KEY POINTS FOR CLINICIANS
The way in which physicians and patients interact is important because of demonstrated effects on patient satisfaction,1-3 patient understanding and adherence to directions,3 litigation for malpractice,4 and health status.2,5 Physician-patient interaction style is particularly important in primary care,6-8 where patients are seen over time for diverse and often undifferentiated problems.- Different physician-patient interaction styles are actively used in community practice.
- A person-focused style is being used by almost half of the physicians observed, and this style is associated with greater patient-reported quality of primary care and greater patient satisfaction.
- This study provides further evidence to support the widespread implementation of this approach to the physician-patient interaction.
Over the past half century, changing medical technology, law, education, ethics, and research have influenced the current shape of physician-patient interactions.9 In 1956, the traditional model of Activity-Passivity (physician does something to the patient) was challenged with the revolutionary concept of active patient participation.10 The models of Guidance and Cooperation (physician tells patient what to do, patient cooperates) and Mutual Participation (physician enables patient to help him/herself, patient is a partner) were proposed10 and are reflected in modern theoretically-based interaction models. Numerous models have been proposed as variants of the Guidance/Cooperation model (eg, paternalistic model,11 priestly model,12 contractual model13) and the Mutual Participation model (eg, ethnographic model,14 consumerist model,11,15 family systems model16). Few of these models, though, have been empirically evaluated. The best-developed and most-studied mutual participation model is the patient-centered method.5,17-20
When data have been collected using quantitative or qualitative approaches, significant strides have been made in understanding physician-patient interaction3, 21-23 and the effect of such interactions on patient outcomes,5,24,25 primarily patient satisfaction.1,26-29 However, many studies have been limited by their focus on a narrow aspect of physician-patient communication, studying a small number of physicians or patients, and using medical students, residents, and hospital faculty as study subjects.
The purpose of this study was not to develop a new model of physician-patient interaction. Rather, variables characterizing physician style grounded by the direct observation of thousands of encounters for 138 community practicing family physicians were used to empirically cluster physicians into groups that represent distinct interaction styles. Because interaction style may be manifested in all phases of a patient encounter, we used as a guiding framework the 3 primary functions of an interview:30,31gathering information, enhancing a healing relationship, and making and implementing decisions. The importance of each of these functions varies depending on the nature of the encounter, but our overall approach provides a practical way of conceptualizing physician-patient interaction style. The association of the empirically derived and theoretically-based physician styles are tested with 3 outcomes: 1) patient report of delivery of attributes of primary care measured using the Components of Primary Care Instrument (CPCI), 2) patient satisfaction with the visit, and 3) the duration of the visit.
Methods
This study was part of the larger Direct Observation of Primary Care (DOPC) study, a cross sectional observational study that examined the content of 4454 outpatient visits to family physicians in northeast Ohio. Details of the methods of the DOPC study have been described extensively elsewhere.32,34 Briefly, 4 teams of 2 research nurses directly observed consecutive patient visits to 138 participating physicians in 84 practices between October 1994 and August 1995. The research nurses collected data on the content and context of consecutive office visits using the following methods: direct observation of the patient visit, patient exit questionnaire, medical record review, and collection of ethnographic field notes.33,34
Measures
Patients’ perception of the delivery 5 attributes of primary care was measured by the Components of Primary Care Instrument (CPCI). Interpersonal communication was an evaluation of the ease of exchange of information between patient and physician. The physician’s accumulated knowledge about the patient refers to the physician’s understanding of the patient’s medical history, health care needs, and values. Coordination of care refers to the information received from referrals to specialists and previous health care visits, and its incorporation into the current and future care of the patient. Preference to see usual physician refers to the degree to which patients believed and valued that they could go to their regular physician for almost all problems. Scale scores demonstrate good internal consistency reliability (Cronbach’s alpha: .68–.79).35 Continuity of care is measured by the Usual Provider Continuity index (UPC), which is the proportion of visits to the patient’s regular doctor in the past year out of the total number of physician visits in the past year.
Patient satisfaction was measured using the 4 physician-specific items from the MOS 9 Item Visit Rating Form36 (Cronbach’s alpha = .89).33 Also included on the patient survey was a single item assessing the degree to which patients’ expectations with the visit were met. Duration of the visit was the total face-to-face time the physician spent with the patient and was measured by direct observation.