Family Practice

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Family Practice Vol. 19, No. 3, 257-263
© Oxford University Press 2002

The ‘Medical Interview Satisfaction Scale’ (MISS-21) adapted for British general practice

Richard Meakin and John Weinman^a

Royal Free & University College Medical School, Archway Campus, 4th Floor, Holborn Union Building, Highgate Hill, London N19 3UA and
^a Unit of Psychology, Division of Psychological Medicine, GKT, Guy's Hospital, London Bridge, London SE1 9RT, UK.

Meakin R and Weinman J. The ‘Medical Interview Satisfaction Scale’ (MISS-21) adapted for British general practice. Family Practice 2002; 19: 257–263.

Received 14 August 2001; Accepted 7 January 2002.

	Abstract

Top Abstract Introduction Method Results Discussion Appendix 1. The MISS-21 References

 
Background. The 29-item ‘Medical Interview Satisfaction Scale’ (MISS-29) was developed in the USA to assess patient satisfaction with individual doctor–patient consultations. It has been used in studies from British general practice. However, there is limited evidence for its psychometric properties in this population.

Objectives. The present study was designed to examine the validity, reliability and applicability of the MISS-29 in British general practice populations.

Methods. The study was divided into two phases. The first investigated the properties of the MISS-29 in a UK general practice population and resulted in a modified MISS (MISS-21). The second investigated the properties of the MISS-21 in a wider UK general practice population. In phase 1, 150 patients over 16 years were recruited sequentially from patients attending a large group practice in suburban north London. Patients completed a questionnaire which collected demographic data and the MISS-29. In phase 2, 159 patients with a new problem were recruited from patients over 16 years consulting 18 GPs in north London, Essex and Suffolk. Patients completed a questionnaire while waiting to see the doctor; this collected demographic data and included six separate items, designed by the author, intended to measure patient satisfaction with previous consultations with the doctor. The patients completed the MISS-21 when they left the doctor's consulting room.

Results. The response rates for the phase 1 and phase 2 studies were 76.9 and 72.6%, respectively. Factor analysis, using principal component analysis with a varimax rotation, of the data collected in phase 1 resulted in a 21-item scale with the same four subscales as the original MISS-29. Correlations between subscales range from 0.46 to 0.65. Values of Cronbach's alpha between 0.67 and 0.92 suggest that the subscales are internally consistent under the conditions of the study. In phase 2, 92.1% completed all the items in the MISS-21 and there were no significant relationships between patients' demographic variables and the proportion of completed MISS-21 questionnaires, nor were there any differences in the proportion of completed MISS-21 questionnaires between type of practice or between practices serving different geographic populations, suggesting that the items were acceptable to patients. There were highly significant positive correlations (0.21–0.63) between scores on the MISS-21 and all aspects of satisfaction with previous consultations, providing supportive evidence for the construct validity of the MISS-21.

Conclusion. This study has demonstrated that the use in British general practice of the 29-item MISS developed in the USA should be treated with caution. However, a new 21-item version with the same four subscales as the 29-item MISS was developed which has satisfactory internal reliability. The correlations between subscales suggest that they represent fairly discrete but overlapping aspects of satisfaction. Evidence is produced suggesting that patients have less difficulty completing the MISS-21 and that it is applicable for assessing satisfaction with the consultation in different practice types and populations in the UK. Limited data supporting the construct validity of the MISS-21 are presented. While this study does not provide a full assessment of the MISS-21, we believe it provides evidence for its psychometric properties, which suggests that it is a valid and reliable instrument for the assessment of patient satisfaction with individual consultations in British general practice.

Keywords. Consultation, general practice, Medical Interview Satisfaction Scale, patient satisfaction.

	Introduction

Top Abstract Introduction Method Results Discussion Appendix 1. The MISS-21 References

 
Patient satisfaction is important not only as a measure of quality of care in terms of acceptability to individual patients or populations, but also as a predictor of important health outcomes. Satisfaction with the consultation predicts compliance with treatment,^1–3 which has both implications for the effectiveness of the medical professions' treatments and economic implications in terms of wasted medicines. It also predicts whether patients re-attend for treatment.^4,5 Clearly this may also have implications for the effectiveness of both therapeutic and preventive interventions. There is also evidence that higher patient satisfaction is associated with improved health status.^6–14

In the UK, the GP's role as the gatekeeper to the National Health Service (NHS) means that the general practice consultation has a central role in patient contacts with the NHS. Understanding what determines patient satisfaction with the consultation may have practical implications for improving patients' health outcomes, the quality assessment of novel service provision and the doctor–patient interaction, and thus implications for clinical governance, training and re-validation. Also delivering a service that satisfies patients may be important for GPs' finances as there is evidence that dissatisfied patients are more likely to change doctors.^15,16 Therefore, it is important to develop valid, reliable and sensitive tools for the measurement of patient satisfaction in this context.

The Consultation Satisfaction Questionnaire (CSQ) is the only published measure of patient satisfaction with individual consultations in English general practice.¹⁷ This is an 18-item questionnaire which has three subscales (Professional Care, Depth of Relationship and Perceived Time) and three items concerning general satisfaction with the consultation. Baker presents evidence for its internal consistency, content validity and more limited evidence for construct validity.¹⁷ However, the Perceived Time subscale is also not a discrete outcome measure of the doctor–patient interaction in the consultation itself as the perception of enough time may be influenced by service factors such as the appointment system. A more specific tool that focuses on the doctor–patient interaction in the consultation may have benefits for investigating patient satisfaction with the consultation.

The Medical Interview Satisfaction Scale (MISS) was developed in the USA^18,19 to look specifically at satisfaction with individual consultations. The first version (MISS-26)¹⁸ was a 26-item questionnaire and has three subscales (Cognitive, Affective and Behavioural), and was criticized for lack of evidence of validity and intercorrelations between the subscales. As a result, a second 29-item version (MISS-29)¹⁹ with four subscales (Communication Comfort, Distress Relief, Compliance Intent and Rapport) was produced. These subscales were more independent and the pattern of responses less skewed towards satisfaction, but it has also been criticized for lack of validity data.²⁰ There is little published information about how the items in the MISS-29 were derived, although seven items appear in the MISS-26 and these items were derived from patient interviews and observations of consultations.¹⁸ Wolf and Stiles¹⁹ cite correlations with various personality traits, attitudes towards medical care and health beliefs, which are independent of the quality of the consultation, as evidence for construct validity for MISS-29. Kinnersley et al.²¹ have also demonstrated evidence of concurrent validity. There is also evidence for the internal consistency of the MISS-29.¹⁹

The MISS has been used in studies performed in UK general practice.^22–25 Also, Kinnersley et al.²¹ have compared the CSQ and the MISS-29 in British general practice and found neither to be superior in psychometric terms. They reported no particular problems with the wording of the MISS-29 but they found slightly lower levels of satisfaction with a wider range of scores than that reported in the USA. They also found levels of reliability (internal consistency) for the MISS-29 similar to those reported in the USA. However, analysis of the data from an earlier study by one of the authors²⁴ suggested that its factor structure might be different in a British general practice population. In view of this, the present study was designed to examine the validity, reliability and applicability of the MISS-29 in British general practice populations.

	Method

Top Abstract Introduction Method Results Discussion Appendix 1. The MISS-21 References

 
The study was divided into two phases. The first investigated the properties of the MISS-29 in a UK general practice population and resulted in a modified MISS (MISS-21). The second investigated the properties of the MISS-21 in a wider UK general practice population.

Phase 1—the evaluation of the MISS-29 in a British general practice
The co-operation of a large group practice (13 500 patients) in suburban north London was sought. Patients over 16 years were recruited sequentially from those attending the study surgery sessions to consult their doctor. Since 150 patients are required to factor analyse a 29-item scale, recruiting continued until at least 150 patients were recruited who had completed all the items in the MISS-29.

All patients participating were given a questionnaire which collected demographic data to complete while they were waiting for the doctor. This was collected before patients saw the doctor. As the patient left the doctor's consulting room, they were given the MISS-29. This was collected before patients left the surgery premises.

Phase 2—evaluation of the MISS-21 in a wider British population and the assessment of construct validity
The co-operation of 16 GPs within north London, Essex and Suffolk was sought. The GPs were chosen sequentially from health authority lists to represent one male and one female GP from each of the following types of practice: single-handed inner city; inner city partnership; single-handed suburban; suburban partnership; single-handed market town; market town partnership; single-handed rural; and rural partnership. Each GP was asked to allow 10 patients with a new problem to be recruited to the study.

Patients over 16 years attending the study surgery sessions to consult their GP were recruited sequentially. All participating patients were given a questionnaire to complete while waiting to see the doctor. This questionnaire collected demographic data. It also included six separate items, designed by the author, intended to measure patients' satisfaction with previous consultations between themselves and this doctor. The questionnaires were collected before the patient saw the doctor. The patients were given the MISS-21 (see Appendix 1) to complete when they left the doctor's consulting room. This was collected before patients left the surgery premises.

Analysis
Descriptive statistics were used to describe the distribution of the demographic features and patients' perceptions in the sample population. Univariate associations were tested using the chi-squared test for categorical variables, Mann–Whitney U test for ordinal variables or non-normally distributed continuous variables, Student t-test for normally distributed continuous variables and Spearman's rank correlation coefficient for ordinal or non-normally distributed continuous variables. Exploratory factor analysis was performed using principal component analysis with a varimax rotation.²⁶ This used the same technique as the original work in the USA (WB Stiles, personal communication, 1993). Internal reliability was assessed using Cronbach's alpha.²⁷

	Results

Top Abstract Introduction Method Results Discussion Appendix 1. The MISS-21 References

 
Phase 1—the evaluation of the MISS-29 in a British general practice and the development of the MISS-21
Of the 360 patients attending the study surgeries, 277 (76.9%) agreed to participate. However, 95 patients failed to complete all twenty-nine items in the MISS-29 questionnaire. The mean age of the 182 patients who completed the MISS-29 was 48.3 years (SD 18.5). Fifty-eight per cent were female. Eighty-six per cent gave their first language as English. Eighty-six per cent described themselves as white. The mean age of leaving full-time education was 18.3 years (SD 4.6).

The anonymity of the questionnaire did not allow comparison between those who refused to participate in the study and those who agreed. However, those who did not complete all the items in the MISS-29 questionnaire had all completed the pre-consultation demographic questionnaire, enabling a comparison between this group and those who completed the MISS-29. There was a significantly larger proportion of women (chi-square = 4.75, d.f. = 1, P < 0.03) in the group who did not complete all the items in the MISS-29 (72% women) questionnaire compared with the group who did (58% women). However, there were no significant differences in other demographic features between the groups.

Acceptability of items in the MISS-29
In order to ascertain whether particular items were difficult to complete, a comparison was made for each item in the MISS-29 questionnaire between patients who completed all the items and those who did not. This showed no significant differences in age, sex, first language or racial group. However, for four items, patients who did not complete the item were more likely to have left full-time education at an earlier age (‘the doctor seemed interested in me as a person’ U = 3085.5, z = –2.37, P < 0.02; ‘the doctor seemed warm and friendly to me’ U = 3120.0, z = –2.13, P < 0.04; ‘I felt that this doctor did not treat me as an equal’ U = 3288.0, z = –1.98, P < 0.05; and ‘the doctor seemed to take my problems seriously’ U = 3172.5, z = –2.14, P < 0.04).

Factor analysis
The exploratory factor analysis performed on the items in the MISS-29 resulted in a 5-factor solution. This result was in contrast to the four factors described in the MISS-29 developed in the USA.²⁰ However, two of the factors were composed mainly of items attributed to the same factor in the MISS-29, and closer inspection did not suggest that these new factors represented separate concepts. The factor analysis was re-run using a 4-factor solution and excluding eight items that did not load highly onto any factor (factor loading < 0.4) or that loaded highly onto more than one factor. This resulted in a 21-item scale (MISS-21) with the same factor structure as the original MISS-29. The factor matrix for MISS-21 is shown in Table 1.

View this table: [in this window] [in a new window]   TABLE 1 The rotated (varimax) factor matrix for the MISS-21

 
The four factors represented the same concepts of ‘Distress Relief’, ‘Communication Comfort’, ‘Rapport’ and ‘Compliance Intent’. Correlations between subscales range from 0.46 to 0.65 (see Table 2), suggesting that they represent fairly discrete aspects of patient satisfaction though there is sufficient intercorrelation between the subscales to suggest that they are also aspects of a more global evaluation.

View this table: [in this window] [in a new window]   TABLE 2 The MISS-21 subscale correlation matrix

 
The mean item scores (sum of item scores/number of items) and their standard deviations together with measures of kurtosis, skewness and Cronbach's alpha for the individual subscales and the whole MISS-21 questionnaire are given in Table 3.

View this table: [in this window] [in a new window]   TABLE 3 The MISS-21 descriptive statistics

 
The values of Cronbach's alpha between 0.67 and 0.92 suggest that the subscales of the questionnaire are internally consistent under the conditions of this study.

Phase 2—evaluation of the MISS-21 in a wider British population and the assessment of construct validity
Eighteen GPs were recruited (nine males and nine females). It proved impossible to recruit an inner city single-handed female GP. Therefore, an additional inner city female GP from a partnership was recruited instead to maintain the gender balance among inner city GPs. Also one single-handed female and one male GP from a partnership in the market town category withdrew before sufficient patients had been recruited. In view of this, a replacement GP was recruited for each category.

The sample consisted of 208 patients attending the study surgeries and who believed themselves to have a new problem. Of these, 159 patients agreed to participate. Unfortunately, eight patients did not receive the MISS-21 after the consultation and were therefore excluded. The response rate was 72.6% (151/208). The mean age of the sample was 43.3 years (SD 17.1). Sixty-three per cent (93/151, 61.3%) were female. Ninety-one per cent (137/151, 90.7%) considered themselves to be white. English was the first language of 91.4% (138/151, 91.4%). Seven were still in full-time education. Among those who had left full-time education, the mean age of leaving was 17.7 years (SD 3.7).

Acceptability of MISS-21 items
Ninety-two per cent (139/151, 92.1%) of the sample completed all the items in the MISS-21. There were no significant relationships between patients' demographic variables and the proportion of completed MISS-21 questionnaires (see Table 4).

View this table: [in this window] [in a new window]   TABLE 4 Completion of MISS-21 with demographic variables

 
Also there was no significant difference in the proportion of completed MISS-21 questionnaires between single-handed practices and partnerships (chi-square = 0.155, d.f. = 1, P = 0.694) nor between practices serving different geographic populations (chi-square = 4.233, d.f. = 3, P = 0.237).

Assessing construct validity
In order to examine the construct validity of the MISS-21, associations between MISS-21 scores and scores on items in the pre-consultation questionnaire regarding patients' satisfaction with previous consultations were examined. There were highly significant positive associations between satisfaction with the current consultation and all aspects of satisfaction with previous consultations (see Table 5)

View this table: [in this window] [in a new window]   TABLE 5 The rotated (varimax) factor matrix for the MISS-21

 

	Discussion

Top Abstract Introduction Method Results Discussion Appendix 1. The MISS-21 References

 
This study has demonstrated that the use of the 29-item version of the MISS developed in the USA^18,19 should be treated with caution. In this study, 34% of respondents failed to complete this questionnaire. This compares with the 15% reported by Kinnersley et al.²¹ The study also confirmed earlier observations by one of the authors that the MISS-29 did not appear to have the same factor structure when evaluated in a British general practice population as when it was developed in the USA. However, by excluding some of the items that did not load highly onto any factor, a new version of the MISS was constructed that has the same factor structure.

This new 21-item version (MISS-21) has four subscales representing the same areas of satisfaction as the subscales of the MISS-29 and does not include any new items. It has satisfactory internal reliability which is consistent with levels reported for the MISS-29.^19,21 The correlations between subscales lie between 0.46 and 0.65, suggesting that they represent fairly discrete but overlapping aspects of satisfaction. This compares with the higher levels of correlation between subscales (0.58–0.84) reported by Kinnersley et al.²¹ in their study of the MISS-29 in British general practice. This development work was undertaken in a single group practice in north London and, in order to assess the MISS-21 in a wider general practice population, a second phase study was undertaken. This study demonstrated that only 8% of respondents failed to complete the questionnaire compared with 34% in our phase 1 study of the MISS-29 and the 15% reported by Kinnersley et al.²¹ There were no associations between patient demographic variables or practice type and non-completion. This suggests that patients have less difficulty completing the MISS-21 and that it is applicable for assessing satisfaction with the consultation in different practice types and populations in the UK.

The phase 2 study also enabled us to collect limited data to support the construct validity of the MISS-21. The highly significant correlations (0.21–0.63) between the items designed to assess patients' satisfaction with previous consultations and all aspects of satisfaction with the current consultation using the MISS-21 provide supportive evidence for the construct validity of the MISS-21.

While this study does not provide a full assessment of the MISS-21, we believe it provides evidence for the psychometric properties of the MISS-21, which suggests that it is a valid and reliable instrument for the assessment of patient satisfaction with individual consultations in British general practice.

	Appendix 1. The MISS-21

Top Abstract Introduction Method Results Discussion Appendix 1. The MISS-21 References

 
The patient is asked to indicate their level of agreement on a 7-point Likert scale.

Very strongly disagree = 1

Strongly disagree = 2

Disagree = 3

Uncertain = 4

Agree = 5

Strongly agree = 6

Very strongly agree = 7

• 1 The doctor told me just what my trouble is. (DR)
  
• 2 After talking with the doctor, I know just how serious my illness is. (DR)
  
• 3 The doctor told me all I wanted to know about my illness. (DR)
  
• 4 I am not really certain about how to follow the doctor's advice. (CC)
  
• 5 After talking with the doctor, I have a good idea of how long it will be before I am well again. (DR)
  
• 6 The doctor seemed interested in me as a person. (R)
  
• 7 The doctor seemed warm and friendly to me. (R)
  
• 8 The doctor seemed to take my problems seriously. (R)
  
• 9 I felt embarrassed while talking with the doctor. (CC)
  

1. 0 I felt free to talk to this doctor about private matters. (R)
   
2. 1 The doctor gave me a chance to say what was really on my mind. (R)
   
3. 2 I really felt understood by my doctor. (R)
   
4. 3 The doctor did not allow me to say everything I had wanted about my problems. (CC)
   
5. 4 The doctor did not really understand my main reason for coming. (CC)
   
6. 5 This is a doctor I would trust with my life. (R)
   
7. 6 The doctor seemed to know what (s)he was doing. (R)
   
8. 7 The doctor has relieved my worries about my illness. (DR)
   
9. 8 The doctor seemed to know just what to do for my problem. (DR)
   
10. 9 I expect that it will be easy for me to follow the doctor's advice. (CI)
    
11. 0 It may be difficult for me to do exactly what the doctor told me to do. (CI)
    
12. 1 I’m not sure the doctor's treatment will be worth the trouble it will take. (CI)
    

DR = Distress Relief subscale; CC = Communication Comfort subscale; R = Rapport subscale; CI = Compliance Intent subscale.

	Acknowledgments

 
We would like to thank all the GPs and patients who participated in this research and Corinna White and Eva Meakin our research assistants. We would also like to thank Dr R Morris for his statistical advice. This work was supported by a grant (No. 825) from the Peter Samuel Fund, Royal Free Hospital School of Medicine.

	References

Top Abstract Introduction Method Results Discussion Appendix 1. The MISS-21 References

 
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