Eight data sets, four of which are UK-based, confirm the high importance that consumers attach to interaction factors and the quality of the patient–practitioner relationship in general when they are evaluating care.100,124,223,254,261,263,269,274,275
This evidence is summarised in Table 24 in alpha-betical order of first author.
A total of 42 studies, 26 of which were conducted in the USA, and seven in the UK, investigated the characteristics of patient–doctor interactions in order to identify the features most closely associ-ated with satisfaction. The main findings are summarised in Table 25 in alphabetical order of first author. A range of methods and settings are represented.
Three experimental studies investigated the effect of training doctors in communication or psycho-social skills276,277and of encouraging patients to participate more actively in consultations.278 Although doctor training had a significant positive effect on satisfaction, a leaflet provided to patients did not, possibly because such an approach is insufficiently proactive and personal.278 There is no evidence that the gender or age of physicians had a consistent effect on satis-faction. Gender was not significant in eight studies.197,212,224,234,267,279–281In one study greater satisfaction with female doctors amongst female patients than amongst male patients was reported.279Another showed trained female residents to be better on disclosure and empathy than their male counterparts.277There is
contradictory evidence on the effect of physician
TABLE 21 Summary of studies investigating the determinants of in-hospital satisfaction ReferenceCountryContextNo.responsesData collectionFactors contributing to satisfaction Design Abramovitz et al.,USAPragmatic767TelephoneNurse explanations were most important determinants of satisfaction 193 1987Observational 251 Bruster et al.,1994UKPragmatic5150Questionnaire after dischargeSatisfaction ratings were high,but when patients were asked about 36 aspects of Observationalin-hospital experience,56% reported problems with communication/information, 33% had suffered pain,70% were dissatisfied with discharge planning 241 Carmel,1985IsraelEmpirical476InterviewSatisfaction with physicians was a better predictor of overall satisfaction than Observationalsatisfaction with nurses 238 Cleary et al.,1989USAEmpirical598MailSatisfaction with physicians and nurses predicted overall satisfaction better than Observationalfood and room attributes 239 Cleary et al.,1991USAEmpirical6455TelephoneOnly 9% of variance in problems reported by patients explained by their Observationalsociodemographic factors,health status and insurance cover,suggesting that institutional factors may be important 229 Fleming,1981USATheoretical589Household interviewSatisfaction with hospital was inversely related to teaching status ObservationalPrivate hospitals generated more satisfaction than those that were government owned Longer length of stay and regular source of care increased satisfaction 72 Hardy et al.,1996UKTheoretical1183Questionnaire in hospital3 components of satisfaction from 100 items: Observational1) Process of care by doctors and nurses,attentiveness,hospital environment, cleanliness,patient participation,socialization 2) Health improvement 3) Psychological well-being Jakobsson et al.,SwedenPragmatic242MailSatisfaction with information,decision-making,ward facilities,treatment,and a 257 1994Observationallarge number of aspects of care all improved significantly when nursing care was (Natural experiment)reorganised around the team nursing concept 258 Koerner et al.,1985USATheoretical280Questionnaire in hospitalCompared satisfaction in a collaborative practice unit (primary nursing) and a Observationalteam nursing unit (Natural experiment)No differences in environment or tests,length of stay,complications,deaths,but collaborative practice unit patients reported significantly higher ratings for interaction with providers and communication 256 Leiter et al.,1998CanadaTheoretical605Questionnaire in hospitalSignificantly lower patient satisfaction in units where nurses reported strain, Observationalexhaustion,desire to quit continued 53
54 TABLE 21 contd Summary of studies investigating the determinants of in-hospital satisfaction ReferenceCountryContextNo.responsesData collectionFactors contributing to satisfaction Design 253 Miller Bader,1988USAEmpirical50Questionnaire in hospitalOf 15 nursing care behaviours reflected in satisfaction,12 were affective (nurse Observationalspends time,explains,is friendly,sensitive,attentive etc.) Remaining 3 related to technical/professional aspects of care Nelson and Larson,USAEmpirical2160MailSurprises,especially bad ones,affected satisfaction 199 1993ObservationalGood surprises:overall quality of care,perks/extras,staff attitudes Bad surprises:staff attitudes,value/cost,restfulness,room-mate,treatment of family/friends 249 Pilpel,1996IsraelEmpirical148Interview in hospitalCorrelations with global satisfaction:nurses’ conduct (0.64),doctors’ conduct Observational(0.62),physical surroundings (0.46) 252 Taylor et al.,1991USAEmpirical70TelephonePatients emphasised psychosocial factors as most important determinants of Observationalhigh-quality nursing care 259 Thomas et al.,1996UKEmpirical 1572Questionnaire in hospitalCompared satisfaction between wards organised by functional (task orientated) Observationalnursing,team nursing,primary nursing:no significant differences (Natural experiment)Satisfaction significantly related to knowing own nurse in charge of care Walker and Restuccia,USAEmpirical527MailNursing care more closely related to overall satisfaction than 157 1984ObservationalTelephoneother aspects of hospital stay Williams and Calnan,UKEmpirical454Mail questionnaire sent Satisfaction with hospital:83% 254 1991Observationalto general populationOnly significant influence on overall satisfaction was confidence in doctor Main areas of dissatisfaction (mentioned by 73%):access,hospital organisation, facilities,communication of information 255 Woodside et al.,1989USATheoretical392TelephoneNursing care most important determinant of overall satisfaction with Observationalhospital stay
TABLE 22 Summary of studies investigating the determinants of satisfaction with hospital outpatient care ReferenceCountryContextNo.responsesData collectionMethod ofFactors contributing to satisfaction Designanalysis 116 Avis et al.,1997UKTheoretical89InterviewQualitativeHumanity:friendliness,dignity,privacy ObservationalOrderly clinic organisation Information Continuity of care 260 Bishop et al.,1991UKEmpirical143Questionnaire in clinicQuantitativeFixed appointment times ObservationalTo see same doctor on successive visits Formal dress for staff Chaperone for examinations 209 De la Cuesta,1997ColombiaEmpirical364InterviewQualitativeGood relationship,including information,personal treatment, Observationalconfidence in doctor Expectations met Mediating factor:trust TABLE 23 Summary of studies investigating the determinants of satisfaction with primary care ReferenceCountryContextNo.responsesData collectionFactors contributing to satisfaction Design Baker and UKEmpirical16,015Questionnaire in clinicPersonal list systems associated with better access and continuity and 262 Streatfield,1995Observationalhigher satisfaction Larger list sizes associated with less doctor availability,worse continuity of care, less good premises and lower satisfaction Training practices associated with less doctor availability and continuity and lower satisfaction 267 Baker,1996UKEmpirical9,450Questionnaire in clinicCharacteristics of practices associated with falls in satisfaction were:list size, Observationalabsence of personal list system,training practice,number of appointments booked per hour 208 Brody et al.,1989USAEmpirical118Questionnaire in clinicPatients who indicated that they received non-technical interventions Observational(education,stress counselling,negotiation) were significantly more satisfied than those who did not Technical interventions not related to satisfaction 261 Calnan et al.,1994England,Greece,Empirical2,489MailCorrelates of general satisfaction were more to do with the patient–doctor USSR,YugoslaviaObservationalInterviewrelationship and professional skills,and less to do with access and availability continued 55
56 TABLE 23 contd Summary of studies investigating the determinants of satisfaction with primary care ReferenceCountryContextNo.responsesData collectionFactors contributing to satisfaction Design 268 Campbell,1994UK (Scotland)Empirical5,310Questionnaire in clinicLarger patient list size correlated with lower satisfaction ObservationalDissatisfaction correlated with less availability of appointments Self-referral to hospital emergency department related to distance not GP appointment availability 263 Coyle et al.,1992UKEmpirical2,783MailHigh overall levels of satisfaction,but dissatisfaction with waiting times,lack of Observationaladvice on health promotion,opportunity to discuss personal problems (Natural experiment) Department of UKPragmatic50,000MailHighest level of discontent arose from:problems in obtaining an 264 Health,1999Observationalappointment,waiting 202 Gray,1980USATheoretical821TelephoneSatisfaction with primary care services associated with having a personal Observationalphysician and availability (waiting times:for appointments,in clinic,out of hours) Halpin SchaufflerUSAEmpirical5,432MailPatients receiving health promotion information were more satisfied 270 et al.,1996Observational 225 Hopton et al.,1993UKEmpirical1,599Questionnaire in clinicMost dissatisfaction arose from:waiting,doctor being hurried,issues not Observationaldiscussed or disregarded 272 Howie et al.,1991UKEmpirical21,707Questionnaire in clinicDoctors and patients would prefer longer consultations,which could include Observationalmore health promotion and deal with more health problems 206 Kerr et al.,1998USAPragmatic17,196TelephoneDesire to disenrol from health plan associated with quality of care,convenience, Observationaldenied access to specialty care 271 Kottke et al.,1997USAPragmatic6,830MailWeak positive association between general satisfaction with healthcare and Observationalbeing advised by physicians to make use of preventive services 265 Malbon et al.,1999UKEmpirical1,139TelephoneHigh level of satisfaction,but >20% had considered making a complaint ObservationalMost dissatisfaction was with waiting 273 Morrell et al.,1986UKEmpirical788Questionnaire in clinicShorter consultations associated with less blood pressure measurement,less Observationalattention to psychosocial problems,and lower satisfaction Steven and AustraliaEmpirical2,822Questionnaire in clinicMost dissatisfaction related to accessibility (opening hours) and communication 266 Douglas,1988Observational Weingarten et al.,USAEmpirical2,799MailPatients receiving any preventive service were more satisfied then those who 217 1995ObservationalTelephonedid not continued
TABLE 23 contd Summary of studies investigating the determinants of satisfaction with primary care ReferenceCountryContextNo.responsesData collectionFactors contributing to satisfaction Design Williams and Calnan,UKEmpirical357MailCommunication,information,nature and quality of doctor–patient relationship, 269 1991ObservationalGP’s professional skills,more strongly (positively) associated with overall satisfaction than access and availability 48 Zapka et al.,1995USAPragmatic3,151MailSatisfaction related to indicators of system performance,especially access, Observationalcoordination,continuity and communication TABLE 24 Summary of studies investigating the importance of the patient–practitioner relationship for satisfaction in general ReferenceCountryContextNo.responsesData collectionMain findings SettingDesign 261 Calnan et al.,1994England,Greece,Empirical2489Mail/interviewCorrelates of general satisfaction were more to do with patient–doctor Russia,YugoslaviaObservationalrelationship and professional skills and less to do with access,availability and Primary caretype of service 223 Cohen,1996UK (Scotland)Empirical2569MailMain sources of dissatisfaction with care were a lack of opportunity to ask Hospital inpatient Observationalquestions,choices not explained,inadequate time with doctor,doctor’s attitude and outpatient 263 Coyle et al.,1992UKEmpirical2783MailOverall satisfaction related to doctor being understanding,GP medical skills,out General practiceObservationalof hours,preventive care (Natural experiment)Dissatisfaction associated with not being able to discuss personal problems 100 Howie et al.,1998UKTheoretical613Questionnaire in clinicAuthor’s concept of patient enablement related to but different from General practiceObservationalsatisfaction with consultation Roghmann et al.,USAEmpirical311InterviewRelationships varied strongly with provider 124 1979Healthcare in generalObservational 274 Snell,1996USAPragmatic40Focus groupPrimary issue that patients use for judging medical care is interaction with the Healthcare in generalObservationalphysician:especially enough time,and that the physician listens and explains continued 57
58 TABLE 24 contd Summary of studies investigating the importance of the patient–practitioner relationship for satisfaction in general ReferenceCountryContextNo.responsesData collectionMain findings SettingDesign 275 Ware et al.,1975USAEmpirical903InterviewPhysician behaviour (competence,humaneness,caring) identified as an important Healthcare in generalObservationaldimension of satisfaction Williams and Calnan,UKEmpirical454MailConvergence across hospital and GP settings of importance for satisfaction of 254,269 1991General practice/Observationalprofessional competence and nature of patient–professional relationship,rather hospitalthan access,availability and facilities 77% of variance in general satisfaction with GP explained by information giving, UKEmpirical357Mailmedical and personal skills,confidence in doctor General practiceObservationalOnly significant influence on general satisfaction with hospital was confidence in doctor TABLE 25 Summary of studies investigating the importance of features of the patient–practitioner relationship for satisfaction ReferenceCountryContextNo.PhysicianConsultationGeneralAffectiveInformationInformationHealthPhysician SettingDesignrespondentscharacteristicstimeinterpersonalbehaviourgatheringgivingpromotioncontrol skills Anderson and USAEmpirical134–ns–––––– Zimmerman,Ambulatory Observational 287 1993care 267 Baker,1996UKEmpirical9,450Age:–ve––––––– General ObservationalGender:ns practice Bartlett et al.,USAEmpirical63––+ve––Teaching –– 288 1984Ambulatory Observationalstatement –ve care Ben-Sira,IsraelTheoretical1,026–––Affective –––– 294 1990Healthcare in Observationalbehaviour generalgenerates trust +ve continued
TABLE 25 contd Summary of studies investigating the importance of features of the patient–practitioner relationship for satisfaction ReferenceCountryContextNo.PhysicianConsultationGeneralAffectiveInformationInformationHealthPhysician SettingDesignrespondentscharacteristicstimeinterpersonalbehaviourgatheringgivingpromotioncontrol skills Bertakis et al.,USA,CanadaEmpirical550Gender:ns––Interest in –––Doctor talks a 234 1991Primary careObservationalpsychosociallot,controlling issues,behaviour –ve friendliness +ve Brody et al.,USAEmpirical118–––––Non-technical –– 208 1989Primary careObservationalintervention (education) +ve Buller and USATheoretical219Age:+veNo effect+veAffective –––Expression of 282 Buller,1987AmbulatoryObservationalSatisfaction varied physicians control –ve carewith specialty+ve Comstock USAEmpirical150Gender,appear-Weak Verbal skills Physician Physician +ve–– 279 et al.,1982Hospital Observationalance:nscorrelation+ve,non-courtesy,listens +ve outpatientFemale doctorverbal empathy preferred morebehaviour ns+ve by female patients than by male patients De la Cuesta,ColombiaEmpirical364––Alertness/on Personal–+ve–– 209 1997Ambulatory Observationaltop of problem treatment, care+vetrust +ve DiMatteo USAEmpirical327––Non-verbal ––––– 289 et al.,1998Ambulatory Observationalcommunication and in hospital+ve DiMatteo and USAEmpirical327––+ve+ve–––– 290 Hays,1980Family practiceObservational Evans et al.,AustraliaEmpirical406––Training in ––––– 276 1987GeneralExperimentalcommunication practiceskills +ve continued 59
60 TABLE 25 contd Summary of studies investigating the importance of features of the patient–practitioner relationship for satisfaction ReferenceCountryContextNo.PhysicianConsultationGeneralAffectiveInformationInformationHealthPhysician SettingDesignrespondentscharacteristicstimeinterpersonalbehaviourgatheringgivingpromotioncontrol skills Fitzpatrick UKEmpirical95––Superficial –ve––––– 218 et al.,1983OutpatientObservational Fitzpatrick and Hopkins, 244,291 1981 Fox and USATheoretical2,582––––––Preventive– 297 Storms,1981Healthcare in Observationalcare generalvisits +ve Greene et al.,USAEmpirical100–+ve–Shared Physician ––– 284 1994Hospital Observationallaughter,questions, outpatientsupportive patient gives +veinformation +ve Gross et al.,USAEmpirical2,315ns+ve–Doctor –Doctor Nutrition – 224 1998Primary careObservationalchatting +veevaluation advice +ve and feedback +ve Hall et al.,InternationalEmpirical (41 data ––+ve including Social –+ve–Partnership +ve 130 1988Healthcare in Reviewsets)non-verbal conversation generalbehaviour+ve Halpin USAEmpirical5,432––––––Health – SchaufflerPrimary careObservationaleducation +ve 270 et al.,1996 Harvey et al.,USAEmpirical266–––––––More decision- 211 1999Ambulatory Observationalmaking oppor- caretunities +ve Hjortdahl and NorwayEmpirical3,044Age,gender:ns–Personal ––––– Laerum,General Observationaldoctor–patient 280 1992practicerelationship +ve Holloway et al.,USAEmpirical1,142––Personalised Sensitivity–––– 292 1989General Observationalapproach to patient’s practiceincludingneeds and promptness and concerns follow-up +ve+ve continued
TABLE 25 contd Summary of studies investigating the importance of features of the patient–practitioner relationship for satisfaction ReferenceCountryContextNo.PhysicianConsultationGeneralAffectiveInformationInformationHealthPhysician SettingDesignrespondentscharacteristicstimeinterpersonalbehaviourgatheringgivingpromotioncontrol skills Howie et al.,UKEmpirical21,707–+ve–––––– 272 1991General Observational practice Jackson et al.,USAEmpirical500––+ve––+ve–– 150 2001Ambulatory Observational care 212 Kenny,1995AustraliaEmpirical272Gender of ––Warmth and –Amount of –– Ambulatory Observationaldoctor:nsrespect +veinformation caregiven +ve Kent-Smith USAEmpirical 29–+ve––Chart reviewInformation-Prevention – 285 et al.,1981Primary careObservationaltime –vegiving +vediscussions +ve Korsch et al.,USAEmpirical800–––Friendly –+ve–– 213 1968AmbulatoryObservationalmanner care+ve Krupat et al.,USAEmpirical3,602–––––+ve–– 240 2000In hospitalObservational Krupat et al.,USAEmpirical453–––––––Patient centred 298 2000Primary careObservational+ve Kvamme and NorwayEmpirical431–Consultation ––Also Also–– Hjortdahl,Primary careObservationaltime ranked importantimportant 286 1997most important Linder-Pelz USATheoretical155Doctor’s age,––––––– and Stewart,Ambulatory Observationalgender:ns 197 1986care McCann and UKEmpirical120–––––––More Weinman,General Experimentalparticipation ns 278 1996practice continued 61
62 TABLE 25 contd Summary of studies investigating the importance of features of the patient–practitioner relationship for satisfaction ReferenceCountryContextNo.PhysicianConsultationGeneralAffectiveInformationInformationHealthPhysician SettingDesignrespondentscharacteristicstimeinterpersonalbehaviourgatheringgivingpromotioncontrol skills Meland et al.,NorwayEmpirical468–––––––Self-directed 299 1996General Observationalcare –ve practice Morrel et al.,UKEmpirical780–+ve–––––– 273 1986General Observational practice Robbins et al.,USAEmpirical100––––Physical Treatment Health – 203 1993Hospital Observationalexamination discussion education outpatient+ve+ve+ve History-taking –ve Ross and Duff,USATheoretical376If no choice,––––––– 283 1982Ambulatory Observationalmiddle aged, carewhite,non- Catholic male doctor preferred Rowland-USAEmpirical52––Silence +ve––––– Morin and Ambulatory Observational 293 Carroll,1990care Savage and UKEmpirical320–+ve–––––Directing style Armstrong,General Experimentalpreferred if 169 1990practicephysical problem Smith et al.,USAEmpirical86Trained female doctors:+ve–Training in ––––– 277 1995OutpatientExperimentalpsychosocial skills +ve 17 Stewart,1989InternationalEmpirical (61 data ––+veSocialns+ve–Partnership Healthcare in Review sets)conversation building +ve general+ve Stiles et al.,USAEmpirical52––––Patient Physician –– 295 1979Primary careObservationalexposition +vefeedback +ve continued
TABLE 25 contd Summary of studies investigating the importance of features of the patient–practitioner relationship for satisfaction ReferenceCountryContextNo.PhysicianConsultationGeneralAffectiveInformationInformationHealthPhysician SettingDesignrespondentscharacteristicstimeinterpersonalbehaviourgatheringgivingpromotioncontrol skills Treadway,UKEmpirical81Gender:ns–+vePatient feels Listening +ve––ns 281 1983General Observationalunderstood practice+ve Wartman et al.,USAEmpirical515––––––ve–– 296 1983Ambulatory Observational care –,feature not investigated;ns,not a significant determinant of satisfaction;+ve,positively related to satisfaction;–ve,negatively related to satisfaction 63
64
age.267,282It has been suggested that when patients do not have a choice of physician they prefer middle-aged, white, non-Catholic, male doctors.283 With regard to consultation time, longer consul-tations were associated with higher satisfaction in eight studies.169,224,272,273,279,284–286Two American studies showed no association,282,287but average consultation times in the USA are longer than in the UK.
There is general evidence that physicians’ inter-personal skills affect satisfaction,17,130,150,209,218,276, 279,281,282,288–291and that a personalised approach is appreciated by consumers.280,292One study showed a link between the use of silence in the interview and satisfaction.293
Affective behaviour by the physician was consis-tently related to satisfaction, although this was variously described by investigators in terms of warmth and respect,212friendliness,213,234trust,209,294 courtesy, empathy,279supportiveness,284sensitivity292 and understanding.281Shared laughter and
chatting with patients have been associated with higher satisfaction.17,130,224,284
With respect to information gathering and giving, most evidence showed that satisfaction correlated positively with physician feedback and discussions about treatment.17,130,150,203,208,209,212,213,224,240,279,285,286,295
Giving better information about drug regimens was shown to improve compliance but reduce
satisfaction.296“Teaching” styles were unpopular.288 The provision of general health promotion advice also generated satisfaction.203,224,270,285,297
Information collection by physicians, by means of chart reviews or history taking, has been observed to have a negative impact on satisfaction.203,285 However, physician listening, undertaking a physical examination, and explaining patients’
problems were noted to be positively related to satisfaction.203,279,281,284,295Expressions of physician control, including dominating the conversation, reduced reported levels of satisfaction.234,282 A directing style has been found to be more satisfactory for patients with physical problems,169 but in general partnership arrangements were preferred.17,130,211,298,299