Family Practice Vol. 19, No. 4, 326-332
© Oxford University Press 2002
Health Services Research |
Illness behaviour and patient satisfaction as correlates of self-referral in Japan
Department of General Medicine and
a Department of Psychiatry, Saga Medical School, Saga, Nabeshima 5-1-1, Saga 849-8501, Japan.
Yingqiu Guo; E-mail: g9817{at}post.saga-med.ac.jp
Guo Y, Kuroki T, Yamashiro S and Koizumi S. Illness behaviour and patient satisfaction as correlates of self-referral in Japan. Family Practice 2002; 19: 326–332.
Received 26 July 2001; Revised 11 December 2001; Accepted 11 March 2002.
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Abstract |
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Background. Patients who frequently change physicians without letters of referral are common, and this has become a source of concern among primary care doctors in Japan. Previous studies have shown a correlation between psychiatric disorders and patient dissatisfaction and the utilization of medical resources. Abnormal illness behaviours such as hypochondria and inappropriate treatment seeking have been associated with various psychiatric disorders. The relationship between illness behaviour and self-referral in Japan has yet to be fully explored.
Objectives. Our aim was to describe the characteristic illness behaviour and satisfaction level of self-referred patients in the general medicine clinic of Saga Medical School Hospital.
Methods. Using the Japanese version of the Illness Behaviour Questionnaire (J-IBQ), we examined the illness behaviour of 277 self-referred patients visiting the clinic. Patient satisfaction with previous medical care was examined with the use of our original Patient Satisfaction Questionnaire. The results were compared with those for physician-referred patients.
Results. Self-referred patients differed significantly from original-visit patients on the GH (general hypochondriasis), DC (disease conviction), AD (affect disturbance) and I (irritability) scales and from physician-referred patients on the GH and DC scales. In comparison with physician-referred patients, self-referred patients showed significant dissatisfaction with their most recent medical visit elsewhere. Dissatisfaction toward the medical staff, especially the doctors, was stronger than that toward the medical environment, waiting time or the on-site medical equipment.
Conclusions. It is important to give patients appropriate overall support, not only physical but also emotional, when they first visit a general physician for medical advice. The J-IBQ may be a useful instrument for primary identification of self-referral patients with probable somatization syndromes. Open doctor–doctor and patient–doctor communication is necessary to increase patient satisfaction, which may be helpful to minimize the self-referral phenomenon in Japan.
Keywords. IBQ, illness behaviour, patient satisfaction, primary care, self-referral.
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Introduction |
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On average, individuals in Japan consult doctors much more often than do individuals in the USA (11.9 visits per year per person in Japan versus 1.7–7.1 visits per year per person in the USA, according to recent studies), a considerable number of them for only minor complaints or common illnesses.1–3 In addition, the phenomenon of self-referral, i.e. frequent changing of physicians without letters of referral, has been observed quite often in Japanese primary care clinics, so often that it has become a source of concern due to its contribution to high costs and inefficiencies in health care.4 The national health insurance system in Japan (instituted in 1961) requires that every citizen be covered by some type of public health insurance, of which there are three types: (i) for employees and their families; (ii) for self-employed persons and their families; and (iii) for persons
70 years.5 Insurance premiums cover 57% of medical expenses, the patient's responsibility is 12%, and public funds pay ~31%. Beyond out-of-pocket expenses at ~63 000 yen (~US $500) per month per person, costs are covered by an additional public subsidy. The fee schedule is standardized country-wide, with most fees lower than those in the USA, and physicianss’apos; fees are uniform.5,6 Thus, citizens of Japan have access to medical care at relatively low cost, so cost is not an important issue for patients.7 In addition, many out-patient clinics do not require appointments for consultation, and patients can choose hospitals or clinics for their convenience without any restriction by medical insurance payers; there is opportunity for frequent self-referral and overuse of medical services. In the case of the general medicine clinic of Saga Medical School Hospital, some 20–30% of patients are referred from primary care physicians (independent solo practitioners) mostly in Saga city or nearby communities. However, the majority of new patients visit the general clinic of their own volition. There are specific predictors that motivate some patients to change doctors without professional referral. These include inconvenient clinic location and hours, long waiting hours, dissatisfaction with the original diagnosis or treatment plan and lack of a favourable impression regarding the doctor's personal qualities. Patients with such complaints are more likely than others to ‘self-refer’.4,8–10
Psychiatric disorders in primary care patients have been associated with the frequent use of medical resources.11–14 Kasteler et al.8 surveyed 7500 households to investigate issues underlying the prevalence of ‘doctor-shopping’, which was defined as changing doctors without professional referral during a single illness episode. They were particularly interested in the influence of social class, self-reliance, hypochondriasis, the tendency of patients to adopt the sick role and various attitudes toward doctors. The tendency to adopt the sick role and hypochondriasis were clearly related to doctor-shopping. Sato et al.4 found that doctor-shopping patients have an increased General Health Questionnaire (a self-administered screening instrument designed to detect currently diagnosable psychiatric disorders) score and that the lifetime prevalence of somatization disorder is significantly higher in this group than in non-doctor-shopping patients. In addition, socio-cultural background may have a significant impact on utilization of medical services and illness behaviour; such behaviour may differ between cultures and countries.15–17
Pilowsky coined the term ‘abnormal illness behaviour’ to describe the excessive concern with somatic symptoms and inappropriate treatment seeking observed in patients who apparently are motivated by the fear of disease or by the potential rewards of the sick role.18–20 Patients with chronic pain,21,22 rheumatoid arthritis,23 heart disease24 and other diseases refractory to treatment25 are reported to show more frequent abnormal illness behaviour. Patients with various psychiatric disorders may also manifest abnormal illness behaviour.18,19,26 For example, some patients with psychiatric disorders tend to overuse medical services, waste time in seeking unnecessary treatment or receive inappropriate treatment at GP clinics rather than appropriate care at psychiatric clinics.
To date, there has been no report on the relationship between abnormal illness behaviour and self-referral in the Japanese primary care arena. The aim of this study was to investigate the illness behaviour and patient satisfaction level of self-referred patients.
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Methods |
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Setting
The study was conducted in the general medicine clinic of Saga Medical School Hospital in Saga, a typical medium-sized Japanese city. The patient population is drawn primarily from an urban community (population ~200 000) surrounding the hospital. The out-patient unit of the hospital has two sections, a general medicine clinic and specialty clinics. The former was opened in 1981, and it was the first such department among national medical schools in Japan to provide an out-patient service in primary care, whereas the latter provide secondary and tertiary care. The general medicine clinic is open every weekday on a non-appointment basis, and referral letters are not needed. On the other hand, specialty clinics open on certain days of the week and require an appointment and a referral letter from a local practitioner. In particular, the general medicine clinic deals with all new patients, except patients who have referral letters to specialty clinics. Consultation to specialty services is performed if needed. Therefore, this clinic has the important task of co-ordinating secondary and tertiary care of the hospital and is somewhat different from smaller private hospitals that provide mainly primary care. The additional objectives of the general medicine clinic are to educate primary care physicians and to provide comprehensive regional care. For example, responsive to the needs of the local public, its aims are to try to give them the best possible medical service available and to provide not only care for the sick but also their prophylactic medicine, home care services, health study courses in various fields, etc.
Subjects and procedures
The subjects of this study were individuals aged 18 years or over with new medical complaints who visited the general medicine clinic of Saga Medical School Hospital during the study period between 1 October 1999 and 31 February 2000.
The patients were asked whether they had visited other medical facilities for the problems that they noticed during the most recent episode of their illness. For ongoing chronic symptoms such as painful joints, patients were asked whether they had visited other medical facilities within the last 2 years. Patients who visited the general medicine clinic without a letter of referral were defined as self-referred patients, and patients who visited the clinic with a letter of referral were defined as physician-referred patients. Original-visit patients were those patients who had not visited other medical facilities for the problems they presented to us.
All patients were asked to complete a socio-demographic questionnaire (for sex, age, occupation, education level and marital status) and a Japanese version of the Illness Behaviour Questionnaire (J-IBQ), for which validity and reliability have been established by Honda et al.27 This 62-item self-administered questionnaire yields scores reflecting various aspects of illness behaviour and affective states. Scales are used to rate seven dimensions of illness behaviour (Table 1
).20 Self-referred patients and physician-referred patients were asked to complete our original Patient Satisfaction Questionnaire (PSQ), a 10-item questionnaire concerning degree of satisfaction with the previous medical facility and medical care most recently experienced. The questionnaire was developed by the authors and covers the following areas: (i) medical environment; (ii) medical equipment; (iii) waiting time; (iv) attitudes of nurse(s); (v) medical knowledge of the doctor; (vi) time spent by the doctor in examining the patient; (vii) time taken by the doctor to listen to the patient's problem; (viii) explanation by the doctor regarding examination or treatment; (ix) the doctor's comprehension of the patient's overall state; and (x) the doctor's personal qualities. Satisfaction was rated on a 5-point scale (see Appendix for a sample questionnaire). The reliability of the questionnaire has been tested; Cronbach's alpha coefficient for standardized variables is 0.82. Written informed consent was obtained from all subjects who returned completed questionnaires.
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Statistical analysis
Data are shown as mean ± SD. Categorical data were compared between groups by chi-square test. One-way ANOVA and Mann–Whitney U-test were used for comparisons of J-IBQ scale scores and patient satisfaction scores between groups. Fisher's PLSD test was used for pair-wise comparisons. Data were analysed with SAS system software (SAS Institute, Cary, NC, USA), and a P-value of <0.05 was considered statistically significant.
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Results |
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Response rate
Seven hundred and forty-seven out of 1158 consecutive new patients (65% response rate) provided analysable questionnaires. The remainder were excluded on account of time constraints, advanced age, poor health or their own preference (252), incomplete answers to the questionnaires (137), or a diagnosis of neurological disease with psychological complaints or psychiatric history (22). Three hundred and eighty-five (51.5%) patients were original-visit patients, 277 (37.1%) patients were self-referred and 85 (11.4%) patients were physician-referred.
Socio-demographics
Table 2 shows socio-demographic data for all study participants. There were no significant differences between the three groups in any socio-demographic factor.
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J-IBQ scale scores
Comparison of IBQ scores (Table 3
) between groups revealed significant differences in the GH (general hypochondriasis), DC (disease conviction), P/S (psychological versus somatic focusing), AD (affect disturbance) and I (irritability) scales scores. Fisher's PLSD test showed that self-referred patients differed significantly from original-visit patients on the GH, DC, AD and I scales and from physician-referred patients on the GH and DC scales. Most IBQ scores of physician-referred patients fell between those of original-visit patients and those of self-referred patients.
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Patient satisfaction
Self-referred patients were less satisfied than physician-referred patients with regard to previous medical facility and consultation, and dissatisfaction with personnel, especially doctors, was greater than dissatisfaction with the medical environment, waiting time or equipment used (Table 4
).
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Discussion |
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Self-referral and abnormal illness behaviour
Self-referred patients showed higher scores on most of the IBQ scales than physician-referred and original-visit patients, which indicated a higher probability of manifesting abnormal illness behaviour. Abnormal illness behaviour is defined as a maladaptive mode of perceiving, evaluating and acting in relation to one's own health, despite appropriate information and assurances by doctors.19,20 Such behaviour is considered a form of somatization and may reflect a close relationship between functional somatic symptoms and psychological distress. In this study, we found higher GH, DC and AD scores in self-referred patients relative to scores in physician-referred and original-visit patients. These results suggest that some self-referred patients who recognize the existence of personal difficulties may fail to attribute their physical complaints to the psychological distress they experience. The abnormal illness behaviour of self-referred patients thus may be attributed to the underlying psychological distress and not to the somatic symptoms themselves. The present results further support the hypothesis that self-referral is associated with psychological distress, which contributes to development of abnormal illness behaviour. While the higher AD score suggests that the self-referred patients acknowledge more anxiety and depression, this combined with a higher DC score suggests that it might not be too difficult for such patients to reformulate their problems into non-somatic terms.28 However, because they might readily develop abnormal illness behaviour, it is important to treat these patients appropriately when they first visit a general physician for medical advice.
Psychiatric disorders in primary care patients have been associated with the frequent use of medical resources.11–14 Katon et al.29 found the prevalence of DSM-III-R disorders in more frequent users of health care to be as follows: major depression in 23.5%, anxiety disorder in 21.8% and somatization disorder in 20.2%. In our previous psychiatric out-patient study, patients with psychiatric disorders, particularly those with anxiety disorder or somatoform disorder, showed abnormal illness behaviour. We speculated that a psychiatric disorder often underlies abnormal illness behaviour and somatic complaints.26 Therefore, the prevalence of psychiatric disorders may be higher in self-referred patients than in original-visit or physician-referred patients, and further studies on the prevalence of psychiatric disorders among self-referred patients via highly structured diagnostic interview are planned.
Socio-cultural background may have a significant impact on utilization of medical services and illness behaviour; and such behaviour may differ between cultures and countries.15–17 Culture may have a significant impact on beliefs about disease and health, attitudes toward parts of the body, and the value and stigma attached to medical and psychiatric care, which in turn could foster the expression of certain bodily complaints and discourage others. The ratio of somatic to psychological symptoms reportedly differs between cultures and according to ethnicity.30 In this regard, the Japanese are very sensitive to their physical condition, and more likely to show fear regarding their health status.26,31 This is thought to be one reason for the high rate of self-referral in Japan.
Self-referral and patient satisfaction
Patients dissatisfied with a medical facility or medical consultation are more inclined than other patients to change doctors.4,8–10 Patient satisfaction has been positively associated with adherence to the treatment plan,32,33 better treatment outcomes34,35 and a continued relationship with a physician or health care organization.36,37 In the present study, self-referred and physician-referred patients did not differ significantly in terms of sex, age, education level, marital status or occupational status, but they did differ in their attitudes toward medical care they had received previously. Dissatisfaction with personnel, especially doctors, was greater than dissatisfaction with the medical environment, waiting time or equipment used. These results suggest that communication may be an important factor in patient satisfaction. In Japan, the general primary care system is not conducive to good communication between doctors in private practice and general hospitals and doctors in university hospitals; co-operation between primary care doctors and specialists is not strong.6,38 Some Japanese doctors, especially older doctors, tend to expect unspoken agreement from their patients; the way information is conveyed in Japan is different from that in Western countries. Accordingly, an environment where there is open doctor–doctor and patient–doctor communication needs to be created. If the doctor–patient relationship were an open one, doctors could freely tell their patients whether it is necessary to consult a psychiatrist, psychologist or another specialist, and patients could ask their doctors freely whether they would be helped by seeking the opinion of another doctor. A second opinion would not need to be sought in secret. Qualitative empirical approaches that take culture into consideration will be needed to solve the problems of illness behaviour in Japan.
Limitations
It is possible that selection bias influenced our study results. Physician-referred patients treated in the last 2 years had problems similar to those of the self-referred patients, but it is likely that physician-referred patients are referred within a single episode of illness, whereas self-referred patients might have experienced several episodes of illness and thus more distinct episodes of care. When this is the case, it is possible that self-referred patients not only differ in illness behaviour and thus have more psychiatric problems but that they also have more somatic illnesses, causing them to refer themselves more often. We have no information on health differences between these two groups. We also have no insight on differences in problems leading to clinic visits between the two groups. As the physician-referred group was rather small, differences in health could be difficult to detect.
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Conclusion |
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We examined illness behaviour and patient satisfaction in a general medicine clinic of a university hospital in Japan. Although the present low-cost, open-visit medical system in Japan partly accounts for the high rate of self-referral, the self-referred patients themselves showed obvious abnormal illness behaviours. It is important to give patients appropriate overall support, not only physical but also emotional, when they first visit the general physician for medical advice. The J-IBQ may be a useful instrument for primary identification of self-referral patients with probable somatization syndromes. Open doctor–doctor and patient–doctor communications are necessary to increase patient satisfaction, which may be helpful to minimize the self-referral phenomenon in Japan.
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References |
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