Strong Patient doctor Bond for Continuity of Care
The patient–doctor relationship: a synthesis of the qualitative literature on patients' perspectives
Abstract
Background The patient–doctor relationship is an important but poorly defined topic. In order to comprehensively assess its significance for patient care, a clearer understanding of the concept is required.
Aim To derive a conceptual framework of the factors that define patient–doctor relationships from the perspective of patients.
Design of study Systematic review and thematic synthesis of qualitative studies.
Method Medline, EMBASE, PsychINFO and Web of Science databases were searched. Studies were screened for relevance and appraised for quality. The findings were synthesised using a thematic approach.
Results From 1985 abstracts, 11 studies from four countries were included in the final synthesis. They examined the patient–doctor relationship generally (n = 3), or in terms of loyalty (n = 3), personal care (n = 2), trust (n = 2), and continuity (n = 1). Longitudinal care (seeing the same doctor) and consultation experiences (patients' encounters with the doctor) were found to be the main processes by which patient–doctor relationships are promoted. The resulting depth of patient–doctor relationship comprises four main elements: knowledge, trust, loyalty, and regard. These elements have doctor and patient aspects to them, which may be reciprocally related.
Conclusion A framework is proposed that distinguishes between dynamic factors that develop or maintain the relationship, and characteristics that constitute an ongoing depth of relationship. Having identified the different elements involved, future research should examine for associations between longitudinal care, consultation experiences, and depth of patient–doctor relationship, and, in turn, their significance for patient care.
- communication
- continuity of patient care
- physician–patient relations
- qualitative research
INTRODUCTION
The patient–doctor relationship is an important concept in health care, especially primary care. However, it is also a complex topic that means different things to different people. As a consequence of this, research in the area has been somewhat fragmented.
Many studies have investigated it in terms of the communication and interpersonal skills of the doctor.1–4 Another major facet is continuity of patient care, where the relational aspect is referred to as interpersonal continuity.5–7 More recently there has been interest in examining the characteristics of the ongoing relationship itself, such as trust.8 The patient–doctor relationship can be seen as a specialised form of human relationship, and work in other disciplines has distinguished between the dynamic interactive aspects of relationships and the mental associations made by people 'in' relationships, which are 'historically derived representations of experience'.9 All of these elements are thought to be important, but in the absence of a conceptual framework that can be applied to patient–doctor relationships, we are unlikely to establish the significance of the different parts and how they affect patient care.
Broadly speaking, the patient–doctor relationship can be viewed as either a process or an outcome, and opinion on which is most appropriate is divided.1 Although the purpose or function of the relationship is likely to vary according to the perspective of the observer,10 clinical imperatives emphasise its value as a component of the care process that might improve health outcomes. A better understanding of those aspects of patient–doctor relationships that affect patient care is required, because it has implications for how doctors are trained and health care is organised. If continuity, for example, makes a unique contribution to patient–doctor relationships, then it may be unwise to pay excessive attention to doctors' communication skills in isolated consultations; instead greater emphasis on organisational systems that promote continuity may be appropriate.
In the absence of good conceptual frameworks to guide research into patient–doctor relationships,11 the authors decided to undertake a synthesis of the published qualitative literature on patients' views of patient–doctor relationships. Qualitative studies are suited to investigating poorly understood or complex issues, and there is an extensive qualitative literature on patient–doctor relationships, yet the findings have not been drawn together using synthesis techniques. The aim of this study was to map out the key components of the patient–doctor relationship as viewed by patients, to ascertain what they are and how they might interrelate.
METHOD
Identification of relevant studies
The guiding definition for the search was: papers using qualitative methodology whose main focus is how patients experience and evaluate patient–doctor relationships. The Medline, EMBASE, PsychlNFO, and Web of Science (Science Citation Index Expanded, Social Sciences Citation Index and Arts & Humanities Citation Index) databases were searched from inception until early January 2008. The search strategy (Appendix 1) was informed by a prior scoping exercise.12
Duplicate citations were excluded and the primary and secondary screening of the remaining publications was undertaken (Figure 1). Most citations were screened on the basis of their title or abstract, but if more detail was required the original paper was obtained.
In the primary screen qualitative research on patients' views of the patient–doctor relationship using focus groups or interviews were identified. In the secondary screen, the citations were examined for relevance.
The research aimed to obtain a generic understanding of ongoing patient–doctor relationships. Studies were included if they were general investigations of patient–doctor relationships in medical or surgical settings (primary/ambulatory or secondary care); they were excluded if they were restricted by the characteristics of the patient (sex, age, or ethnicity), and/or problem (for example, a specific diagnosis or issue), and/or visit (focus on a single consultation). As an example, a study of HIV prevention in black men who have sex with men, which flagged the importance of their relationship with primary care providers, was excluded. By contrast, a study that examined trust in 40 patients of different sex, age, and ethnicity was included.
How this fits in
The patient–doctor relationship is thought to be important, but research demonstrating its value has been hampered by a lack of clarity about what is meant by the term. Drawing on published qualitative studies with patients, two key aspects are identified: factors that develop or maintain the relationship (longitudinal care and patients' consultation experiences), and factors that characterise an ongoing depth of relationship (knowledge, trust, loyalty, and regard). Further work is required to substantiate the distinctiveness of these elements, how they influence one another, and their significance for patient care.
Full text copies of the remaining articles were independently assessed and, through discussion, agreed which should be included in the synthesis. Quality appraisal of qualitative research is a contentious issue,13 but the final 11 studies were assessed using a framework based on the Critical Appraisal Skills Programme quality-assessment tool for qualitative studies.14
Analysis
It was decided to perform a thematic synthesis,12 which allows clear identification of prominent themes, and provides an organised, structured, and yet flexible, way of dealing with the articles under these themes.15 Where studies interviewed patients and healthcare team members, only sections on patients' views were included. Two researchers independently read the selected papers, focusing on the findings and discussion sections, and identified themes. However, they were from different professional backgrounds and undertook the analysis in alternative ways.
The first researcher was a GP with prior experience of conducting research on continuity and interpersonal care. The researcher approached the studies with a particular interest in identifying how the patient–doctor relationship was described in terms of communication skills, continuity, and ongoing relationship characteristics such as trust. Atlas.ti (version 5.0, Scientific Software) was used to aid the analysis, using electronic copies of the articles as primary documents. After reading and re-reading each document codes were attached to sections of text relating to different aspects of patient–doctor relationships. A detailed indexing system was employed, which meant applying multiple codes to sections of text, even if it was suspected that any differences were minor. All codes were given a working definition to ensure that they were used consistently. It was an iterative process, so the codes evolved over repeated readings of the articles.
The second researcher was a social scientist who was broadly familiar with the patient–doctor relationship literature. This researcher did not approach the data with an explicit prior framework, seeking instead to identify emergent themes from the articles.15 The researcher worked from hard copies of the papers, manually coding the data for different aspects of the patient–doctor relationship, and grouping the findings into broader categories and themes. By comparing and discussing the codes and concepts identified, the two researchers agreed the final themes to include in the synthesis.
RESULTS
From 1985 abstracts, 11 were included in the synthesis (Figure 1). As the search strategy had a low specificity for qualitative papers, the majority were rejected on the grounds that they were not qualitative. No studies were rejected because of serious concerns about methodological quality (Appendix Table 2).
The characteristics of the final 11 studies included in the synthesis16–26 are summarised in Table 1. The aims, participants and key findings are summarised in Table 2. The studies were conducted in four countries – the US (n = 5), UK (n = 3), Canada (n = 2), and Sweden (n = 1) – and some included participants who were doctors, nurses, or other practice staff, rather than patients. Patients varied from 18 to 84 years old. Three studies examined patient–doctor relationships in a general sense.16–18 The other eight explored the topic from one of four closely related perspectives: personal care,19,20 continuity of patient care,21 loyalty,22–24 and trust.25,26
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Table 1
Characteristics of studies in the literature synthesis.
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Table 2
Summary of study aims, participants, and key findings.
The analysis of the included studies identified two overarching themes, each with several elements: the development and maintenance of patient–doctor relationships, and the ongoing depth of the patient–doctor relationship.
Development and maintenance of patient–doctor relationships
The processes by which patient–doctor relationships appear to be developed and maintained can be described in terms of longitudinal care and consultation experiences.
Longitudinal care
Seeing the same doctor, or longitudinal care, was identified as a key process in developing and maintaining patient–doctor relationships.16–21,23–25 Longitudinal care was central to many accounts of personal care experienced by patients in Tarrant et al's study.19 Roberge et al suggested that regularity, rather than frequency, of contact is of greater importance.24
It is important that patients are able to retain some choice regarding who they see, because longitudinal care on its own does not guarantee a depth of relationship.19,20,24,25 It is the quality of patient–doctor encounters that has a major bearing on how the patient–doctor relationship is both developed and maintained.
Consultation experiences
The focus of the majority of studies was patients' personal experience with doctors during consultations, for themselves or family members.16,17,19–21,23–26 Patients seem most likely to form a relationship with a doctor who meets their expectations or needs. Although some patients' initial expectations may be met by virtue of the doctor's sex or age,16,21,26 the key means by which this occurs are the doctor's consultation skills.
Patients want doctors who appear interested, listen well, explain clearly, are open to discussion, and involve the patient in decision making, if it is desired.16,17,19–26 Patients cited actions – for example, the way in which the doctor questioned or examined them – that suggested thoroughness and a caring attitude. 'Human communication' may include social talk or 'chit chat', and appropriate use of humour.18,19,21 Lings et al's idea of 'asymmetry of perception' seems to recognise that patients and doctors have different roles and responsibilities within a relationship.17,23 Some patients may choose to test these and other patient–professional boundaries.16 Although it may be important that the patient communicates as well as they are able,24 from the patient's perspective the emphasis is always on the doctor to facilitate this process.
A closely related element that contributes to the development and maintenance of patient–doctor relationships is time.17–21,23 The studies highlighted the importance patients placed on not feeling hurried, and their appreciation of doctors who 'had time'.19 Lings et al reported that listening was characterised by the sense of being able to talk things over without feeling that time was a critical issue.17
Another aspect of patients' views on how their relationships with doctors develop or are maintained concerns indirect experience: the outcome of problems shared and the opinions of friends or family. A patient–doctor relationship may be deepened or destroyed by good or bad clinical outcomes respectively.16,21,23–26 Word of mouth, positive or negative, about a doctor's behaviour or practice may reinforce or challenge a patient's opinion of a doctor.16,23
Patient–doctor encounters may also be affected by factors at the practice level. For example, being met by friendly reception staff may mean the patient goes into the consultation in a more positive frame of mind.19,21,26 Wiles and Higgins noted how the congenial surroundings and 'positive atmosphere' of private hospitals may enhance a patient's communication with their doctor.18
Depth of patient–doctor relationship
In addition to the processes by which patient–doctor relationships are developed and maintained, the studies suggested that depth of relationship, as a product of longitudinal care and consultation experiences, was important. This encompassed four main elements: knowledge, trust, loyalty, and regard. These elements reflect patients' enduring views about their relationship with the doctor outside of consultations. They appear to be the ongoing product of the dynamic aspects of the relationship.
Knowledge
Knowledge emerged as a dominant aspect contributing to depth of relationship.16,17,19–23,25,26 Studies described both patients' knowledge of the doctor, and doctors' knowledge and understanding of the patient.
Many patients like 'knowing' the doctor.16,20,23,25 This might start with a simple familiarity with what they look like, but may develop into more personal knowledge, for example, concerning the doctor's personality. Of particular importance is the idea that the patient knows or anticipates how the doctor will behave or react.20,23
Similarly, with respect to the doctor's knowledge of the patient, the starting point is basic physical familiarity (putting a name to a face), but also knowledge of the patient's medical history.19–23,25 Patients value these aspects for two reasons – because the doctor is able to see changes in their appearance and hence possibly their health, and because there is a sense of shared history. Patients dislike having to repeat information: they may find it difficult, or feel they do not have enough time to put everything into words every time they see a new doctor.
At a deeper level, the doctor accumulates personal knowledge about the patient, such as their background (including family and social circumstances) and their expectations.17,19–23,25,26 This contributes to a patient feeling understood and treated as an individual in the context of their life and illness, rather than just the presenting problem. Patients perceive that the doctor has achieved a deeper understanding of them at an emotional or personal level. Some studies referred to patients within 'good' patient–doctor relationships as experiencing empathy and holistic care.19–22
Holistic care was more commonly described as occurring in longer-term relationships.20,22 However, von Bultzingslowen et al identified several patients who felt understood in single consultations or short-term relationships, and one patient who complained about a lack of empathy with their 'personal doctor' who had been known for some time.20
Trust
Patients' trust in the doctor was another prominent aspect of the depth of patient–doctor relationships.16,17,19–26 Unlike knowledge, however, trust may start at a generic level of 'trust in doctors in general', which may be refined (usually deepened), in terms of a personal 'trust in my doctor'; that is, in the absence of bad experience, patients usually assume that doctors are trustworthy.20,25
Goold and Klipp reported how patients' comments about doctors in general were more abstract than their comments concerning a specific doctor.25 For some patients, trust in their doctor may remain 'blind',25 but for the majority, trust in a specific doctor was rooted in experience.16,19,20,21 Patients used words such as 'confidence', 'faith', 'security', and 'competence'. Patients' trust was based at least partly on their views of doctors' openness and honesty, including doctors recognising the boundaries of their own abilities, and their readiness to refer on to others.22,23
Patients' perceptions of their doctor's trust in them were associated with feelings of being believed;20 they may feel mistrusted if their symptoms are minimised or not taken seriously.
Loyalty
Roberge et al's study of loyalty defined it in terms of a contract or agreement between the patient and the doctor.24 Loyalty is closely associated with, yet distinct from, longitudinal care.20,22,24 For a given doctor, longitudinal care describes a patient's pattern of visits over time, whereas the loyalty aspect of the depth of the patient–doctor relationship describes the patient's preference for seeing that particular doctor.
Patients' preferences may be shaped by their past experiences and their presenting problem. Discontinuity of a physician may be less of an issue for patients who are used to it; this is suggested by Brown et al's study, whose participants differed from those in other studies because they regularly saw new doctors rotating through their health centre as part of their training programme.22 In addition, patients' preferences regarding who they see may depend on the problem with which they are presenting.19–21,24 Patients generally preferred to see the same doctor when dealing with long-term, complex, or emotional problems.19 However, they may be happy to see any doctor for minor problems, 'any doctor but my usual doctor' for embarrassing problems, and a specific doctor for a specific problem.16,19,25,27
Patient loyalty is also measured in terms of their tolerance of unsatisfactory aspects of care.16,17,21 Lings et al called this a satisfaction paradox, a 'seemingly contradictory phenomenon, whereby patients express dissatisfaction with certain procedures or events but still maintain a positive relationship'.17 Examples of such dissatisfaction relate to characteristics of the practice (distant location, problems with the appointment system) and the doctor (running late, poor availability, unsatisfactory consultations, failing to return phone messages).16,21,23 Patients who have developed a relationship with a doctor 'appear able to accept and tolerate less than optimum care if the usual care is good and satisfactory – that is, they seem to 'forgive' the doctor an occasional lapse'.17
In turn, a doctor's actions may be perceived by patients as a marker of their loyalty to them.16,17,22 Gore and Ogden gave an example of how a doctor remained committed to a patient despite their obviously deceitful behaviour.16
Regard
This final aspect of the depth of patient–doctor relationships is a primarily affective attribute. It comprises comfort17,21 and liking,16,17,23 which reflect perceived care from the doctor and respect in the relationship.20–22,24,25 As a consequence of doctors appearing interested and 'on side' with patients, patients feel that they matter to the doctor.
On the basis of their data, Lings et al defined liking as 'having an easy and comfortable relationship with the doctor'.17 Some patients likened a good patient–doctor relationship to a friendship.18,23 Gabel, et al reported: 'For some, friendship was a reciprocal relationship with both parties perceived to feel the same bond. The relationship was characterised as warm, caring, or comfortable. There was a feeling of closeness that was a result of knowing each other for a long period of time'.23
Relationships between longitudinal care, consultation experiences, and depth of relationship
The relationships between, and distinctiveness of, the different elements of longitudinal care, consultation experiences, and depth of relationship may vary. Some patients may decide in a single consultation (during or after a positive consultation experience), that they like (regard) that doctor, and cite this as a reason to seek longitudinal care with them in the future.19,21 However, because patients have different needs – they interact with the doctor within the context of their unique problem, expectations, and so on – depth of relationship may develop by different routes. For instance, the relationship may deepen more rapidly during a crisis in the patient's life, especially if the doctor demonstrates advocacy or makes an extra effort to help them through a problem.16,22,25
Some aspects of the depth of patient–doctor relationships may be more closely related to either longitudinal care or consultation experiences, yet it is likely that longitudinal care and consultation experiences have synergistic effects. For example, although longitudinal care may facilitate the doctor's accumulation of medical knowledge about a patient, without satisfactory patient–doctor communication, personal knowledge is unlikely to grow.
The distinctiveness of some of the elements identified in this study may be blurred at the margins. For instance, the literature highlights how longitudinal care is the product of a complex interaction between access to a given doctor and the patient's preferences for seeing him or her. Patient loyalty may, therefore, be both the product of, and the driver for, seeing the same doctor.21 Clearly, longitudinal care is affected by a doctor's availability, whatever its determinants,20,23,24,26 and some patients may struggle to maintain a good relationship with their doctor because of lack of availability and appointments.16 Perhaps paradoxically, when physicians acknowledge that patients have consulted other doctors, this may actually build trust.21
DISCUSSION
Summary of main findings
Through a thematic analysis of primary qualitative studies this study has drawn together the data from 11 studies of patients' perspectives to derive a conceptual framework that helps us to understand the complex topic of patient–doctor relationships (Figure 2). Two major elements have been identified (longitudinal care and consultation experiences) that contribute to the development and maintenance of patient–doctor relationships. As a consequence of these dynamic processes, an ongoing depth of relationship may be established. This is characterised by four main elements: knowledge, trust, loyalty, and regard. Each of these elements has two sides: the patient's opinion about the doctor, and the patient's perception of the doctor's opinion about them, which may be reciprocal.
This framework implies that having positive consultations with the same doctor over time builds depth in the patient–doctor relationship which, in turn, may promote further longitudinal care. It also recognises that from the patient's perspective, continuity of doctor and consultation factors are linked, yet distinct, aspects. Longitudinal care alone does not guarantee the depth of a patient–doctor relationship and, given the choice, patients are unlikely to seek care from the same doctor if previous experiences have been negative. Finally, longitudinal care and consultation experiences are influenced by the context in which patients and doctors encounter one another.
Strengths and limitations of this study
The authors are not aware of any other syntheses of qualitative literature on the patient–doctor relationship. Qualitative synthesis is still an emergent field, peppered with controversies, and there is no single agreed way of doing it.15 Following the principle set out by Mays et al of establishing a clear purpose to the review at the outset, this study has sought to present a method marked by critical thought, transparency, and explicitness.12
To ensure robustness, the articles were independently read and coded by two researchers. Predictably, there were variations in the labelling of codes, but the themes and elements presented in this article reflect all of the concepts identified by both researchers. In any qualitative research, primary or secondary, the researcher plays a role as 'research instrument' and shapes the findings by interpreting them through either explicit or more implicit prior concepts.28 It must be acknowledged that this was inevitably the case in the present synthesis, but the authors believe that the findings are strengthened by their different professional backgrounds and contrasting analytical approaches.
Given the amount of research on patient–doctor relationships, it is perhaps surprising that from 1985 potential articles only 11 studies were finally included in the synthesis. This reduction reflects the strategy used for identifying articles. Searching for relevant studies was a challenge. The keyword 'doctor–patient relationship' and its synonyms are loosely defined and applied to a wide range of research. Furthermore, there are recognised problems with identifying published qualitative research.12 Interpretation was necessary at the secondary screening stage when subjective decisions as to which articles should be excluded were made. Broadening the inclusion criteria would have led to the addition of other studies and possibly greater detail within individual themes. However, the findings in the articles included were consistent and having an excessive number of articles can itself cause problems in qualitative synthesis; trading depth for breadth can result in the production of a superficial synthesis.29
Despite the desire to examine the views of patients from general medical settings, it must be acknowledged that the participants in the included studies still represent select groups of patients. The findings, for example, may not necessarily be representative of young, usually healthy, patients who consult with self-limiting problems.
Comparison with existing literature
The framework used encompasses all of the elements of previous quantitative investigations of patient–doctor relationships: longitudinal care,6 communication skills,1,30 knowledge,31 trust,32 empathy,33 and liking.34 The range of issues identified within the themes also fits well with the findings of these earlier studies. For example, similar to the present discussion of trust, the literature on patient–doctor trust has previously discriminated between personal trust (trust in a particular doctor), and social trust (generalised trust in the healthcare system, the medical profession, and/or the patient's practice as a whole).35
Distinguishing between the dynamic, interpersonal processes that occur during consultations and the ongoing quality or depth of relationship is not a new idea – Szasz and Hollender distinguished between function (what the physician does) and the 'abstract' relationship in 1956.36 However, to date, research on patient–doctor relationships has focused on the communication and interpersonal skills of the doctor – an isolated interaction between patient and physician that is quite different from a relationship.37
This study's framework addresses two conceptual issues that have dogged research in this area. It distinguishes between longitudinal care and interpersonal care. Relational aspects of continuity are often referred to as interpersonal continuity,5 which is potentially confusing because it combines notions of length and depth of relationship. Additionally, patient–doctor relationship research has sometimes confused knowledge between doctor and patient with the presence of a relationship.6 The present model identifies knowledge as one aspect of the depth of the patient–doctor relationship that has both factual and affective components.
Implications for future research and clinical practice
It is hoped that the framework from this study is helpful to both clinicians and researchers. For doctors, it represents a fresh way of thinking about encounters with patients – both at the individual patient–doctor level and also at an organisational and team level. Doctors need to remember that how practices are run and how primary healthcare members work together can affect the patient–doctor relationship. For researchers, it defines the key factors that need to be considered for future research in this area, and should discourage a piecemeal approach to this complex topic.
Forthcoming studies should look to explore the different elements of longitudinal care, consultation experiences, and depth of relationship in terms of their distinctness, their inter-relationships, and their relative importance in healthcare delivery. Work to date has been mainly cross-sectional in nature and longitudinal studies are required to examine outstanding questions, including what benefits each aspect may bring, if any, and whether they are more important for certain groups of patients, such as those with complex problems be they health and/or socioeconomic.
Viewing the patient–doctor relationship in terms of longitudinal care, consultation experiences, and depth of relationship represents one unifying framework by which to investigate questions about its value for patient care. It is a framework grounded in empirically-derived data from several qualitative studies, which provides an explicit conceptual underpinning for future research in this complex field.
Appendix 1. Database search strategies
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Appendix 2. Template used to aid the appraisal of the studies included in the synthesis.
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Appendix 3. Long-term attendance at a family practice teaching unit: qualitative study of patients' views.
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Appendix 4. Why do patients continue to see the same physician?
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Appendix 5. Managed care members talk about trust.
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Appendix 6. Developing, validating, and consolidating the doctor–patient relationship: the patients' views of a dynamic process.
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Appendix 7. The doctor–patient relationship in US primary care.
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Appendix 8. A comfortable relationship: a patient-derived dimension of ongoing care.
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Appendix 9. Loyalty to the regular care provider: patients' and physicians' views.
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Appendix 10. Qualitative study of the meaning of personal care in general practice.
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Appendix 11. Patient–physician trust: an exploratory study.
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Appendix 12. Patients' views on interpersonal continuity in primary care: a sense of security based on four core foundations.
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Appendix 13. Doctor–patient relationships in the private sector: patients' perceptions.
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Notes
Funding body
Matthew Ridd is funded by an MRC Clinical Research Training Fellowship and supported by a small grant from the RCGP Scientific Foundation Board (SFB/2004/09)
Ethical approval
Ethical approval was not required as the study only draws on material that has already been published
Competing interests
The authors have stated that there are none
- Received April 14, 2008.
- Revision received July 1, 2008.
- Accepted September 1, 2008.
- © British Journal of General Practice, 2009.
Source: https://bjgp.org/content/59/561/e116