Relationships between physician practice style, patient satisfaction, and attributes of primary care
- OBJECTIVE: Style of physician-patient interaction has been shown to have an impact on patient outcomes. Although many different interaction styles have been proposed, few have been empirically tested. This study was conducted to empirically derive physician interaction styles and to explore the association of style with patient reports of specific attributes of primary care, satisfaction with care received, and duration of the visit.
- STUDY DESIGN: A cross-sectional observational study.
- POPULATION: We observed 2881 patients visiting 138 family physicians for outpatient care in 84 community family practice offices in northeast Ohio.
- OUTCOMES MEASURED: Components of Primary Care Instrument (CPCI), patient satisfaction, and duration of the visit.
- RESULTS: A cluster analysis of variables derived from qualitative field notes identified 4 physician interaction styles: person focused, biopsychosocial, biomedical, and high physician control. Physicians with the person-focused style rated highest on 4 of 5 measures of the quality of the physician-patient relationship and patient satisfaction. In contrast, physicians with the high-control style were lowest or next to lowest on the outcomes. Physicians with a person-focused style granted the longest visits, while high-control physicians held the shortest visits—a difference of 2 minutes per visit on average. The associations were not explained away by patient and physician age and gender.
- CONCLUSIONS: In community-based practices, we found that the person-focused interaction style appears to be the most congruent with patient reported quality of primary care. Further investigation is needed to identify ways to support and encourage person-focused approaches and the time needed to provide such care.
Association of physician characteristics with the interaction styles is presented in Table 2. The percent of male and female physicians differed greatly among the 4 style groups. The proportion of female physicians in the person-focused group was almost 4 times that of the biopsychosocial group and the high physician control group (P
As reported in Table 3, physician style is significantly associated with 3 of the 5 patient reports of the attributes of primary care. Physicians classified as having a person-focused approach have the highest mean score of communication; the other 3 styles score lower, with the high-physician-control style scoring the lowest. Person-focused and biopsychosocial physicians scored highest on patient reports of accumulated knowledge; those in the biomedical group scored the lowest. Coordination of care was highest among the person-focused group and lowest among the high-control group Across the different types of physician style, there was no difference in patient report of preference for his or her regular physician or the measure of continuity of care.
The associations of physician style with 2 indicators of patient satisfaction are displayed in Table 4. The highest group mean of patient satisfaction is for the person-focused style, and the lowest is for the high-physician-control group. The indicator of the degree to which patient expectations were met also follows this pattern. Also displayed in Table 4, the person-focused style demonstrated the longest average duration of visit, at 11.5 minutes; the high-physician-control group visits were the shortest in duration, at about 9.5 minutes.
TABLE 2
Physician and patient characteristics associated with interaction style
| Characteristic | Total | Biopsychosocial | Biomedical | Person focused | High physician control | P |
|---|---|---|---|---|---|---|
| Physician | ||||||
| Number | 138 | 22 | 28 | 68 | 20 | |
| Age (mean years) | 43 | 45 | 43 | 42 | 46 | .06 |
| Female | 26% | 9% | 21% | 38% | 10% | |
| Residency trained | 90% | 86% | 86% | 94% | 85% | .44 |
| Patient | ||||||
| Number | 2881 | 504 | 578 | 1258 | 541 | |
| Age (mean years) | 42 | 44 | 41 | 42 | 43 | .11 |
| Female | 62% | 57% | 61% | 65% | 58% | |
Association of physician style with attributes of primary care1
| Attribute of primary care | Biopsychosocial | Biomedical | Person focused | High physician control | P |
|---|---|---|---|---|---|
| Communication | 4.27 | 4.26 | 4.43 | 4.21 | |
| Accumulated knowledge | 3.54 | 3.33 | 3.56 | 3.51 | |
| Coordination of care | 3.85 | 3.78 | 3.99 | 3.74 | |
| Preference for regular doctor | 4.46 | 4.45 | 4.46 | 4.39 | ns |
| Usual provider continuity2 | 0.67 | 0.66 | 0.64 | 0.65 | ns |
| 1Each row represents a separate multilevel regression model wherein each attribute of primary care is the outcome variable and the number in each column is the group mean of that attribute, adjusted for patient and physician age and sex, as well as the effect of the patients being nested within physicians. | |||||
| 2Usual provide continuity = total number of visits to regular physician in past year, divided by the total number of physician visits in the past year. | |||||
Association of physician interaction style with patient satisfaction and duration of visit1
| Outcome measures | Biopsychosocial | Biomedical | Person focused | High physician control | P |
|---|---|---|---|---|---|
| Patient satisfaction with physician | 4.38 | 4.39 | 4.49 | 4.30 | 002 |
| Patient expectations met | 4.36 | 4.33 | 4.45 | 4.31 | .02 |
| Length of visit (mean minutes) | 9.97 | 10.02 | 11.56 | 9.51 | .005 |
| 1Results from multilevel regression model, analyses include patient and physician age and gende as covariates, and controls for the nested nature of the data. | |||||
Discussion
These data indicate that a person-focused approach is actively used in community practice, and is the style most congruent with patient-reported quality of primary care and satisfaction with care. Our data, in concert with data reported by others,5,24 indicate strong support for the feasibility and value of the person-focused model. We found that, of the 4 distinct interaction styles, physicians with the person-focused style scored highest across all measures of the attributes of primary care and on the indicators of patient satisfaction, with the exception of continuity of care. In contrast, physicians with the high-control style were generally lowest on the primary care and satisfaction indicators.
It is important to emphasize that, even though the vast majority of patients in this sample are likely to have self-selected their primary care physician, patient rating of some attributes of primary care differed across the 4 physician styles. Patients of physicians with different styles equally valued seeing their regular physician, as reported by the preference-for-their-regular-doctor score; they exhibited similar proportions of continuity visits in the past year; and their satisfaction scores were all generally high. Patients appear to want to see their regular physician, regardless of interaction approach, even though some approaches—particularly the high-physician-control style—were rated poorer for communication, coordination of care, and accumulated knowledge.
There may be several explanations as to why a particular physician style is associated with specific patient reports of communication, accumulated knowledge, and coordination of care. Openness to the patient’s agenda and willingness to negotiate options—as was characteristic of the person-focused physicians—may facilitate good communication and convey an understanding of patient preferences and values regarding health. It is interesting to note that different groups scored lowest on some of the attributes of primary care. The high-physician-control group was the lowest on interpersonal communication and coordination of care. High-control physicians were more likely to dominate the agenda and the verbal exchanges. Patients may have felt they could not ask questions or that the physician did not listen to what they tried to say. The biomedical group of physicians were given the lowest scores by patients on accumulated knowledge, suggesting that patients thought these physicians were less likely to know their preferences and values regarding health care, know less about them as persons, and know less about their family and medical histories.
