We conducted this study to identify and describe the specific expectations patients bring to their primary care medical visit, to identify which expectations were most often met or unmet, and to examine the relationship between specific expectations for tests, referrals, and new medications and patient satisfaction. The study produced several key findings.
First, we found little support for the relationship between fulfillment of specific expectations and patient satisfaction. There are several possible explanations for this negative finding. Fulfillment of expectations for tests, referrals, and new medications, in fact, may not be a key determinant of patient satisfaction. Although considerable research has shown that unfulfilled expectations are related to lower patient satisfaction,7,8,10–12,24,34
that same body of research suggests that “nonmedical” services may affect patient satisfaction more than medical or technical services. For example, several studies have shown that patients were more satisfied when they received “nontechnical” interventions, such as education and stress counseling7
and services related to information.10
In our study, we measured only expectations for technical medical services. Another explanation for the lack of association between unmet expectations and satisfaction may be found in the encounter between the physicians and patients during the visit. Physicians may have responded to patients' expectations in ways that left patients satisfied despite not receiving the services they expected. A related issue is that patients may have altered their expectations during the visit. Both of these issues suggest that the study physicians may, in fact, already be engaging patients in their own care.
Perhaps the most plausible explanation for the negative finding between unmet expectations and patient satisfaction is our sample, which differs from previous studies in ways that may have raised the baseline rate of satisfaction. Previous research has shown that reported patient satisfaction typically is high, and certain patient characteristics are associated with higher satisfaction.35–37
For example, age and educational attainment are consistently associated with patient satisfaction, older people tend to have higher levels of satisfaction than younger people, and lower educational attainment is associated with higher satisfaction.38–40
Gender and ethnic origin are also related to patient satisfaction, though the relationships are not as strong or consistent as age and educational attainment.37
The direction of the relationship suggests men typically are more satisfied than women and whites are more satisfied than nonwhites.41
Our sample was comprised largely of patients with the characteristics most associated with high patient satisfaction: men only, mostly older (65 on average) and white (68%), and not well educated (only 16% college educated). Of note, our sample is comparable to those in previous studies in terms of expectations for care, but possibly not the mechanisms that influence satisfaction.
Our second main finding was that a substantial portion of patients present to their clinic visit with vague expectations. When asked what type of test, referral, or new medication they expected from their visit, patients responded most often by describing a physical symptom. Additionally, among patients who responded it was necessary to receive a test, referral, or new medication, approximately 13% could not specify which test, referral, or medication they desired. Previous studies on expectations and their relationship to patient-centered care have focused on the barriers to eliciting,42
patients' expectations for the visit. The most often-cited barriers involve physicians' inability to recognize or act on patients' expectations due to time constraints,44
or not valuing patient input.46
Patients, too, face barriers to expressing expectations. The most notable is that patients are often reluctant to make their expectations known47
to the physician because of the inherent power differential in the patient-physician relationship.48
Implicit in these studies is that patients have specific expectations for care that are not always expressed or recognized. Our findings suggest that patient expectations may not be as specific as previously assumed.
We also found that patients' expectations are quite heterogeneous. Among 253 patients, we identified 65 different expectations for specific tests, referrals, and new medications. The aggregated specific expectations show that 33% of patients reported an expectation for a test, 28% for a referral, and 31% for a new medication. This is similar to findings from previous studies that examined general expectations. For example, Brody et al.7
reported 30% of patients expected medications and 48% expected a test. Reported previsit expectations in our study were in the same general range as actual requests made to the clinician in another study. Kravitz et al.18
reported that a sample of 139 patients made 110 separate requests for tests (n
= 16), referrals (n
= 17), and medications (n
= 77). In the Kravitz study, patients requested medications more frequently than patients in our study stated such expectations. This difference is likely to be the result of our narrowed focus on medications. The Kravitz study measured requests for new medications and refills for medications. In contrast, we measured expectations for new medications only. We excluded expectations for refills because negotiation over prescribing the medication likely occurred at a previous visit.
This study has several limitations. All data were collected at a single VA general medicine clinic, and our sample included men only. Previous research has shown that men and women have different interaction styles with physicians. For example, men prefer longer visits with their physicians than women. Women, however, prefer more in-depth explanations of their treatment and treatment options.21
The patients in this study were also older than the general population. Previous work has shown that older patients ask fewer questions of the physician and often spend less time with their physician, despite generally poorer health.49
As a whole, older patients, especially those in the oldest cohorts, tend to have passive relationships with their physicians and communication complications related to low literacy and poor health status.50
Finally, due to the number of specific expectations within the three general categories of expectations, and the sparseness of responses within each of these specific expectation groups, we were unable to examine fully the relationships among specific expectations, expectation status, and patient satisfaction.
Despite these limitations, this study provides a better understanding of the nature and prevalence of expectations patients bring to the medical encounter. Clinicians trying to implement the values of patient-centered care face a number of challenges. They must be prepared to elicit, identify, and address many expectations, and even within a relatively homogeneous setting such as the VA, may encounter a wide range of expectations.