the patients could have influenced the results of the research, the total expressed satisfaction of respondents with the family physician behaviour in our research is very high. We can assume that the expressed satisfaction of patients in our research is a reflection of the role of a family physician who, with his position in the health care system, should give equal care to all patients regardless of the nature of the problem, sex, age, or social and economic position. Judging by these results, family physicians in the Republic of Croatia, while caring for their patients, respect the basic determinants of their professional behaviour.
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References |
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1 Grol R, Baker R, Wensing M, Jacobs A. Quality assurance in general practice: the state of the art in Europe. Fam Pract 1994; 11: 460–467.
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18
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