This study presents new information on how satisfaction with pediatric chronic disease visits is influenced by both the physician communication style in a single visit and the ongoing relationships children and their parents experience with physicians. Specifically, the physician’s friendliness within the visit is significantly associated with higher satisfaction. Additionally, parents are significantly more satisfied with the care received for their child’s chronic disease when they report higher quality ongoing relationships with their child’s physician across all four measures of relationship quality. These findings inform efforts to improve satisfaction with pediatric chronic disease care and perhaps ultimately enhance adherence to self-management regimens.
Despite the known impact of communication style on visit satisfaction and adherence (Clark et al., 2008
; Wissow et al., 1998
), we demonstrated only one significant association with satisfaction—that of physician friendliness toward the parent. Yet studies based in Social Interaction Theory have supported its premise that communication style may be more important to patient satisfaction than actual content of the communication (Avis, Bond, & Arthur, 1997
; Whitten, Mylod, Gavran, & Sypher, 2008
). Other survey-based studies have found multiple associations between satisfaction and parent or child report of communication style (Clark et al., 2008
; Wissow et al., 1998
). These studies utilized survey measures of communication style and found improvements in satisfaction and outcomes as predicted by social interaction theory.
Various reviews discuss the relationship that parents and children experience with their pediatrician in chronic disease visits, often focusing on communication within a single visit (Drotar, 2009
; Fielding & Duff, 1999
; Nobile & Drotar, 2003
). Relationships, however, are built across multiple interactions around a common goal (Hinde, 1997
). A recent review of effective communication strategies in pediatric chronic disease concludes that little attention has been paid to the importance of long-term relationships to adherence (DiMatteo, 2004
). Yet among children with chronic disease transitioning to adult care, increased hospitalizations occurred among children who switched disease management physicians and allied health teams, in comparison to children who either kept the same physician but experienced a change in the allied health team or kept the same physician and allied health care team (Nakhla et al., 2009
). Our results demonstrating the effect of ongoing relationships on satisfaction with pediatric chronic disease visits are consistent with this study’s findings. Further, little attention has been paid to elucidating the critical aspects of ongoing relationships. We identified four specific aspects of ongoing relationships that were significantly associated with satisfaction, namely, the relationship between the parent and the physician, the relationship between the child and the physician, the parent’s comfort asking the physician questions, and the parent’s trust in the physician.
Our study has notable strengths and limitations. The use of audio and video data in our study fills an important gap in the current understanding of how communication influences outcomes, by allowing observation of communication as it occurs in the visit and including both verbal and non-verbal cues (Ben-Sira, 1976
; Norton, 1978
). Also, when attempting to help physicians improve communication with patients, having video data can provide concrete examples of visits perceived as “friendly” or “less friendly” styles of communicating. Future work could also expand the measures of communication style to further elucidate important influences on outcomes such as visit satisfaction and adherence.
Also, although satisfaction was often quite high, we found evidence to support our hypotheses. Our families’ levels of satisfaction are similar to those in other studies of visits by adults and children (Beach et al., 2005
; Byczkowski, Kollar, & Britto, 2010
; Patel & Cabana, 2010
), with the vast majority reporting they were either extremely or very satisfied. Yet there is still room for improvement if we aim to have all families extremely satisfied with their care, especially in light of how this satisfaction may impact adherence to complex chronic disease self-management regimens (Anderson & Zimmerman, 1993
; Roter, Hall, & Katz, 1988
With regard to limitations, first, our cross-sectional study design does not support longitudinal assessments of satisfaction or the ongoing relationship quality. Given that both the communication style in a single visit and the ongoing relationship influence satisfaction, future longitudinal work could illuminate how ongoing relationships and communication style change over time and how these changes influence satisfaction or adherence. Second, only parent satisfaction with care, and not child satisfaction, was measured, but at least one study suggests parent and child satisfaction may not be significantly different (Byczkowski et al., 2010
). Third, we limited our study population to three pediatric chronic diseases, selected to represent treatment plans requiring varying levels of patient and family involvement (Smith & Shuchman, 2005
; Williams, Holmbeck, & Greenley, 2002
) in addition to capturing diseases with worldwide prevalence (ISAAC, 1998
). Further, we studied care delivered at two academic institutions in the Midwest, which could limit the generalizability of study findings. However, 44% of pediatric subspecialists practice in an academic setting, and these physicians represent the care source for many children with chronic disease (Stoddard et al., 2000
). Additionally, our sample size may have been insufficient to detect some associations and limits our ability to perform subgroup analyses for each disease. Despite the sample size, we did find significant associations between satisfaction and both the communication style within the visit and the ongoing relationship. Lastly, our measures may overestimate satisfaction with pediatric chronic disease visits since study patients were those who attended management visits and therefore may be more satisfied than patients who do not attend.
The results of this study have important implications for the care of children with chronic disease. Attention to communication style, specifically showing friendliness toward parents, can improve satisfaction. Additionally, building ongoing relationships with children and their parents, including comfort asking questions of the physician and high trust, could lead to improvements in visit satisfaction and ultimately adherence. Based on Social Interaction Theory, this may be particularly true for families where the knowledge gap is largest, such as those with limited health literacy. Development of ongoing relationships can be facilitated by showing interest in the patient and parent beyond their disease, respecting the patient and parent input regarding treatment plans, and ensuring adequate time and privacy during visits (Drotar, 2009
). Additionally, medical school, residency, and fellowship programs should offer training on building strong, continuous relationships with pediatric patients with chronic disease and their parents. This recommendation is consistent with research demonstrating that interventions to improve medical student communication skills are feasible and efficacious (Ahsen et al., 2010
) and that continuity of care in resident clinics is feasible to schedule (McBurney, Moran, Ector, Quattlebaum, & Darden, 2004
) and can improve outcomes (Christakis, Wright, Zimmerman, Bassett, & Connell, 2003