METHODS: We performed a longitudinal observational study in which participants completed a validated questionnaire at baseline (1996) and follow-up (1999). The questionnaire measured 4 elements of the quality of physician-patient relations (communication, interpersonal treatment, physician’s knowledge of the patient, and patient trust) and 4 structural features of care (access, visit-based continuity, relationship duration, and integration of care).
RESULTS: One fifth of the patients voluntarily left their primary physician’s practice during the study period. When tested independently, all 8 scales significantly predicted voluntary disenrollment (P <.001), with somewhat larger effects associated with the 4 relationship quality measures. In multivariable models, a composite relationship quality factor most strongly predicted voluntary disenrollment (odds ratio [OR]=1.6; P <.001), and the 2 continuity scales also significantly predicted disenrollment (OR=1.1; P <.05). Access and integration did not significantly predict disenrollment in the presence of these variables.
CONCLUSIONS: These findings highlight the importance of relationship quality in determining patients’ loyalty to a physician’s practice. They suggest that in the race to the bottom line medical practices and health plans cannot afford to ignore that the essence of medical care involves the interaction of one human being with another.
The presence of sustained relationships between physicians and patients is a defining characteristic of primary care.1 Family physicians use these relationships to acquire the depth of medical and personal knowledge about a patient that is essential to primary care practice.2 It is also the reason some physicians choose this area of medicine.
A substantial body of empirical research points to the value of continuity in the physician-patient relationship, particularly in primary care. The benefits of continuity have been shown to accrue in the form of cost savings, improved health outcomes, and greater satisfaction for patients and physicians.3-15 Yet little empirical research exists to indicate the amount of physician switching that occurs in primary care or the reasons for it.
In 1976 Kastler and colleagues16 examined the association between patients’ assessments of their care and their “doctor shopping” behavior. They found that patients’ evaluations of both interpersonal and structural features of care were significantly associated with the likelihood of voluntarily changing physicians. Those authors did not attempt to determine the relative importance of the 2 domains with respect to physician switching. The cross-sectional design precluded the study from determining which factor (if either) prospectively predicted switching.
Marquis and coworkers17 studied the sequencing of the satisfaction-disenrollment relationship using longitudinal data from the RAND Health Insurance Experiment (HIE). The HIE data showed that patients’ general satisfaction with their medical care significantly predicted physician switching over the following year. However, the HIE data did not afford the ability to differentiate among the many components of patient satisfaction and to discern which aspects specifically drive disenrollment.
Thus, little is known about the relative importance of the many factors that shape patients’ overall satisfaction with their physician and the extent to which performance on any of these ultimately drives a patient’s decision to leave a physician’s practice. Moreover, these earlier studies pre-date the recent surge in managed care enrollment and in consumerism among patients, both of which are presumed to be having a substantial impact on the rates of physician switching and the reasons for it. The generalizability of earlier findings to the present circumstances is unclear.
Our longitudinal observational study includes a population of insured adults who were employed by the Commonwealth of Massachusetts at baseline (1996), completed a self-administered questionnaire at baseline and follow-up (1999), and reported having a regular personal physician at baseline. Between January 1996 and April 1996 the baseline questionnaire was administered to a random sample of commonwealth employees who subscribed to any of 12 health plans available to employees, their dependents, and retirees. A 68.5% response rate was achieved (n=7204) using a standard 3-stage mail survey protocol with limited telephone follow-up of nonrespondents (mail responses=6810; telephone responses=394). Further details of the baseline sampling and data collection methods are documented elsewhere.
Follow-up data collection occurred precisely 3 years after baseline (January 1999-April 1999). Respondents who identified a primary care physician at baseline and participated by mail were eligible for follow-up (n=6075). Data were obtained using a standard 3-stage mail survey protocol with a final targeted mailing to racial and ethnic minorities (n=311) and to those without a college diploma (n=521). The targeted mailings were done because these subgroups were found to be underrepresented among follow-up respondents near the conclusion of data collection, and their representation in the longitudinal sample was important to our objectives. A 69.4% response rate was achieved in follow-up (n=4108) after accounting for respondents who died (n=21), were too ill to participate (n=2), or could not be located by mail in 1999 (n=136). At baseline and follow-up, respondents were somewhat older than nonrespondents, more likely to be women and white, and less likely to be poor (Appendix, Table 1A.