- Email: [email protected]
Doctor-patient relationship in the light of patients' experiences
Sot. Sci. & Med. 1972, Vol. 6,
pp. 723-730. Pergamon Press. Printed in Great Britain.
DOCTOR-PATIENT RELATIONSHIP IN THE LIGHT OF PATIENTS’ EXPERIENCES HANNU VUORI, TAPIO AAKU, ESKO AINE, RISTO ERKKO and REIJO JOHANSSON Institute of Hygiene and Social Medicine. University of Turku, Finland
Abstract-In order to investigate the claims that the quality of doctor-patient relationship has deteriorated, the experiences of 330 ambulatory care patients and of 360 hospitalized patients were collected by means of a mailed questionnaire. The relationships between three groups of variables were studied : background variables describing the doctor and the patient; variables pertaining to certain salient instrumental, communicative, and expressive factors of the doctor-patient relationship, and variables measuring the success of this relationship.
ABOUT three-fourths of the patients in both samples had clearly positive experiences, Hospital patients were significantly less often satisfied with the information they had received than ambulatory patients. The success of the doctor-patient relationship was measured by asking how willing the patients were to return to the same doctor and how well they had followed the instructions they had got. There was no relationship between the background variables and the following of the doctor’s instructions. In the ambulatory care sample, the willingness to return to the same doctor was related to the respondent’s income and by the doctor’s age, in the hospital care sample, to the age of the respondent. On the basis of cross tabulations, instrumentality, expressivity, and communication indexes, and regression analysis, it can be concluded that in the hospital care sample, expressive factors exerted the greatest influence on the willingness to return to the same doctor. In the ambulatory care sample, this willingness was primarily determined by instrumental factors. In both samples, following of the doctor’s instructions was primarily determined by the communicative aspects of the doctor-patient relationship.
DOCTOR-PATIENT RELATIONSHIP IN THE LIGHT PATIENTS’ EXPERIENCES
OF
The doctor-patient relationship can be conceptualized as consisting of three kinds of interaction: instrumental interaction, that is application of the doctor’s skills and knowledge in solving the problems of the patient; expressive interaction which is concerned with the emotions caused by the illness and the treatment situation; and communication [l, 21. Recently, it has often been claimed that medical progress, especially increasing specialization, emphasize the instrumental aspects of the doctor-patient relationship at the expense of communicative and expressive aspects [3]. Several studies have shown that patients pay attention to both instrumental and expressive factors in evaluating their doctors and the doctor-patient relationship and that the need for information may often be greater than the doctors assume. S.S.M. 616-E
723
724
HANNU VLJON, TAPIO AAKLJ,
ESKO
AIM,
RISTO
ERGO
and
REIJO JOHAXSO~
The purpose of the stud\, The goals of this study are: 1. to study how ambulatory and hospitalized patients compare in their experiences \\~th the doctor-patient relationship in the context of specific treatment situations: 2. to study the relationship between patients’ experiences and background 1 ariablcs characterizing the patient and his doctor: and 3. to study the relationship between patients’ experiences and the swxss of the doctorpatient relationship. Material and methods Two samples were formed consisting of patients over 16 years of age who lived in Turl\u. Finland. The ambulatory care sample consisted of those 423 patients who claimed their sickness insurance benefits on December 16, 1969. They had been treated by a pri\,ate practitioner in his office. The hospital care sample consisted of those 445 patients who were discharged from Turku University Hospital between December 4 and 16. 1969. These samples did not differ statistically significantly with regard to the background lrariables. The data were obtained by means of a mailed questionnaire. The items of the questionnaire were closed-ended questions pertaining to different aspects of the patients’ experiences (Table 1). In the analysis of the data, cross tabulations, indexes constructed by combining individual variables, and regression analysis were used. In the ambulatory care sample, the rate of response was 78 per cent and in the hospital care sample 81 per cent. The results reported are based on the numbers of those who returned the questionnaire (in the ambulatory care sample, N = 330, and in the hospital care sample, :V = 360). The statistical significance of differences observed was tested by means of the x2-test. Variables used in the study This study is concerned on one hand with the most important social background variables characterizing the patient and his doctor and, on the other hand, with those instrumental. expressive and communicative factors characterizing the doctor-patient relationship that have most often been mentioned in discussions concerning the quality of this relationship (Table 1). These variables were measured by means of the respondents’ answers to the items In a mailed questionnaire. In this study, the doctor-patient relationship is characterized by the patients’ subjectike experiences. These experiences need not correspond with objective reality; they influence. however, the patients’ satisfaction with the doctor-patient relationship and their willingness to continue and renew it. The success of the relationship was measured by asking the patients how willing they were to return to the same doctor and to what extent they had followed instructions given to them.
RESULTS
Patients’ experiences of doctor-patient relatiorlship Table 1 shows the proportion of patients having positive experiences. both patients who have negative experiences and who have not answered latter group was in all cases considerably greater.
The rest contains the question. The
Doctor-Patient
Relationship
in
the Light of Patients’ Experiences
725
TABLE 1. PATIEKTS’POSITIVEEXPERIENCES OF DOCTOR-PATIENT RELATIONSHIP Positive experiences Variable
Ambulatory (%)
I. Instrumental variables Thoroughness of examination Was a diagnosis established Doctor’s competence No mistake in diagnosis and treatment II. Communication variables Information about disease to patient No strange medical terms* Clearness of doctor’s instructions? III. Expressive variables Doctor’s friendliness1 Doctor’s interest in patients’ symptoms Patient could tell all he wanted about his disease Seeing the patient as an individual
care
Hospital care (%I
75 79 92 72
77
79 81 90
73 52 79
89 76 79 64
83 70 80 60
84 94 75
* Difference between the materials significant at the O+Ol level. 7 Difference between the materials significant at the 0.01 level. $ Difference between the materials significant at the 0.05 level.
Both ambulatory and hospital patients seem to be fairly satisfied with the doctor-patient relationship: approximately three-quarters of the respondents have had positive experiences. The differences between the two samples are small. With regard to communication, ambulatory patients think more frequently (P < 0X101) than hospital patients that doctors have given their instructions clearly and have not used too much medical terminology. With regard to expressive variables, the only difference is that ambulatory patients think their doctors are more friendly (P < 0.05) than hospital patients do. Relationship
between experiences
of doctor-patient
relationship
and background
variables
As there were no differences between ambulatory and hospital patients with regard to the background variables, the samples have been combined in the following presentation. There is no relationship between the patient’s experiences and his sex or the speciality ofthe doctor. The older and the less educated the patient is, the more often (P < 0.001) he has difficulties in understanding the terminology used and instructions given by the doctors. Younger patients are more often (P < 0.01) of the opinion that their doctors have been friendly and sufficiently interested in their symptoms than are older patients. The better educated do not feel as often (P < 0.01) as the less educated patients that the doctor has made some mistake in the diagnosis or treatment.,With regard to income, there is a curvilinear relationship that has been observed in many other social studies too [4]. The members of the lowest and highest income groups are most satisfied with the thoroughness of the ex,amination (P < O.Ol), the establishment of a diagnosis (P < 0*05), the competence of the doctor (P < 0.05), the possibility of mistakes in diagnosis or treatment (P < O*OOl), and the amount of information given to them on the nature of their disease (P -C 0.01). In the ambulatory care sample, patients were less satisfied with the information given by an older physician than with that given by a younger physician (P < 0.001).
HANNU VUORI, TAPIO AAKU, ESKO AINE, RISTO ERKKO and REWJ JOHAXSO\
726
The success of doctor-patient relationship The success of the doctor-patient relationship as measured by the patient.5 willingness return to the same doctor and his following of the doctor’s instructions was as follo~~~~ Ambulatory 73 “;,
willing to return to the same doctor followed instructions
care
to
Hospital care 73 O/) 68”,,
74°C)
There is no relationship between the following of instructions and the background Lariables. Ambulatory patients are more willing to return to the same doctor, the higher their incomes are (P < 0.01) and the younger the doctor is (P < 0.001). Older hospital patients are more willing to return than the younger ones (P < 0.001). Tile success of doctor-patient relationship and patients’ esperiences In Table 2, the variables characterizing the doctor-patient relationship are presented in the order in which they distinguish those willing to return to the same doctor from those who are unwilling. The discriminating function of the variables is measured by the percent point difference ( l). TABLE 2. RELATIONSHIP BETWEEN WILLINGNESS TO RETURN TO THE SAME DOCTOR AND F.ACTORS DESCRIBING THE DOCTOR-PATIENT RELATIONSHIP’ I. Ambulatory Variable
1. Doctor’s 2. 3. 4. 5. 6. 7. 8. 9.
10. 11.
1
Information about disease to patient Thoroughness of examination Doctor’s interest in patient’s symptoms Doctor’s friendliness Clearness of doctor’s instructions Seeing the patient as an individual No mistake in diagnosis and treatment Was a diagnosis established Patient could tell all he wanted about his disease No strange medical terms
For explanation
C = communication
see
II. Hospital Variable
E
competence
‘I = instrumental; *t
care
65*
1 7
care
Doctor’s interest in patient’s symptoms Doctor’s competence
C
42+
-.
I
41* _
3. Thoroughness of examination friendliness 4. Doctor’s
E E C E
40* 39* 36* 3.5*
I I
34* 29*
E C
25* 5
variable:
Seeing the patient as an individual Information about disease to patient Was a diagnosis established Patient could tell all he wanted about his disease 9. Clearness of doctor’s instructions 10. No mistake in diagnosis and treatment 11. No strange medical terms 5. 6. 7. 8.
E = expressive
e
E
51*
I
45*
I
44*
E
13*
E C I
30* 2x* ‘3* -_
t
‘3*
C
12*
I (_’
7,* ;;_
variable.
Table I.
In ambulatory care, the competence of the doctor has the highest discriminating capacity. In the hospital care sample, no variable distinguishes itself in the same way. With regard to the groups of variables-instrumental, expressive and communicative--no clear picture emerges. In ambulatory care, the discriminating capacity of most variables with regard to the following of doctor’s instructions is good, whereas in the hospital sample, only three variables exert a statistically significant discriminating function. In both samples, the clear.
Doctor-Patient
Relationship
in the Light of Patients’ Experiences d TABLE
RELATIONSHIP
BETWEEN
I. Ambulatory Variable
3.
FOLLOWING OF DOCTOR'S INSTRUCTIONS AND DOCTOR-PATIENT RELATIONSHIP'
care
6. Was a diagnosis established 7. Information about disease to patient 8. Doctor’s friendliness
C
I
.59* 39*
E
27+
I I
25; 22*
I
22*
C E
22* 15
9. Patient could tell all he wanted about his disease 10. Seeing the patient as an individual
E E
10 8
11. No strange medical terms
c
4
‘I = instrumental variable; C = communication *t For explanation see Table 1.
ness of the instructions discriminates no clear picture emerges.
FACTORS DESCRIBING THE
II. Hospital care Variable
E
1. Clearness of doctor’s instructions 2. DoctorXcompetence 3. Doctor’s interest in patient’s symptoms 4. No mistake in diagnosis and treatment 5. Thoroughness of examination
727
d
1. Clearness of doctor’s instructions 2. Doctor’s competence 3. Doctor’s friendliness
C
I E
59* 24 13
4. Was a diagnosis established
I
12
5. Doctor’s interest in patient’s symptoms 6. Seeing the patient as an individual 7. Thoroughness of examination
E E I
11t
C
10
I
9
E c
9 7
8. Information about disease to patient 9. No mistake in diagnosis and treatment 10. Patient could tell all he wanted about his disease 11. No strange medical terms
11t 11
variable; E = expressive variable.
most effectively.
With regard to the groups of variables,
The success of doctor-patient relationship and instrumentality, communication, and expressivity indexes To get a clearer picture of the relative importance of the groups of variables with regard to the success of the doctor-patient relationship, instrumentality, communication, and TABLE 4. RELATIONSHIP BETWEEN WILLINGNESS TO RETURN TO THE DOCTORANDINSTRUMENTALITY,COMMUNICATION,ANDEXPRESSIV~Y INDEXES
SAME
Willing to return Index
Ambulatory (%I
Instrumentality 3 2 1 Communication 3 ;?
84 40 62
Expressivity 3 2 1
90 73 42
* For explanation
88 74 38
see Table 1.
care (cl
50*
44*
48*
Hospital care (%I (E) 85 67 40 88 52 72 89 78 44
45*
36*
45*
728
HANNU Vuo~r, TAPIO .&KU, ESKO AI&E, RISTO ERKKO and REIJO JOHASSSO~
expressivity indexes were formed by giving index \zalue 2 to p0sitiL.e experiences and index value 1 to negative experiences in every variable. The highest index \a1 ue in Tables 1 and 5 represents the most positive experience. With regard to the willingness to return to the same doctor. all indeses ha\t: :L h~yh discriminating capacity. This analysis does not however. clarify the re!ati\.e imporrance 01‘ the groups of variables in determining the willingness to renew a doctor-patient relati~~nship. Communicalion plays, however, a minor role in comparison with the other tnc,. With regard to the following of doctor’s instructions. the picture is clear: communi~~~tlc~n discriminates best. TABLE 5. RELATIONSHIPBETWEENFOLLOWIP~COFDOCTOR‘SINSTRUCTIONS AND INSTRUMENTALITY, COMMUNICATION, AUD EYPRESSIVITY INDT\ES
Followed instructions
Index
.4mbulatory care (Cl fOO)
Hospital care
co0 )
(6)
Instrumentality 3 3
1 Communication 3 3 1 Expressivity 3 ;-l
*t:
For explanation
The success of the doctor-patient
see Table 1.
relationship and analysis of regression
The picture obtained by means of the indexes can be completed by means of an analysis of regression that permits one to estimate what proportion of the total i.ariance of the dependent variable can be explained by means of the independent variables. Although most of the independent variables and the indexes hate a high discriminating capacity, they explain a relatively minor part of the total variance of the dependent variables. Consequently, rest variance is great. In Table 6. those two variables whose explanation power is greatest are presented. Other variables explain at most one percent of the total variance. In the case of the following of instructions, the clearness of the instructions explains just about all that can be explained by means of the variables included in this study. Also with regard to the willingness to return to the same doctor. the situation is relatively clear. In both samples, the doctors’ competence and his interest in the patients’ symptoms explain nearly everything that can be explained by means of this regression model. As for the indexes, in both samples. the following of doctor‘s instructions can primarily be explained by communication. With regard to the willingness to return. the most important factor in the ambulatory care is instrumentality (explanation proportion 26 per cent) and in hospital care, expressivity (explanation proportion 17 per cent).
Doctor-Patient
Relationship
in the Light of Patients’ Experiences
729
TABLE 6.
Cumulative proportion of explanation (%) 1. Ambulatory A.
B.
care
Willingness to return to the same doctor 1. Doctor’s competence 2. Doctor’s interest in the patients’ symptoms Rest variance (55 %)
28 38
Following of doctor’s instructions 1. Clearness of doctor’s instructions 2. Patient’s age Rest variance (53 “,,J
42 43
II. Hospital care A.
B.
Willingness to return to the same doctor 1. Doctor’s interest in the patients’ symptoms 2. Doctor’s competence Rest variance (68 %)
17 24
Following of doctor’s instructions 1. Clearness of doctor’s instructions 2. Thoroughness of the examination Rest variance (61%)
34 35
DISCUSSION
Organized medical care is only one of a number of alternatives to seek care [5, 61. The experiences the patients have from their earlier contacts with professional health culture [7] influence their willingness to renew these contacts and follow the instructions they receive. If the claims concerning the overemphasis of the instrumental aspects of the doctor-patient relationship at the expense of communicative and expressive aspects are justified, it could be assumed that these latter factors would be more important determinants of the success of the doctor-patient relationship. With regard to the following of the doctor’s instructions this assumption seems to be correct. The communicative aspects of the doctor-patient relationship have the best discriminating capacity. With regard to willingness to return to the same doctor, the picture is not as clear. Individual variables give no information. Even the yield of the indexes is limited. Only the relatively minor importance of the communication with regard to this criterion of the success of the doctor-patient relationship is evident. The analysis of regression throws a little more light on the problem of the relative importance of instrumental and expressive factors. In ambulatory care, it is instrumentality that determines the result. In particular the patient’s notion of the doctor’s competence plays an important role. In the second pIace, however, there is a typically expressive factor, the doctor’s interest in his patient’s symptoms. Absence of this interest has often been mentioned in discussions concerning the quality of the doctor-patient relationship. In hospital sample the willingness to return to the same doctor is primarily determined by expressive factors, but here too the patient’s conception of the doctor’s competence plays an. important role. These findings support earlier studies.
730
HANNU
VUORI, TAPIO AAKLJ,ESKO .~INE, RISTO ERKKO and REIJO JOHANSSOL
A possible explanation of the fact that expressive factors are more important determinants of the success of the doctor-patient relationship in hospital care than in ambulatory care may be that in hospitals a high instrumental level is taken for granted and the patients. consequently, pay more attention to the expressive aspects. Among the hospital patients, the discrimination capacity of the independent \-ariables and indexes is lower and rest variance in the analysis of regression higher than in the ambulatory care sample. This may mean that hospital patients are more homogeneous than ambulatory care patients with regard to the dependent variables or. which seems more plausible, that hospital care is more complicated than ambulatory care. ConsequentI>. the variables used in this study do not suffice to explain the patient’s experiences and the success of doctor-patient relationship in hospitals. Obviously, a more CornprehensiLe explanatory model is needed. REFERENCES sjukhuset (How does the patient experience the hoapltal). Almqvist & Wiksell, Uppsala, 1962. 1 BLOOM,SAMUELW. The Doctor und His Patient. Free Press, New York, 1905. ; : VUORI, HANNU. Doctor-pafienf relationship in transition. Report from the Instltutc or‘ Sociology, University of Turku. No. 11, 1968. VUORI, HANNU. Juomaveden fluoraus sosiologisena ongelmana (Fluoridation of drinking water as :L sociological problem). Sosiologiu 7, 230-134, 1970. FREIDSON,ELIOT. Patient’s Views of Medical Practice. Russell Sage Foundation, New York, lYc>I. KING, STANLEYH. Perceptions of Illness and Medical Pmctice. Russell Sage Foundation. New Yorh, 1962. POLGAR, STEVEN. Health action in cross-cultural perspective. In Handbook of .Wcdicr/l Soc~wlo~y. (edited by FREEhfAN,HOWARDE. et al.). Prentice-Hall, Englewood Cliffs, N.J., 1963.
1.
ISRAEL, JOACHIM.
Hur Patienten
Upplrrer
pp. 723-730. Pergamon Press. Printed in Great Britain.
DOCTOR-PATIENT RELATIONSHIP IN THE LIGHT OF PATIENTS’ EXPERIENCES HANNU VUORI, TAPIO AAKU, ESKO AINE, RISTO ERKKO and REIJO JOHANSSON Institute of Hygiene and Social Medicine. University of Turku, Finland
Abstract-In order to investigate the claims that the quality of doctor-patient relationship has deteriorated, the experiences of 330 ambulatory care patients and of 360 hospitalized patients were collected by means of a mailed questionnaire. The relationships between three groups of variables were studied : background variables describing the doctor and the patient; variables pertaining to certain salient instrumental, communicative, and expressive factors of the doctor-patient relationship, and variables measuring the success of this relationship.
ABOUT three-fourths of the patients in both samples had clearly positive experiences, Hospital patients were significantly less often satisfied with the information they had received than ambulatory patients. The success of the doctor-patient relationship was measured by asking how willing the patients were to return to the same doctor and how well they had followed the instructions they had got. There was no relationship between the background variables and the following of the doctor’s instructions. In the ambulatory care sample, the willingness to return to the same doctor was related to the respondent’s income and by the doctor’s age, in the hospital care sample, to the age of the respondent. On the basis of cross tabulations, instrumentality, expressivity, and communication indexes, and regression analysis, it can be concluded that in the hospital care sample, expressive factors exerted the greatest influence on the willingness to return to the same doctor. In the ambulatory care sample, this willingness was primarily determined by instrumental factors. In both samples, following of the doctor’s instructions was primarily determined by the communicative aspects of the doctor-patient relationship.
DOCTOR-PATIENT RELATIONSHIP IN THE LIGHT PATIENTS’ EXPERIENCES
OF
The doctor-patient relationship can be conceptualized as consisting of three kinds of interaction: instrumental interaction, that is application of the doctor’s skills and knowledge in solving the problems of the patient; expressive interaction which is concerned with the emotions caused by the illness and the treatment situation; and communication [l, 21. Recently, it has often been claimed that medical progress, especially increasing specialization, emphasize the instrumental aspects of the doctor-patient relationship at the expense of communicative and expressive aspects [3]. Several studies have shown that patients pay attention to both instrumental and expressive factors in evaluating their doctors and the doctor-patient relationship and that the need for information may often be greater than the doctors assume. S.S.M. 616-E
723
724
HANNU VLJON, TAPIO AAKLJ,
ESKO
AIM,
RISTO
ERGO
and
REIJO JOHAXSO~
The purpose of the stud\, The goals of this study are: 1. to study how ambulatory and hospitalized patients compare in their experiences \\~th the doctor-patient relationship in the context of specific treatment situations: 2. to study the relationship between patients’ experiences and background 1 ariablcs characterizing the patient and his doctor: and 3. to study the relationship between patients’ experiences and the swxss of the doctorpatient relationship. Material and methods Two samples were formed consisting of patients over 16 years of age who lived in Turl\u. Finland. The ambulatory care sample consisted of those 423 patients who claimed their sickness insurance benefits on December 16, 1969. They had been treated by a pri\,ate practitioner in his office. The hospital care sample consisted of those 445 patients who were discharged from Turku University Hospital between December 4 and 16. 1969. These samples did not differ statistically significantly with regard to the background lrariables. The data were obtained by means of a mailed questionnaire. The items of the questionnaire were closed-ended questions pertaining to different aspects of the patients’ experiences (Table 1). In the analysis of the data, cross tabulations, indexes constructed by combining individual variables, and regression analysis were used. In the ambulatory care sample, the rate of response was 78 per cent and in the hospital care sample 81 per cent. The results reported are based on the numbers of those who returned the questionnaire (in the ambulatory care sample, N = 330, and in the hospital care sample, :V = 360). The statistical significance of differences observed was tested by means of the x2-test. Variables used in the study This study is concerned on one hand with the most important social background variables characterizing the patient and his doctor and, on the other hand, with those instrumental. expressive and communicative factors characterizing the doctor-patient relationship that have most often been mentioned in discussions concerning the quality of this relationship (Table 1). These variables were measured by means of the respondents’ answers to the items In a mailed questionnaire. In this study, the doctor-patient relationship is characterized by the patients’ subjectike experiences. These experiences need not correspond with objective reality; they influence. however, the patients’ satisfaction with the doctor-patient relationship and their willingness to continue and renew it. The success of the relationship was measured by asking the patients how willing they were to return to the same doctor and to what extent they had followed instructions given to them.
RESULTS
Patients’ experiences of doctor-patient relatiorlship Table 1 shows the proportion of patients having positive experiences. both patients who have negative experiences and who have not answered latter group was in all cases considerably greater.
The rest contains the question. The
Doctor-Patient
Relationship
in
the Light of Patients’ Experiences
725
TABLE 1. PATIEKTS’POSITIVEEXPERIENCES OF DOCTOR-PATIENT RELATIONSHIP Positive experiences Variable
Ambulatory (%)
I. Instrumental variables Thoroughness of examination Was a diagnosis established Doctor’s competence No mistake in diagnosis and treatment II. Communication variables Information about disease to patient No strange medical terms* Clearness of doctor’s instructions? III. Expressive variables Doctor’s friendliness1 Doctor’s interest in patients’ symptoms Patient could tell all he wanted about his disease Seeing the patient as an individual
care
Hospital care (%I
75 79 92 72
77
79 81 90
73 52 79
89 76 79 64
83 70 80 60
84 94 75
* Difference between the materials significant at the O+Ol level. 7 Difference between the materials significant at the 0.01 level. $ Difference between the materials significant at the 0.05 level.
Both ambulatory and hospital patients seem to be fairly satisfied with the doctor-patient relationship: approximately three-quarters of the respondents have had positive experiences. The differences between the two samples are small. With regard to communication, ambulatory patients think more frequently (P < 0X101) than hospital patients that doctors have given their instructions clearly and have not used too much medical terminology. With regard to expressive variables, the only difference is that ambulatory patients think their doctors are more friendly (P < 0.05) than hospital patients do. Relationship
between experiences
of doctor-patient
relationship
and background
variables
As there were no differences between ambulatory and hospital patients with regard to the background variables, the samples have been combined in the following presentation. There is no relationship between the patient’s experiences and his sex or the speciality ofthe doctor. The older and the less educated the patient is, the more often (P < 0.001) he has difficulties in understanding the terminology used and instructions given by the doctors. Younger patients are more often (P < 0.01) of the opinion that their doctors have been friendly and sufficiently interested in their symptoms than are older patients. The better educated do not feel as often (P < 0.01) as the less educated patients that the doctor has made some mistake in the diagnosis or treatment.,With regard to income, there is a curvilinear relationship that has been observed in many other social studies too [4]. The members of the lowest and highest income groups are most satisfied with the thoroughness of the ex,amination (P < O.Ol), the establishment of a diagnosis (P < 0*05), the competence of the doctor (P < 0.05), the possibility of mistakes in diagnosis or treatment (P < O*OOl), and the amount of information given to them on the nature of their disease (P -C 0.01). In the ambulatory care sample, patients were less satisfied with the information given by an older physician than with that given by a younger physician (P < 0.001).
HANNU VUORI, TAPIO AAKU, ESKO AINE, RISTO ERKKO and REWJ JOHAXSO\
726
The success of doctor-patient relationship The success of the doctor-patient relationship as measured by the patient.5 willingness return to the same doctor and his following of the doctor’s instructions was as follo~~~~ Ambulatory 73 “;,
willing to return to the same doctor followed instructions
care
to
Hospital care 73 O/) 68”,,
74°C)
There is no relationship between the following of instructions and the background Lariables. Ambulatory patients are more willing to return to the same doctor, the higher their incomes are (P < 0.01) and the younger the doctor is (P < 0.001). Older hospital patients are more willing to return than the younger ones (P < 0.001). Tile success of doctor-patient relationship and patients’ esperiences In Table 2, the variables characterizing the doctor-patient relationship are presented in the order in which they distinguish those willing to return to the same doctor from those who are unwilling. The discriminating function of the variables is measured by the percent point difference ( l). TABLE 2. RELATIONSHIP BETWEEN WILLINGNESS TO RETURN TO THE SAME DOCTOR AND F.ACTORS DESCRIBING THE DOCTOR-PATIENT RELATIONSHIP’ I. Ambulatory Variable
1. Doctor’s 2. 3. 4. 5. 6. 7. 8. 9.
10. 11.
1
Information about disease to patient Thoroughness of examination Doctor’s interest in patient’s symptoms Doctor’s friendliness Clearness of doctor’s instructions Seeing the patient as an individual No mistake in diagnosis and treatment Was a diagnosis established Patient could tell all he wanted about his disease No strange medical terms
For explanation
C = communication
see
II. Hospital Variable
E
competence
‘I = instrumental; *t
care
65*
1 7
care
Doctor’s interest in patient’s symptoms Doctor’s competence
C
42+
-.
I
41* _
3. Thoroughness of examination friendliness 4. Doctor’s
E E C E
40* 39* 36* 3.5*
I I
34* 29*
E C
25* 5
variable:
Seeing the patient as an individual Information about disease to patient Was a diagnosis established Patient could tell all he wanted about his disease 9. Clearness of doctor’s instructions 10. No mistake in diagnosis and treatment 11. No strange medical terms 5. 6. 7. 8.
E = expressive
e
E
51*
I
45*
I
44*
E
13*
E C I
30* 2x* ‘3* -_
t
‘3*
C
12*
I (_’
7,* ;;_
variable.
Table I.
In ambulatory care, the competence of the doctor has the highest discriminating capacity. In the hospital care sample, no variable distinguishes itself in the same way. With regard to the groups of variables-instrumental, expressive and communicative--no clear picture emerges. In ambulatory care, the discriminating capacity of most variables with regard to the following of doctor’s instructions is good, whereas in the hospital sample, only three variables exert a statistically significant discriminating function. In both samples, the clear.
Doctor-Patient
Relationship
in the Light of Patients’ Experiences d TABLE
RELATIONSHIP
BETWEEN
I. Ambulatory Variable
3.
FOLLOWING OF DOCTOR'S INSTRUCTIONS AND DOCTOR-PATIENT RELATIONSHIP'
care
6. Was a diagnosis established 7. Information about disease to patient 8. Doctor’s friendliness
C
I
.59* 39*
E
27+
I I
25; 22*
I
22*
C E
22* 15
9. Patient could tell all he wanted about his disease 10. Seeing the patient as an individual
E E
10 8
11. No strange medical terms
c
4
‘I = instrumental variable; C = communication *t For explanation see Table 1.
ness of the instructions discriminates no clear picture emerges.
FACTORS DESCRIBING THE
II. Hospital care Variable
E
1. Clearness of doctor’s instructions 2. DoctorXcompetence 3. Doctor’s interest in patient’s symptoms 4. No mistake in diagnosis and treatment 5. Thoroughness of examination
727
d
1. Clearness of doctor’s instructions 2. Doctor’s competence 3. Doctor’s friendliness
C
I E
59* 24 13
4. Was a diagnosis established
I
12
5. Doctor’s interest in patient’s symptoms 6. Seeing the patient as an individual 7. Thoroughness of examination
E E I
11t
C
10
I
9
E c
9 7
8. Information about disease to patient 9. No mistake in diagnosis and treatment 10. Patient could tell all he wanted about his disease 11. No strange medical terms
11t 11
variable; E = expressive variable.
most effectively.
With regard to the groups of variables,
The success of doctor-patient relationship and instrumentality, communication, and expressivity indexes To get a clearer picture of the relative importance of the groups of variables with regard to the success of the doctor-patient relationship, instrumentality, communication, and TABLE 4. RELATIONSHIP BETWEEN WILLINGNESS TO RETURN TO THE DOCTORANDINSTRUMENTALITY,COMMUNICATION,ANDEXPRESSIV~Y INDEXES
SAME
Willing to return Index
Ambulatory (%I
Instrumentality 3 2 1 Communication 3 ;?
84 40 62
Expressivity 3 2 1
90 73 42
* For explanation
88 74 38
see Table 1.
care (cl
50*
44*
48*
Hospital care (%I (E) 85 67 40 88 52 72 89 78 44
45*
36*
45*
728
HANNU Vuo~r, TAPIO .&KU, ESKO AI&E, RISTO ERKKO and REIJO JOHASSSO~
expressivity indexes were formed by giving index \zalue 2 to p0sitiL.e experiences and index value 1 to negative experiences in every variable. The highest index \a1 ue in Tables 1 and 5 represents the most positive experience. With regard to the willingness to return to the same doctor. all indeses ha\t: :L h~yh discriminating capacity. This analysis does not however. clarify the re!ati\.e imporrance 01‘ the groups of variables in determining the willingness to renew a doctor-patient relati~~nship. Communicalion plays, however, a minor role in comparison with the other tnc,. With regard to the following of doctor’s instructions. the picture is clear: communi~~~tlc~n discriminates best. TABLE 5. RELATIONSHIPBETWEENFOLLOWIP~COFDOCTOR‘SINSTRUCTIONS AND INSTRUMENTALITY, COMMUNICATION, AUD EYPRESSIVITY INDT\ES
Followed instructions
Index
.4mbulatory care (Cl fOO)
Hospital care
co0 )
(6)
Instrumentality 3 3
1 Communication 3 3 1 Expressivity 3 ;-l
*t:
For explanation
The success of the doctor-patient
see Table 1.
relationship and analysis of regression
The picture obtained by means of the indexes can be completed by means of an analysis of regression that permits one to estimate what proportion of the total i.ariance of the dependent variable can be explained by means of the independent variables. Although most of the independent variables and the indexes hate a high discriminating capacity, they explain a relatively minor part of the total variance of the dependent variables. Consequently, rest variance is great. In Table 6. those two variables whose explanation power is greatest are presented. Other variables explain at most one percent of the total variance. In the case of the following of instructions, the clearness of the instructions explains just about all that can be explained by means of the variables included in this study. Also with regard to the willingness to return to the same doctor. the situation is relatively clear. In both samples, the doctors’ competence and his interest in the patients’ symptoms explain nearly everything that can be explained by means of this regression model. As for the indexes, in both samples. the following of doctor‘s instructions can primarily be explained by communication. With regard to the willingness to return. the most important factor in the ambulatory care is instrumentality (explanation proportion 26 per cent) and in hospital care, expressivity (explanation proportion 17 per cent).
Doctor-Patient
Relationship
in the Light of Patients’ Experiences
729
TABLE 6.
Cumulative proportion of explanation (%) 1. Ambulatory A.
B.
care
Willingness to return to the same doctor 1. Doctor’s competence 2. Doctor’s interest in the patients’ symptoms Rest variance (55 %)
28 38
Following of doctor’s instructions 1. Clearness of doctor’s instructions 2. Patient’s age Rest variance (53 “,,J
42 43
II. Hospital care A.
B.
Willingness to return to the same doctor 1. Doctor’s interest in the patients’ symptoms 2. Doctor’s competence Rest variance (68 %)
17 24
Following of doctor’s instructions 1. Clearness of doctor’s instructions 2. Thoroughness of the examination Rest variance (61%)
34 35
DISCUSSION
Organized medical care is only one of a number of alternatives to seek care [5, 61. The experiences the patients have from their earlier contacts with professional health culture [7] influence their willingness to renew these contacts and follow the instructions they receive. If the claims concerning the overemphasis of the instrumental aspects of the doctor-patient relationship at the expense of communicative and expressive aspects are justified, it could be assumed that these latter factors would be more important determinants of the success of the doctor-patient relationship. With regard to the following of the doctor’s instructions this assumption seems to be correct. The communicative aspects of the doctor-patient relationship have the best discriminating capacity. With regard to willingness to return to the same doctor, the picture is not as clear. Individual variables give no information. Even the yield of the indexes is limited. Only the relatively minor importance of the communication with regard to this criterion of the success of the doctor-patient relationship is evident. The analysis of regression throws a little more light on the problem of the relative importance of instrumental and expressive factors. In ambulatory care, it is instrumentality that determines the result. In particular the patient’s notion of the doctor’s competence plays an important role. In the second pIace, however, there is a typically expressive factor, the doctor’s interest in his patient’s symptoms. Absence of this interest has often been mentioned in discussions concerning the quality of the doctor-patient relationship. In hospital sample the willingness to return to the same doctor is primarily determined by expressive factors, but here too the patient’s conception of the doctor’s competence plays an. important role. These findings support earlier studies.
730
HANNU
VUORI, TAPIO AAKLJ,ESKO .~INE, RISTO ERKKO and REIJO JOHANSSOL
A possible explanation of the fact that expressive factors are more important determinants of the success of the doctor-patient relationship in hospital care than in ambulatory care may be that in hospitals a high instrumental level is taken for granted and the patients. consequently, pay more attention to the expressive aspects. Among the hospital patients, the discrimination capacity of the independent \-ariables and indexes is lower and rest variance in the analysis of regression higher than in the ambulatory care sample. This may mean that hospital patients are more homogeneous than ambulatory care patients with regard to the dependent variables or. which seems more plausible, that hospital care is more complicated than ambulatory care. ConsequentI>. the variables used in this study do not suffice to explain the patient’s experiences and the success of doctor-patient relationship in hospitals. Obviously, a more CornprehensiLe explanatory model is needed. REFERENCES sjukhuset (How does the patient experience the hoapltal). Almqvist & Wiksell, Uppsala, 1962. 1 BLOOM,SAMUELW. The Doctor und His Patient. Free Press, New York, 1905. ; : VUORI, HANNU. Doctor-pafienf relationship in transition. Report from the Instltutc or‘ Sociology, University of Turku. No. 11, 1968. VUORI, HANNU. Juomaveden fluoraus sosiologisena ongelmana (Fluoridation of drinking water as :L sociological problem). Sosiologiu 7, 230-134, 1970. FREIDSON,ELIOT. Patient’s Views of Medical Practice. Russell Sage Foundation, New York, lYc>I. KING, STANLEYH. Perceptions of Illness and Medical Pmctice. Russell Sage Foundation. New Yorh, 1962. POLGAR, STEVEN. Health action in cross-cultural perspective. In Handbook of .Wcdicr/l Soc~wlo~y. (edited by FREEhfAN,HOWARDE. et al.). Prentice-Hall, Englewood Cliffs, N.J., 1963.
1.
ISRAEL, JOACHIM.
Hur Patienten
Upplrrer