Family Practice Advance Access originally published online on January 7, 2005
Family Practice 2005 22(1):15-19; doi:10.1093/fampra/cmh721
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Familiarity with a GP and patients' evaluations of care. A cross-sectional study
a Department of General Practice, University Medical Centre St Radboud Nijmegen, and b Centre for Quality of Care Research (WOK), University Medical Centre St Radboud Nijmegen and University of Maastricht, The Netherlands
Correspondence to HJ Schers; Email: H.schers{at}hag.umcn.nl
Received 25 June 2004; Accepted 28 July 2004.
Schers H, van den Hoogen H, Bor H, Grol R and van den Bosch W. Familiarity with a GP and patients' evaluations of care. A cross-sectional study. Family Practice 2004; 22: 15–19.
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Abstract |
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Background. Personal continuity is considered a core feature of general practice care. Nowadays, another important concept for general practice may be patients' familiarity with a GP.
Objectives. We studied the extent to which patients see a familiar GP, and how this matches their preferences. Furthermore we studied the impact of knowing the GP on patients' evaluations of consultations.
Methods. A cross-sectional design was used and 2400 patients visiting 17 general practices (30 GPs) in The Netherlands for a consultation were approached; 2152 patients completed the questionnaire. The main outcome measures were: i) the extent to which patients saw a familiar GP in relation to the reason for encounter, perceived seriousness of symptoms, and concern about symptoms; and ii) the impact of ‘knowing the GP’ on patients' overall satisfaction with the consultation, feeling of being helped to move forwards, trust in the GP, and perceived clearness of treatment plans.
Results. Patients saw a familiar GP to a high extent, regardless of the reason for encounter, perceived seriousness of symptoms and worries. Higher levels of familiarity with a GP were associated with higher levels of satisfaction, with increased feelings of being helped forward, with more trust in the GP, and with the perception of clearer treatment plans made. A multivariate model including the variable ‘knowing the GP’ explained 11% of the observed variance in patients' evaluations of consultations.
Conclusion. Familiarity with a GP improves patients' assessment of general practice care. Also in the future, personal continuity should be promoted.
Keywords. Continuity of patient care, cross-sectional design.
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Introduction |
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Personal continuity is considered a core feature of general practice care. However, studies on the achievement and evaluation of personal continuity are methodologically complicated due to the absence of a clear operationalization of the concept. For instance, the significance of contacting the ‘regular’ GP is ambiguous, since its impact on outcome measures appears to be limited. Still, there is evidence that seeing a regular GP is associated with significant higher levels of patient and doctor satisfaction,1,2 and increased enablement.3 Studies have also shown that seeing the regular GP, trust in the GP, and patient satisfaction are interrelated themes.4,5 Consultation outcome is also influenced by the extent to which GP and patient know each other.6–8 It is hypothesized that repeating contacts with patients build knowledge and trust which leads to better outcome.
In daily practice, many factors may act upon the attainment of seeing a familiar GP. For instance, patients occasionally prefer a convenient appointment time rather than a consultation with their regular doctor.9 Also, patients may weigh up their GP preference against the reason for encounter. Patients seem to value personal continuity especially for serious and psychosocial or family conditions, and less so for minor illness or regular checks.10,11 Professionals' views have shown to match patient preferences in this field.11–13 It is conceivable that GPs' and practice assistants' attitudes towards continuity,14 as well as practice type and organization may influence the chance of seeing a familiar doctor. At the present time, a growing number of GPs work part time in The Netherlands, and strong movements exist to enlarge practices. Patients may perceive to have more than one personal GP in such settings, and the extent of knowing a GP might become more important than the concept of having one regular GP.
Clearness on issues of possible benefits of seeing a familiar GP could give us important clues for planning and directing general practice care in the future. Changes in practice organization make personal continuity less self-evident. Certainly now triaging by other health professionals has become more common world-wide, questions on the importance of personal continuity will have to be addressed. The aim of our study was therefore bipartite. Firstly, we explored if the extent of seeing a familiar GP matches patient preferences at present. Secondly, we were interested to study how the extent of knowing the GP relates to patients' evaluations of consultations.
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Methods |
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Samples
We invited 49 practices (102 GPs) to participate in a project on continuity of care. We situated the study in one district (covering about 800 000 inhabitants) in the eastern part of The Netherlands. Due to study requisites, we approached all practices that used a specific GP computerized system. There is no indication that these practices differ from practices using alternative information systems. We aimed to approach 80 consecutive patients per GP who visited the practice. The only exclusion criterion was difficulty understanding the Dutch language. For children, we asked the accompanying parents to participate.
Variables and instruments
We developed a patient questionnaire consisting of a pre- and post-consultation part. We measured the extent to which patients perceived to know the GP they were seeing today using a 5-point Likert scale. Patients also completed questions concerning the following independent variables: reason for encounter, perceived seriousness of symptoms, extent to which patients were worried, age, gender, perceived health status and the presence of chronic illness. Patients could seal the pre-consultation part, so that the GP was not able to see the answers.
After the consultation, patients completed four questions on consultation quality: overall satisfaction with the consultation, the feeling of being helped forward, trust in the GP, and perceived clearness of treatment plans—all on 5-point Likert scales. Moreover, the participating GPs completed a questionnaire on how continuity in their practice was arranged formally and practically (combined–personal list).
Procedure
The study was carried out in 2002/2003. We asked the practice staff, mostly practice assistants, to distribute the questionnaires in the course of several days to consecutive patients in the waiting room during consultation hours. We offered help to the practice in order to reduce the workload, and in addition offered payment to compensate proportionally for the extra work being done. Patients would fill in the pre-consultation part of the questionnaire during their waiting time, and returned to the waiting room to finish the post-consultation part. The questionnaires were collected in a sealed box, but patients were also allowed to take the questionnaire home and post it.
Analysis
Firstly, we calculated the extent to which patients saw a personal GP for the practices by dichotomising the answers to the question ‘How well do you know the GP you are seeing today’ (‘very well, well, rather well’ versus ‘not well, not well at all’) and related this to the reason for encounter, perceived seriousness of symptoms and worries; we calculated 95% confidence intervals.
Secondly, we related the extent of personal continuity to the separate outcome measures satisfaction, being helped forward, trust, and clearness of treatment plans by calculating mean scores, using a multivariate approach (Mixed Procedure SAS), controlling for patients' age, gender, health status, chronic illness, reason for encounter and perceived seriousness and worries, and the GP as random effect.
We explored the four outcome measures with principal component analysis and calculated correlation coefficients using standardized Cronbach's alpha. Next, we determined patients' overall evaluations of care by calculating unweighted sum scores (satisfied, being helped forward, trust, and clearness of treatment plans; ‘very much’ 5 points, ‘very little’ 1 point; scale min–max 4–20), and subsequently used multilevel analysis (SAS) to determine how patients, GPs and practices contributed to the variance in outcome. Finally, we used multivariate analysis (Mixed Procedure SAS) to study the contribution of the following independent variables to overall consultation outcome: knowing the GP, patients' age, gender, chronic illness, and health status, reason for encounter, and perceived seriousness and concern about symptoms.
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Results |
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Seventeen practices participated in the study. Most non-participants declined for reasons of lack of time and the feeling of being overtaxed. From 2400 questionnaires handed out, we received 2197 replies; 2142 had less than 3 missing values (response effectively 92%). One hundred and four (5%) did not know which GP they would be seeing, and 18 left the question how well they knew the GP blank. The mean age of the remaining 2019 respondents was 41.3 (SD 19). Sixty percent of the respondents were female, and 33% stated they suffered from a chronic illness.
Familiarity with the GP
Table 1 shows the characteristics of the participating practices, underlining the diversity in practice organization. The extent to which patients saw a familiar GP was comparable between practices, and we observed no relevant differences between practices with personal lists and practices with combined lists.
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Patients more often saw a familiar doctor for regular checks. Perceived seriousness of symptoms, and concern about symptoms were not related to the extent of familiarity with a GP (Table 2).
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Familiarity with the GP and evaluations of care
If patients saw a familiar GP this was related to higher levels of satisfaction and trust, and moreover to an increased feeling of being helped forward, and the perception of clearer treatment plans made (Table 3).
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Principal component analysis demonstrated that all 4 items loaded more than 0.6 on one factor (Eigen value 2.6), which could explain 65% of the variance. Standardized Cronbach's alpha for the four items was 0.82. This justified the calculation of sum scores. From the multilevel procedure, it appeared that differences between patients' overall evaluations of consultations were explained by the practices only for 0.3%, and by the GPs for 4.0%. The remaining variance could thus be explained at the patient level. Therefore we excluded practice and GP characteristics, such as GPs' and practice assistants' attitudes to continuity in the multivariate analysis, but included patient and consultation characteristics.
We found that older patients and patients reporting a better health status evaluated consultations significantly more positively. Knowing the GP well was most strongly related to more positive consultation outcome (Table 4). The overall variance that could be explained by the model including the variable ‘knowing the GP’ was 11%. The proportion of variance explained only by the factor ‘knowing the GP’ was 8%.
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Discussion |
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This study shows that familiarity with a GP matters. We found that patients in The Netherlands still often see a familiar GP, also for serious and emotional conditions. This tailors to patient priorities, which have been studied in postal surveys. Although it appeared from these surveys that patients do not particularly value personal continuity for checks,10,11 this study shows that patients see a familiar doctor frequently for these conditions. Patients evaluate consultations more positively if they know a doctor well. Positive patients are in average older and experience fewer health problems.
This study adds to a growing amount of evidence suggesting the benefits of personal continuity. Other studies have already shown that provider continuity is related to higher levels of patients' trust, satisfaction, and enablement.6,15,16 It appears to be cost-effective as well.17 Higher levels of provider continuity may enhance trust.18 The feeling of knowing the doctor well, more than seeing a regular doctor, has been shown to be an important predictor of patient enablement.5 One study in the US and UK showed that trust in the GP is related to more patient satisfaction with consultations.7 This study again shows that knowing the GP well is related to better evaluations of care.
In general, patients evaluate consultations with a GP very positively. The superlative degree is reached mainly in consultations with a GP that is known very well. This applies both to minor conditions and serious illness, as we found no relation between perceived seriousness and concern and outcome in the multivariate analysis. Strikingly, differences in patients' evaluations could only to a negligible extent be explained on the practice or GP level. In other words, we did not find differences between practices or GPs as regards patients' evaluations, meaning that prototypes of a trustworthy GP, or a trustworthy practice may not exist.
Our study results indicate that higher levels of knowing the GP are correlated to patients being more positive about their care. Therefore, it may be recommendable for patients to visit the same doctor on most available occasions, which include contacts for minor conditions and regular checks. On the other hand, studies have shown that it may be important for patients to have the opportunity to choose their ‘regular’ doctor. Only if a well-known GP is also trusted, the ‘personal doctor chemistry’ works.7 In that sense, it may be well possible to have two or three personal GPs.
This study had some limitations. Firstly, it applies to the Dutch environment and measured personal continuity only in day-to-day consultations. Moreover, only 35% of the approached practices actually took part. Although this may induce some bias, this is unlikely as the variance explained on the levels of practice and GP was minimal. The study shows mainly relative continuity measures: practice differences, differences for varying conditions and relations with outcome. Moreover, the interpretation of the relationship between personal continuity and intermediate outcome measures is complicated. Positive evaluations may be the reflection of a general positive feeling towards the familiar doctor and may not reflect actual care quality. On the other hand, there is some consensus that patients' evaluations of care are important indicators of quality in themselves.
What are the implications of this study? Although the relation between higher continuity and better outcome is not a proof of causality, we think—with coming reforms and changes of the organization of general practice—that there should be emphasis on guarding personal continuity as a valued pillar of general practice care in the future. Expansion of primary health care teams should not affect the feeling of knowing individuals from this team. At this point, a small, well-known team is likely to suit patients better than larger teams. If general practice of the future is organized and managed large-scale, it will likely still benefit from smaller units within these organizations, which are able to supply the essence of general practice care: personal and nearby care of familiar professionals. Policy-makers, health services, and reorganising GPs should take this into account.
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Declaration |
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Funding: the study was funded and initiated by the Dutch Institute for Scientific Research (SGO/NWO), a governmental institution.
Ethical approval: n/a.
Conflicts of interest: none.
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References |
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1 Baker R. Characteristics of practices, general practitioners and patients related to levels of patients' satisfaction with consultations. Br J Gen Pract 1996; 46: 601–605.[Web of Science][Medline]
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