This study examined associations between seven IPC measures (reports of patients' experiences) and three patient satisfaction measures (patients' ratings of that experience) in a large diverse sample that included English- and Spanish-speaking Latinos, African Americans, and non-Latino Whites. Results overwhelmingly suggest that these interpersonal processes mattered for all groups in terms of satisfaction. It is notable that scales from all three dimensions—communication, patient-centered decision making, and interpersonal style—were independently associated with all satisfaction measures.
Two IPC scales, eliciting and responding to patient concerns and patient-centered decision making, were consistently and strongly related to all outcomes regardless of race/ethnicity and language. The associations between the various IPC measures and whether patients would recommend their physicians were also similar for all race/ethnic groups, with four of the scales being positively associated with this outcome. Discrimination was also negatively associated with the two global satisfaction measures across all groups. However, the associations of four IPC scales (lack of clarity, explained results, compassionate/respectful, and disrespectful staff) with the two global satisfaction measures differed by race/ethnicity and language, suggesting that some interpersonal processes may be more important to patients from some groups compared to those from others. Differences in the relative importance of specific interpersonal processes may identify potential mechanisms of disparities in health care and patient satisfaction.
For Latinos, some effects of IPC depended on language. Notably, unclear communication (lack of clarity)
was negatively associated with satisfaction only for Spanish-speaking Latinos. This is consistent with a study that found that Spanish-speaking Latinos were more dissatisfied than English-speaking Latinos and Whites with how well medical staff listened, answered their questions, explained medications, explained medical procedures and tests results, and provided reassurance and support (Morales et al. 1999
). These findings suggest that we need more studies of interventions that aim to improve the clarity of communication among non-English speaking patients, such as professional interpreter services. Another difference associated with language was that the quality of explanations of examination and test results was not significantly associated with satisfaction with physicians among Spanish-speaking Latinos (although it was associated with satisfaction with health care and recommending physicians in all groups). It could be that in encounters where language barriers exist, Spanish-speaking Latinos feel less confident in reporting on the quality of specific explanations provided by physicians.
Disrespect on the part of office staff was negatively associated with satisfaction with health care in all groups, but its effects on satisfaction with physicians differed across groups. For African Americans, reporting more disrespect from office staff was associated with greater satisfaction with their physicians, while this was not the case in the other groups. Reasons for this are unclear and require further study and confirmation in other samples. Perhaps, greater sensitivity to discrimination by office staff makes African Americans more appreciative of positive encounters with physicians. Disrespectful office staff did not affect reports of recommending physicians, suggesting that interactions with office staff are not of central importance in patient recommendations.
Our findings that compassionate and respectful care was associated with the two physician-related outcomes regardless of race/ethnicity are similar to those of Saha, Arbelaez, and Cooper (2003)
who found that respect was associated with satisfaction for African Americans, Whites, and Asians, and another study in diverse ethnic groups that found that being treated with dignity by providers was associated with greater patient satisfaction (Beach et al. 2005
Similar to others (Gattellari, Butow, and Tattersall 2001
; Beach et al. 2005
;), we found that eliciting and responding to patient concerns as well as patient-centered decision making were consistently and strongly related to patient satisfaction. These results suggest specific ways in which physician behavior might improve satisfaction—an advantage of assessing reports of physician behavior rather than ratings. Only a few studies have focused on interventions that aim to improve skills to elicit patients' concerns and involve them in their care (Carrillo, Green, and Betancourt 1999
; Epstein and Street 2007
;). Limited evidence suggests that whereas physician behavior can be changed (frequency with which physicians elicit patient's concerns), interventions may not affect patient outcomes, such as adherence and satisfaction, without similar attention to patient activation (Joos et al. 1996
; Kiesler and Auerbach 2006
;). Development of interventions to improve IPC in clinical practice is an important future direction.
Because our sample was drawn from a single academic health care system, generalizability of the findings is a major limitation of the study. The IPC survey is a new instrument; thus, further investigation and replication are warranted. Another limitation is that we had no provider-specific covariates since the IPC survey asks patients to average reports across all providers seen in the previous year. We did, however, control for clinic site as a covariate. In addition, the sample did not include Asian/Pacific Islander patients among whom determinants of satisfaction may differ from the groups included in this study.
Our findings support the conclusion that various IPC contribute uniquely to each satisfaction measure, suggesting that patients distinguish these dimensions in evaluating their health care. For example, four IPC measures influenced whether patients would recommend their physicians, with elicitation of concerns and compassion being more strongly associated with this outcome than the other measures; a one-point increase on the elicitation or compassion/respect measures was associated with more than a twofold increase in the odds that patients would recommend their physicians to others. The fact that all models included unique effects of multiple IPC measures suggests a need to focus on multiple facets of IPC to maximize patient satisfaction. In fact, in a review of the processes of decision making in cancer care, Epstein and colleagues emphasize that listening, clear explanations, and unhurried manner are all elements of patient-centered decisions (Epstein and Street Jr. 2007
In previous studies, ethnic differences in IPC or satisfaction might reflect actual differences in care or, alternatively, measurement bias. Our results offer a significant advancement in the field as the multi-item IPC scales were subjected to rigorous psychometric testing to ensure their measurement invariance (lack of bias) across the four groups (Stewart et al. 2007
). Furthermore, as reports of what actually happened during medical encounters, the IPC scales may be more objective and better able to capture group differences in care, compared to ratings, which are more strongly influenced by expectations (Cleary et al. 1988
; Weech-Maldonado et al. 2003
Substantial literature supports the link between effective physician–patient interactions and positive patient outcomes (Stewart 1995
; Beach et al. 2005
; Epstein and Street Jr. 2007
;). Future research can explore associations of specific interpersonal processes to patient outcomes, such as self-care behaviors, adherence to recommended follow-up care, and psychological well-being. Such research would make a substantial contribution to addressing disparities in health and health care.