This investigation expands our understanding of patients' unmet expectations for medical care in several ways. First, in this study of 3 distinct specialties, unmet expectations were reported by about 12% of patients. This estimate is lower than has been reported in other studies, but it is within the same general range as that reported by Kravitz et al.2
and Marple et al.11
Thus, unmet patient expectations in medical office settings, while not common, are also not rare. Consistent with previous research,2
unmet expectations were seen more frequently among younger patients (who may harbor more expectations), unmarried patients (who may lack an accompanying medical advocate), and patients who lack trust in their physicians (who may be less likely to communicate their desires clearly or more likely to perceive shortcomings in the medical exchange). Clearly, efforts to address patients' expectations require a focus on the physician-patient relationship.
The comparatively low rate of unmet expectations in this study raises questions about the sensitivity of our measurement procedures. We do not believe that these results can be attributed to measurement insensitivity. Our measurement strategy, taken from Kravitz et al.,2
prompts patients to reflect specifically upon the potential for unmet expectations in each of 9 realms of patient care. We believe it is more reasonable to suggest that discontented patients were less inclined to select themselves into this particular study, which would result in fewer reports of unmet expectations. In a similar vein, it is possible that physicians most competent in communicating with patients were more likely to volunteer for the study. If the patients of such physicians have fewer unmet expectations, then this selection bias would result in lower rates of unmet expectations for the patient sample as a whole.
The observed associations between different types of unmet expectations and specific outcomes reinforce previous studies and support the validity of our measures. For example, prior research has suggested that feeling understood is a key component of patient satisfaction.34
Thus it is not surprising that in the current study, unmet expectations for clinical data collection (e.g., history taking) principally affected patients' visit satisfaction and perceptions of symptom improvement. Thorough history taking is presumably a prerequisite for a comprehensive understanding of the patient's situation. In a similar vein, physician counseling behaviors have been shown to affect patient adherence35,36
; in our data, patients' adherence intentions were most affected by unmet expectations regarding the physician's provision of information. Finally, unmet expectations for clinical resources (e.g., tests, procedures, drugs, and referrals) were most strongly associated with subsequent health system contacts. This effect might be attributable to lingering questions about the physician's thoroughness or diagnostic accuracy.
Patients' unmet expectations affect physicians as well. Our findings indicate that visits in which patients held an unmet expectation were experienced by physicians to be less satisfying. We cannot speak to the questions of if and how physicians become aware of their patients' unfulfilled expectations. Unmet expectations also lead to more demanding visits. Attempts to explain to the patient why his or her expectations are unreasonable can be effortful, even in the absence of overt conflict.
Even after imposing extensive statistical controls, there was some indication that patients who leave their medical visits with unmet expectations fare more poorly. These patients reported less symptom improvement than patients with no unmet expectations. Furthermore, patients who held unmet expectations for clinical resource allocation reported more postvisit health system contacts than patients with no such unmet expectations. We cannot determine from our data if these contacts were justified on the basis of the patients' objective health situations, but the effect held even after controlling for previsit general health perceptions.
Finally, this study suggests that unmet expectations may stem directly from how physicians communicate with patients regarding their requests for help. Quite simply, patients with an unmet expectation for medical information or a particular type of clinical resource usually had asked (or thought they had asked) unsuccessfully for that information or resource. This finding suggests that when patients make requests based on expectations that are not realistic or medically valid, the physician needs to address the underlying beliefs and worries that motivated the request in the first place.
This study is not without limitations. First, the study is based on patients' postvisit, direct ratings of unmet expectations. As a result, we do not know if these expectations were brought to the visit or emerged over the course of the visit. Second, we made no attempt to distinguish between unmet expectations that were reasonable and those that were not. Third, these results reflect patients' perceptions of the care they received rather than objective assessments of the appropriateness of physicians' actions. We defend our focus on the patient's viewpoint, noting that the patient's perceptions are often what is most significant.37
Fourth, this investigation was carried out within a single managed care market in California, albeit at 11 geographic sites within 2 very different health care systems.
Patients' expectations provide the yardstick against which physicians' clinical activities are evaluated. Satisfying patients' perceived needs is a fundamental goal in medicine.38
Physicians who take seriously the value of patient-centered health care need to make systematic efforts to solicit their patients' expectations and understand how these are driving the patients' desires for information and treatment, as well as their adherence to prescribed regimens. In this era of managed care, in which physicians' job performance evaluations are increasingly taking into account their patients' satisfaction reports, the physician who ignores a patient's expectations for care may do damage to the clinical relationship. Reasonable patient expectations need to be considered and unreasonable ones need to be denied with a full and compassionate discussion with the patient of his or her concerns.