Doctor:Patient Communication in Ophthalmic Outpatient Visits

Viewpoint

Doctor:Patient Communication in Ophthalmic Outpatient Visits JONATHAN D. TROBE, MD,· RANDY KRAFT,· JEFFREY P. KRISCHER, PhDt

Abstract: Interviews with 163 patients and the 19 ophthalmologists who examined them disclosed that patients considered an adequate explanation of diagnosis, treatment, and prognosis as the most important communication items in determining satisfaction with care. Ophthalmologists in private practice appeared to share this valuation, except that explaining the prognosis of an illness was not rated as highly. Resident ophthalmologists rated all explanatory items far less important than did their patients. Among items related to personalization of the encounter, ophthalmologists in private practice underrated the importance of dealing with the patient's concerns, while residents underrated familiarity, undivided attention, and encouragement. In spite of these differences, ophthalmologists apparently are sensitive to patient expectations, inasmuch as they received generally high ratings for their performance in each of the items that patients valued highly and poorer ratings for those items that were held less important. [Key words: communication, interview, patient satisfaction.] Ophthalmology 90:49A-53A, 1983

There has been a recent increase in emphasis on patient satisfaction with medical care, motivated by three factors: (1) the evidence that patient adherence to treatment is influence by satisfaction 1,2; (2) the growing sense that physicians should be more accountable for the services they render3 ; and (3) the fear that greater reliance upon technological tools in diagnosis and third party reimbursement have led to increasing impersonality and alienation. 4 Patient satisfaction has been found to depend upon the art of care (the provider's concern, friendliness, sincerity), the technical quality of care (the provider's skills and equipment), the accessibility, convenience, availability, and continuity of care, the physical environment in which the care takes place, the patient's ability to pay, From the Gainesville Veterans Administration Medical Center, and Departments of Ophthalmology' and Pediatrics. t University of Florida, College of Medicine, Gainesville, Florida. Supported by Grant #HS03647 from National Center for Health Services Research, Department of Health and Human Services, and Grant #466 from the Veterans Administration Health Services Research and Devel· opment Service, and an unrestricted departmental grant from Research to Prevent Blindness, Inc. Reprint requests to Jonathan D. Trobe, MD, Department of Ophthalmology, University of Florida, Box J-2B4, JHMHC, Gainesville, FL 32610.

0161-6420/83/1000/049A/$1.05 © American Academy of Ophthalmology

and the patient's perception of how helpful the medical care is. 3 Most of the information about satisfaction with the art of care is derived from questionnaires and interviews with patients. No data of this sort have been collected for ophthalmic care. Information from other specialties reveals that patients value most highly the physician's showing a personalized interest in them,5-7 and secondarily providing them with an adequate explanation of their medical condition. 5,8,9 Would physicians rate these items as paramount? In the only available study,lO when physicians were asked "What two characteristics are most important in making a good physician?", they most often listed professional qualities, such as skill in diagnosis and knowledge regarding treatment. 10 Next in importance were establishing rapport with patients, inspiring confidence, ability to "recognize and control feelings" toward patients, and honesty, sincerity, kindness, and intelligence. Giving information to patients about their medical condition was not mentioned. To our knowledge, no study in any medical specialty has asked physicians specifically about which doctor:patient communication items are important in patient satisfaction. We compared the importance ratings rendered by patients and their examining ophthalmologists of a list of

51A

OPHTHALMOLOGY •

OCTOBER 1983 •

Table 1. Demographies of Patients in GVAMC Eye Clinic and Five Local Practices of Ophthalmology

Median age (years) Medial educational level (years) Male Nonwhite Married "White collar" Employed full time

GVAMC (81)*

Private Practices (82)*

58.3 11.7 97.2% 10.2% 80.2% 1.9% 20.6%

45.0 14.5 36.9% 16.7% 74.7% 25.0% 58.7%

* Number of patients studied.

communication items believed to contribute to satisfaction with a medical encounter. We also elicited the patients' evaluation of the examining ophthalmologists' performance in each of these items. The "importance to satisfaction" ratings and performance ratings were then combined into an "index of encounter satisfaction."

METHODS A sociologist interviewed 81 patients immediately after they underwent initial ophthalmic examination at the Gainesville Veterans Administration Medical Center (GVAMC), 82 patients immediately after they underwent initial ophthalmic examination in the offices of private practitioners in the same community, and the 19 ophthalmologists who examined them. The 14 ophthalmologists who examined the GVAMC patients were residents (five first year, five second year, and four third year) in the training program of the Department of Ophthalmology, College of Medicine, University of Florida. The remaining five ophthalmologists were in community practice in Gainesville. The patient populations at the two examining sites differed strikingly in educational level, sex, and employment (Table 1). Based upon a review of the literature on patient satisfaction with medical care;l,12 the following 11 "communication" items were selected: (1) displays entering courtesies (makes friendly small talk to "break the ice" when the physician first meets the patient); (2) is familiar with patient's background (as gleaned from a prior scanning ofthe medical record); (3) warns patient of uncomfortable procedures; (4) encourages patient to cooperate with procedural parts of the examination; (5) gives patient full attention and does not allow any unnecessary interruptions; (6) deals with patient concerns; (7) explains diagnosis; (8) explains treatment; (9) explains prognosis in terms clear to the patient; (10) shows empathy; and (11) displays exiting courtesies (ends the interview with friendly small talk and directions on how to check out). Each item was placed on a card, and after the medical encounter, each card was shown to the patients, who were asked to rate the item as "very important," "somewhat

52A

VOLUME 90 •

NUMBER 10

important," or "not important," in its contribution to satisfaction with the medical encounter. The patients' 19 examining ophthalmologists were later shown the same items and asked to rate them in the same fashion. The patients were also asked to rate the performance on each of these items of the ophthalmologists who had previously examined them. In evaluating the examining ophthalmologist's performance, the patient could indicate "poor performance," "satisfactory performance," or "excellent performance. " The sign test for paired comparisons 13 was used to compare patients' and ophthalmologists' importance rating of each communication item. Test results revealed the number of times a patient and his examining ophthalmologist indicated the same score for an item (ties), and the number of times the patient rated the item higher or lower than his doctor.

RESULTS 1. IMPORTANCE RATINGS (TABLE 2)

The three explanation items ("explains diagnosis," "explains treatment," "explains prognosis") were considered very important by 90% or more of the patients interviewed at both the GVAMC and in private practice. All other items were considered very important by less than 80% of patients. Entering and exiting courtesies were considered the least important items. The ophthalmologists in private practice concurred with their patients in the importance of explaining diagnosis and treatment, but not prognosis. Private ophthalmologist overrated the importance of "gives full attention" and underrated the importance of "deals with patient concerns" relative to their patients. In contrast, the GVAMC ophthalmology residents rated all explanatory items far lower than did their patients. The resident ophthalmologists also considered "gives full attention," "is familiar with patient's background," and "encourages patient" significantly less important to satisfaction than did their patients. 2. PERFORMANCE RATINGS (TABLE 3)

Ophthalmologists generally earned satisfactory or excellent ratings in their performance on all selected communication items. However, in four items, ophthalmology residents received poor performance ratings by at least 10% of their patients ("displays entering courtesies"10.4%, "is familiar with patient's background"-11.6%, "warns of uncomfortable procedures"-13.4%, "displays exiting courtesies"-11.8%). . 3. ENCOUNTER SATISFACTION (FIGS 1, 2)

In order to determine a patient's measure of satisfaction with the overall encounter, we constructed an index of encounter satisfaction based on the sum of the products of the importance ratings and physician performance ratings for each of the 11 items. Since each rating of per-

TROSE, et aI •

DOCTOR:PATIENT COMMUNICATION

Table 2. Importance Rating of 11 Communication Items in the Ophthalmologic Examination Percent of Encounters With Item Rated as Very Important Private Practices (82)*

GVAMC (81)* Communication Item

Patients

Resident Ophthalmologists

Patients

Ophthalmologists

Explains diagnosis Explains treatment Explains prognosis Deals with patient concerns Gives full attention Is familiar with patient's background Warns of uncomfortable procedures Encourages patient Shows empathy Displays entering courtesies Displays exiting courtesies

94.3 94.3 90.0 61.4 76.1 74.6 65.7 63.4 63.4 57.7 51.4

78.6* 71.4* 64.3* 71.4 42.9* 28.6* 78.6 42.9· 92.9t 50.0 28.6

95.7 94.2 92.8 79.7 69.6 70.6 69.6 36.2 45.6 44.9 32.4

100.0 100.0 40.0· 20.0· 100.0t 80.0 60.0

o·

80.0t 40.0 60.0t

*

* Significant at P !5: 0.05 by sign test of paired comparisons 13 of patient encounters; patient importance> doctor importance. t Significant at P !5: 0.05 by sign test of paired comparisons13 of

patient encounters; doctor importance> patient importance. Number of encounters.

formance could range from one to three, with three being the best, and each rating of importance could also range from one to three, with three being most important, the overall index of encounter satisfaction could range from 11 to 99, since there are 11 items rated. These scores were calculated and then normalized on a scale ranging from 0 to 1.0. The index of encounter satisfaction scale can be interpreted, therefore, as the percent of the maximum possible satisfaction expressed over all eleven items. Constructed in this way, the index of encounter satisfaction is a measure of whether there was an association between how important an item was, in the patient's judgment, and how well the physician performed on that item. That is, to score highly on encounter satisfaction, the patient must rate a physician's performance high in the same areas that are the most important. The results are provided for encounters with ophthalmologists in private practice (Fig 1) and encounters with ophthalmologists at the GV AMC (Fig 2). These encoun-

ters reflect those instances in which all 11 items were rated by the patient. The majority of patients scored their encounters in the highly satisfied range, indicating that the ophthalmologists' performance was rated highly in the areas the patients consider most important. Some small differences were noted between settings: 22% of GVAMC patients had an index of encounter satisfaction score of 0.90 or greater, while only 15% of patients in private practice had a score that high. At the low end of the scale, the reverse is true, with 6% ofGVAMC patients but only 3% of private practice encounters having an index less than 0.50. Neither of these differences is statistically significantly different (chi square = 1.4, P = 0.2).

DISCUSSION In this study, patients rated explanation of diagnosis, treatment, and prognosis of their illness as the most im-

Table 3. Performance Rating by Patients of 11 Communication Items in the Ophthalmologic Examination Private Practice Ophthalmologists

GVAMC Resident Ophthalmologists Communication Item

Poor

Satisfactory

Excellent

Poor

Satisfactory

Excellent

Displays entering courtesies Is familiar with patient's background Warns of uncomfortable procedures Encourages patient Gives full attention Deals with patient concerns Explains diagnosis Explains treatment Explains prognosis Shows empathy Displays exiting courtesies

10.4% 11.6 13.4 8.0 3.8 6.8 3.8 2.8 9.0 5.3 11.8

28.6% 26.1 25.4 20.0 21.8 18.9 12.8 11.3 10.4 24.0 27.6

61.0% 62.3 61.2 72.0 74.4 74.3 83.3 85.9 80.6 70.7 60.5

5.3% 4.8 6.5 1.5 1.3 1.5

32.9% 34.9 27.4 41.8 17.1 21.5 10.7 20.3 21.7 35.5 36.0

61.8% 60.3 66.1 56.7 81.6 76.9 89.3 79.7 73.9 59.7 54.7

4.3 4.8 9.3

53A

OPHTHALMOLOGY •

OCTOBER 1983 •

VOLUME 90 •

NUMBER 10

20

15 fJ)

ex:

.-zw

o:::>

10 Fig 1. Encounter satisfaction of patients examined in ophthalmic private practices.

()

z

w 5 . ..' . ":', . '

o .05

.15

.25

.35

.45

.55

.75

.65

.95

.85

INDEX OF ENCOUNTER SATISFACTION The resident ophthalmologists at the GVAMC considered all explanatory items much less important than did their patients. The only item consistently overrated by physicians was empathy. We suspect that patients misun-

portant communication items leading to satisfaction with an ophthalmologic medical encounter. Ophthalmologists in private practice shared this valuation, except that they placed relatively less importance on explaining prognosis. 20

..

15 fJ)

ex:

.-zw :::>

o()

.............. 10

>

:

.

:.

.................•.••.....••••.•.•...••

-':' .. ' '.... '.:<.:' .

z

. .', ':, :..:': ~ .

w "

5

.. . ..

. .

'.

..

.........

.. : .. . . . .. -:-:-'.'.~. ~ .. . :', ': :.:..... . ~. '. .. .

""

: .'

.,'

.'

-:-.

. .. . . '

'

O~r----.----.-~~~~~~~~~~~~~~~~~~

0.05

.15

.25

.35

.45

.55

.65

.75

INDEX OF ENCOUNTER SA TISF ACTION

54A

.85

.95

Fig 2. Encounter satisfaction of patients examined in a Veterans Administration ophthalmology clinic.

TROBE, et

aI • DOCTOR:PATIENT COMMUNICATION

derstood empathy and, believing it to be "sympathy," declined its importance. Studies in general medical practice have found that "personalization" of the encounter is more important to patients than explanation. 1,4,14 This contrasts with our finding that patients seeking ophthalmologic examination rate explanation above all else. Perhaps patients recognize that the ophthalmologic examination is intended to be less comprehensive and therefore do not expect as much personalization as explanation. Yet our patients did not ignore the importance of personalization, and the results in the two settings in which this study was carried out appear to spotlight some differences in attitudes between physicians in training (at least at the VA) and in community practice. 15 For example, resident physicians seemed to be relatively insensitive to the importance that patients placed on familiarity, undivided attention, and encouragement. These components seem better appreciated by ophthalmologists in private practice, who recognize them as critical in developing the rapport essential for continuing care. Overall patient satisfaction with the ophthalmologic encounter was high in both GVAMC and private practice settings. Physicians evidently performed well in those items deemed most important to patients even though physicians and patients may not always have appeared to agree on their importance. It is interesting to note that while GVAMC residents underrated the importance of many of the items felt important by their patients, they had a higher proportion of "high satisfaction" encounters than did private practice physicians. They also had a higher proportion of "low satisfaction" encounters than did their private practice colleagues. One explanation might be that private practice patients select their physicians and GVAMC patients do not. Hence, a dissatisfied patient in a private setting is likely to choose another physician, which would tend to reduce the number of low satisfaction encounters observed in this study. At the other end of the scale, patients at the GVMAC may be much less demanding of their physicians than patients in the private sector, accounting for lower percentages of highly satisfied encounters in private practice encounters. Our conclusions must be that, while overall satisfaction is high, ophthalmologists in training need more education regarding patient expectations and values. Also, private practice ophthalmologists should be more cognizant of the importance to patients of an explanation of disease prognosis and a response to their "concerns."

ACKNOWLEDGMENTS Lee Crandall, PhD, Alfred DeMaris, PhD, Ronald G. Marks, PhD, Jacqueline Orlando, PhD, and Cindy Sorosky, MS assisted in the research.

REFERENCES 1. Svarstad Bl. Physician-patient communication and patient conformity with medical advice. In: Mechanic D, ed. The Growth of Bureaucratic Medicine; An Inquiry into the Dynamics of Patient Behavior and the Organization of Medical Care. New York: John Wiley & Sons, 1976;

220-38. 2. Francis V, Korsch BM, Morris MJ. Gaps in doctor-patient communication. Patients' response to medical advice. N Engl J Med 1969;

280:535-40. 3. Ware JE, Davies-Avery A, Stewart AL. The measurement and meaning of patient satisfaction. Health Med Care Serv Rev, 1978; 1:2-15. 4. Mechanic D. The Growth of Bureaucratic Medicine; An Inquiry into the Dynamics of Patient Behavior and the Organization of Medical Care. New York: John Wiley & Sons, 1976; 1-22. 5. Fisher AW. Patients' evaluation of outpatient medical care. J Med Educ 1971 ; 46:238-44. 6. Friedson E. Patients' View of Medical Practice. New York: Russell Sage Foundation, 1961. 7. Weinerman ER. Patients ' perceptions of group medical care; a review and analysis of studies on choice and utilization of prepaid group practice plans. Am J Publ Hlth 1964; 54:880-9. 8. Houston CS, Pasanen WE. Patients' perceptions of hospital care. Hospitals 1972; 46:70-4. 9 . Jolly C , Held B, Caraway AF, Prystowsky H. Research in the delivery of female health care : the recipients' reaction. Am J Obstet Gynecol

1971; 110:291-4. 10. Davis MS. Research in medical education. Attitudinal and behavioral aspects of the doctor-patient relationship as expressed and exhibited by medical students and their mentors. J Med Educ 1968; 43:337-

43. 11 . Wolf MH, Putnam SM, James SA, Stiles WB. The Medical Interview Satisfaction Scale: development of a scale to measure patient perceptions of physican behavior. J Behav Med 1978; 1:391-401. 12. DiMatteo MR, Hays R. The significance of patients' perceptions of physician conduct: a study of patient satisfaction in a family practice center. J Community Health 1980; 6:18-34. 13. Lehmann EL. Non-parameters: Statistical Methods Based on Ranks. San Francisco: McGraw Hill, 1975; 120-3. 14. Anderson RM, Fleming GV, Aday L. Study points out medical manpower needs. American Medical News, November 20/27, 1981 ; 19-

20. 15. Duffy DL, Hamerman D, Cohen MA. Communication skills of house officers; a study in a medical clinic. Ann Intern Med 1980; 93:3547.

55A