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1.  Instrumental and socioemotional communications in doctor-patient interactions in urban and rural clinics 
Location of practice, such as working in a rural or urban clinic, may influence how physicians communicate with their patients. This exploratory pilot study examines the communication styles used during doctor-patient interactions in urban and rural family practice settings in Western Canada.
We analyzed observation and interview data from four physicians practicing in these different locations. Using a grounded theory approach, communications were categorized as either instrumental or socioemotional. Instrumental communication refers to “cure-oriented interactions” and tends to be more task-oriented focusing on the patient’s health concerns and reason for the appointment. In contrast, socioemotional communication refers to more “care-oriented interactions” that may make the patient feel comfortable, relieve patient anxiety and build a trusting relationship.
The physicians in small, rural towns appear to know their patients and their families on a more personal level and outside of their office, and engage in more socioemotional communications compared to those practicing in suburban clinics in a large urban centre. Knowing patients outside the clinic seems to change the nature of the doctor-patient interaction, and, in turn, the doctor-patient relationship itself. Interactions between urban doctors and their patients had a mixture of instrumental and socioemotional communications, while interactions between rural doctors and their patients tended to be highly interpersonal, often involving considerable socioemotional communication and relationship-building.
Despite the different ways that doctors and patients communicate with each other in the two settings, rural and urban doctors spend approximately the same amount of time with their patients. Thus, greater use of socioemotional communication by rural doctors, which may ease patient anxiety and increase patient trust, did not appear to add extra time to the patient visit. Research suggests that socioemotional communication may ultimately lead to better patient outcomes, which implies that health differences between rural and urban settings could be linked to differences in doctor-patient communication styles.
PMCID: PMC3734115  PMID: 23835062
Physicians; Family practice; Rural clinics; Urban clinics; Patient-physician communication; Patient-physician interaction
2.  Decision-Making of Older Patients in Context of the Doctor-Patient Relationship: A Typology Ranging from “Self-Determined” to “Doctor-Trusting” Patients 
Background. This qualitative study aims to gain insight into the perceptions and experiences of older patients with regard to sharing health care decisions with their general practitioners. Patients and Methods. Thirty-four general practice patients (≥70 years) were asked about their preferences and experiences concerning shared decision making with their doctors using qualitative semistructured interviews. All interviews were analysed according to principles of content analysis. The resulting categories were then arranged into a classification grid to develop a typology of preferences for participating in decision-making processes. Results. Older patients generally preferred to make decisions concerning everyday life rather than medical decisions, which they preferred to leave to their doctors. We characterised eight different patient types based on four interdependent positions (self-determination, adherence, information seeking, and trust). Experiences of a good doctor-patient relationship were associated with trust, reliance on the doctor for information and decision making, and adherence. Conclusion. Owing to the varied patient decision-making types, it is not easy for doctors to anticipate the desired level of patient involvement. However, the decision matter and the self-determination of patients provide good starting points in preparing the ground for shared decision making. A good relationship with the doctor facilitates satisfying decision-making experiences.
PMCID: PMC3652207  PMID: 23691317
3.  The compatibility of prescribing guidelines and the doctor-patient partnership: a primary care mixed-methods study 
The British Journal of General Practice  2012;62(597):e275-e281.
UK policy expects health professionals to involve patients in decisions about their care (including medicines use) and, at the same time, to follow prescribing guidelines. The compatibility of these approaches is unclear.
To explore the relationship between prescribing guidelines and patient-partnership by exploring the attitudes of patients, GPs and primary care trust (PCT) prescribing advisors.
Design and setting
A mixed-methods study using qualitative, semi-structured interviews followed by a quantitative, questionnaire survey in primary care in Northern England.
Interviews were conducted with 14 patients taking a statin or a proton pump inhibitor, eight GPs and two prescribing advisors. A multi-variate sampling strategy was used. Qualitative findings were analysed using framework analysis. Questionnaires based on themes derived from the interviews were distributed to 533 patients and 305 GPs of whom 286 (54%) and 142 (43%) responded.
Areas of tension between guidelines and patient partnership were identified, including potential damage to trust in the doctor and reduced patient choice, through the introduction of the policy maker as a third stakeholder in prescribing decisions. Other areas of tension related to applying single condition guidelines to patients with multiple illnesses, competition for doctors' time and the perception of cost containment. Many GPs coped with these tensions by adopting a flexible approach or prioritising the doctor–patient relationship over guidelines.
Rigidly applied guidelines can limit patient choice and may damage the doctor–patient relationship. GPs need flexibility in order to optimise the implementation of prescribing guidelines, while responding to individuals' needs and preferences.
PMCID: PMC3310034  PMID: 22520915
decision making; evidence-based practice; patient compliance; physician-patient relations; professional practice
4.  “Doctor, please tell me it’s nothing serious”: an exploration of patients’ worrying and reassuring cognitions using stimulated recall interviews 
BMC Family Practice  2014;15:73.
Many patients who consult their GP are worried about their health, but there is little empirical data on strategies for effective reassurance. To gain a better understanding of mechanisms for effective patient reassurance, we explored cognitions underlying patients’ worries, cognitions underlying reassurance and factors supporting patients’ reassuring cognitions.
In a qualitative study, we conducted stimulated recall interviews with 21 patients of 12 different GPs shortly after their consultation. We selected consultations in which the GPs aimed to reassure worried patients and used their videotaped consultation as a stimulus for the interview. The interviews were analysed with thematic coding and by writing interpretive summaries.
Patients expressed four different core cognitions underlying their concerns: ‘I have a serious illness’, ‘my health problem will have adverse physical effects’, ‘my treatment will have adverse effects’ and ‘my health problem will negatively impact my life’. Patients mentioned a range of person-specific and context-specific cognitions as reasons for these core cognitions. Patients described five core reassuring cognitions: ‘I trust my doctor’s expertise’, ‘I have a trusting and supporting relationship with my doctor’, ‘I do not have a serious disease’, ‘my health problem is harmless’ and ‘my health problem will disappear.’ Factors expressed as reasons for these reassuring cognitions were GPs’ actions during the consultation as well as patients’ pre-existing cognitions about their GP, the doctor-patient relationship and previous events. Patients’ worrying cognitions were counterbalanced by specific reassuring cognitions, i.e. worrying and reassuring cognitions seemed to be interrelated.
Patients described a wide range of worrying cognitions, some of which were not expressed during the consultation. Gaining a thorough understanding of the specific cognitions and tailoring reassuring strategies to them should be an effective way of achieving reassurance. The identified reassuring cognitions can guide doctors in applying these strategies in their daily practice.
PMCID: PMC4008437  PMID: 24762333
5.  How Doctors Choose Medications to Treat Type 2 Diabetes 
Diabetes care  2007;30(6):10.2337/dc06-2499.
Glycemic control remains suboptimal despite the wide range of available medications. More effective medication prescription might result in better control. However, the process by which physicians choose glucose-lowering medicines is poorly understood. We sought to study the means by which physicians choose medications for type 2 diabetic patients.
We surveyed 886 physician members of either the Society of General Internal Medicine (academic generalists, response rate 30%) or the American Diabetes Association (specialists, response rate 23%) currently managing patients with type 2 diabetes. Respondents weighed the importance of 15 patient, physician, and nonclinical factors when deciding which medications to prescribe for type 2 diabetic subjects at each of three management stages (initiation, use of second-line oral agents, and insulin).
Respondents reported using a median of five major considerations (interquartile range 4–6) at each stage. Frequently cited major considerations included overall assessment of the patient’s health/comorbidity, A1C level, and patient’s adherence behavior but not expert guidelines/hospital algorithms or patient age. For insulin initiation, academic generalists placed greater emphasis on patient adherence (76 vs. 60% of specialists, P < 0.001). These generalists also identified patient fear of injections (68%) and patient desire to prolong noninsulin therapy (68%) as major insulin barriers. Overall, qualitative factors (e.g., adherence, motivation, overall health assessment) were somewhat more highly considered than quantitative factors (e.g., A1C, age, weight) with mean aggregate scores of 7.3 vs. 6.9 on a scale of 0–10, P < 0.001.
The physicians in our survey considered a wide range of qualitative and quantitative factors when making medication choices for hyperglycemia management. The apparent complexity of the medication choice process contrasts with current evidence-based treatment guidelines.
PMCID: PMC3829641  PMID: 17337497
6.  Primary Health Care Consumers’ Acceptance, Trust and Gender Preferences towards Omani Doctors 
Oman Medical Journal  2007;22(3):51-56.
The percentage of Omani physicians from total number of physicians working in the Sultanate tripled from 9% in 1999 to 27% in 2006 and is expected to increase to 50% by 2010. The study aimed to asses community attitudes towards Omani doctors and to investigate the different socio-demographic variables related to these attitudes.
It was done in two selected Primary Health Care (PHC) facilities by simple random technique in Batinah region. Face-to-face interview was made on 305 randomly selected samples of PHC customers by trained researchers from Sultan Qaboos University (SQU). Omani Doctors Acceptance Scale (ODAS) was adapted and used to assess participants acceptance of the communication skills of the Omani doctor, care to the patient, absence of language barrier, competence level, preference to be seen by doctor from the same sex, embarrassment from seeing an Omani doctor, qualification, experience, knowledge and skills of the Omani experience of the Omani doctor, and trust on the Omani doctor. Chi squared tests of significance was used in analysis.
Males reported more satisfaction about communication skills of the Omani doctors, whereas female respondents reported higher likelihood of being embarrassed from the latter. Elder age cohort, those reported ever treated by an Omani doctor, married respondents, and those of lower level of education were more likely to report higher level of acceptance than others. Those aged 26-40 and those above 40 years of age were 2.41 and 3.41 times higher than the youngest age cohort respectively. Similarly, older age cohort reported having more trust than the middle age respondents relatively to the youngest age group.
The current study showed an accepted level of acceptance to Omani doctors. Looking for crucial issues in patient-doctor relationships as acceptance, satisfaction, trust, gender preference especially for PHC doctors ensure the continuity of care.
PMCID: PMC3294151  PMID: 22400094
7.  Is networking different with doctors working part-time? Differences in social networks of part-time and full-time doctors 
Part-time working is a growing phenomenon in medicine, which is expected to influence informal networks at work differently compared to full-time working. The opportunity to meet and build up social capital at work has offered a basis for theoretical arguments.
Twenty-eight teams of medical specialists in the Netherlands, including 226 individuals participated in this study. Interviews with team representatives and individual questionnaires were used. Data were gathered on three types of networks: relationships of consulting, communication and trust. For analyses, network and multilevel applications were used. Differences between individual doctors and between teams were both analysed, taking the dependency structure of the data into account, because networks of individual doctors are not independent. Teams were divided into teams with and without doctors working part-time.
Results and Discussion
Contrary to expectations we found no impact of part-time working on the size of personal networks, neither at the individual nor at the team level. The same was found regarding efficient reachability. Whereas we expected part-time doctors to choose their relations as efficiently as possible, we even found the opposite in intended relationships of trust, implying that efficiency in reaching each other was higher for full-time doctors. But we found as expected that in mixed teams with part-time doctors the frequency of regular communication was less compared to full-time teams. Furthermore, as expected the strength of the intended relationships of trust of part-time and full-time doctors was equally high.
From these findings we can conclude that part-time doctors are not aiming at efficiency by limiting the size of networks or by efficient reachability, because they want to contact their colleagues directly in order to prevent from communication errors. On the other hand, together with the growth of teams, we found this strategy, focussed on reaching all colleagues, was diminishing. And our data confirmed that formalisation was increasing together with the growth of teams.
PMCID: PMC2583974  PMID: 18834545
8.  Patient satisfaction with healthcare provided by family doctors: primary dimensions and an attempt at typology 
Patient satisfaction is a complex and difficult concept to measure, thus precluding the use of exclusively quantitative methods for its description. The purpose of this survey was firstly to identify particular healthcare dimensions that determine a patient's satisfaction or dissatisfaction; and secondly to attempt to typologise the patients' responses based on their evaluation of healthcare.
Using a qualitative research design, thirty-six in-depth interviews with patients of family physicians were conducted: four patients from each of 9 family practices in different regions of Poland were interviewed. The main outcome measure was factors associated with patient satisfaction/dissatisfaction.
In their evaluations of their contacts with family doctors, the patients cited mostly issues concerning interpersonal relationships with the doctor. Nearly 40% of the statements referred to this aspect of healthcare, with nearly equal proportions of positive and negative comments. The second most frequent category of responses concerned contextual factors (21%) that related to conditions of medical service, with two-thirds of the evaluations being negative. Statements concerning the doctor's competencies (12.9%) and personal qualities (10.5%) were less common.
To improve the quality of healthcare, family doctors should take special care to ensure the quality of their interactions with patients.
PMCID: PMC2678111  PMID: 19371417
9.  Does Family Medicine training in Thailand affect patient satisfaction with primary care doctors? 
BMC Family Practice  2007;8:14.
Recent national healthcare reforms in Thailand aim to transfer primary care to family physicians, away from more expensive specialists. As Family Medicine has yet to be established as a separate discipline in Thailand, newly trained family physicians work alongside untrained general doctors in primary care. While it has been shown that Family Medicine training programs in Thailand can increase the quality of referrals from primary care doctors to specialists, information is lacking about whether such training affects the quality of patient care. In the Department of Family Medicine at Ramathibodi Hospital, trained family physicians work with residents and general doctors. Although this situation is not typical within Thailand, it offers us the opportunity to look for variations in the levels of satisfaction reported by patients treated by different types of primary care doctor.
During a two-week period in December 2005, 2,600 questionnaires (GPAQ) were given to patients visiting the Department of Family Medicine at Ramathibodi Hospital. Patients were given the choice of whether or not they wanted to participate in the study. A cross-sectional analysis was performed on the completed questionnaires. Mean GPAQ scores were calculated for each dimension and scored out of 100. Student t-tests, ANOVA with F-test statistic and multiple comparisons by Scheffe were used to compare the perceived characteristics of the different groups of doctors. Five dimensions were measured ranging from access to care, continuity of care, communication skills, enablement (the patient's knowledge of a self-care plan after the consultation) and overall satisfaction.
The response rate was 70%. There were significant differences in mean GPAQ scores among faculty family physicians, residents and general doctors. For continuity of care, patients gave higher scores for faculty family physicians (67.87) compared to residents (64.57) and general doctors (62.51). For communication skills, patients gave the highest GPAQ scores to faculty family physicians (69.77) and family medicine residents (69.79). For enablement, faculty family physicians received the highest score (82.44) followed by family medicine residents (80.75) and general doctors (76.29).
Faculty family physicians scored higher for continuity of care when compared with general doctors and residents. General doctors had lower GPAQ scores for communication skills and enablement when compared to faculty family physicians and residents. Faculty family physicians had the highest GPAQ scores in many dimensions of family practice skills, followed by residents and general doctors.
PMCID: PMC1852109  PMID: 17394639
10.  The patient–doctor relationship: a synthesis of the qualitative literature on patients' perspectives 
The British Journal of General Practice  2009;59(561):e116-e133.
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.
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.
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.
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.
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.
PMCID: PMC2662123  PMID: 19341547
communication; continuity of patient care; physician–patient relations; qualitative research
11.  The Doctor–Patient Relationship and HIV-infected Patients' Satisfaction with Primary Care Physicians 
To assess the extent to which perceptions of specific aspects of the doctor–patient relationship are related to overall satisfaction with primary care physicians among HIV-infected patients.
Longitudinal, observational study of HIV-infected persons new to primary HIV care. Data were collected at enrollment and approximately 6 months later by in-person interview.
Two urban medical centers in the northeastern United States.
Patients seeking primary HIV care for the first time.
The primary outcome measure was patient-reported satisfaction with a primary care physician measured 6 months after initiating primary HIV care. Patients who were more comfortable discussing personal issues with their physicians (P = .021), who perceived their primary care physicians as more empathetic (P = .001), and who perceived their primary care physicians as more knowledgeable with respect to HIV (P = .002) were significantly more satisfied with their primary care physicians, adjusted for characteristics of the patient and characteristics of primary care. Collectively, specific aspects of the doctor–patient relationship explained 56% of the variation in overall satisfaction with the primary care physician.
Patients' perceptions of their primary care physician's HIV knowledge and empathy were highly related to their satisfaction with this physician. Satisfaction among HIV-infected patients was not associated with patients' sociodemographic characteristics, HIV risk characteristics, alcohol and drug use, health status, quality of life, or concordant patient-physician gender and racial matching.
PMCID: PMC1495486  PMID: 10940132
HIV; satisfaction; doctor–patient relationship
12.  African Migrant Patients’ Trust in Chinese Physicians: A Social Ecological Approach to Understanding Patient-Physician Trust 
PLoS ONE  2015;10(5):e0123255.
Patient trust in physicians is a critical determinant of health seeking behaviors, medication adherence, and health outcomes. A crisis of interpersonal trust exists in China, extending throughout multiple social spheres, including the healthcare system. At the same time, with increased migration from Africa to China in the last two decades, Chinese physicians must establish mutual trust with an increasingly diverse patient population. We undertook a qualitative study to identify factors affecting African migrants’ trust in Chinese physicians and to identify potential mechanisms for promoting trust.
Methods / Principal Findings
We conducted semi-structured, in-depth interviews with 40 African migrants in Guangzhou, China. A modified version of the social ecological model was used as a theoretical framework. At the patient-physician level, interpersonal treatment, technical competence, perceived commitment and motive, and language concordance were associated with enhanced trust. At the health system level, two primary factors influenced African migrants’ trust in their physicians: the fee-for-service payment system and lack of continuity with any one physician. Patients’ social networks and the broader socio-cultural context of interactions between African migrants and Chinese locals also influenced patients’ trust of their physicians.
These findings demonstrate the importance of factors beyond the immediate patient-physician interaction and suggest opportunities to promote trust through health system interventions.
PMCID: PMC4428824  PMID: 25965064
13.  'It gives you an understanding you can't get from any book.' The relationship between medical students' and doctors' personal illness experiences and their performance: a qualitative and quantitative study 
Anecdotes abound about doctors' personal illness experiences and the effect they have on their empathy and care of patients. We formally investigated the relationship between doctors' and medical students' personal illness experiences, their examination results, preparedness for clinical practice, learning and professional attitudes and behaviour towards patients.
Newly-qualified UK doctors in 2005 (n = 2062/4784), and two cohorts of students at one London medical school (n = 640/749) participated in the quantitative arm of the study. 37 Consultants, 1 Specialist Registrar, 2 Clinical Skills Tutors and 25 newly-qualified doctors participated in the qualitative arm. Newly-qualified doctors and medical students reported their personal illness experiences in a questionnaire. Doctors' experiences were correlated with self-reported preparedness for their new clinical jobs. Students' experiences were correlated with their examination results, and self-reported anxiety and depression. Interviews with clinical teachers, newly-qualified doctors and senior doctors qualitatively investigated how personal illness experiences affect learning, professional attitudes, and behaviour.
85.5% of newly-qualified doctors and 54.4% of medical students reported personal illness experiences. Newly-qualified doctors who had been ill felt less prepared for starting work (p < 0.001), but those who had only experienced illness in a relative or friend felt more prepared (p = 0.02). Clinical medical students who had been ill were more anxious (p = 0.01) and had lower examination scores (p = 0.006). Doctors felt their personal illness experiences helped them empathise and communicate with patients. Medical students with more life experience were perceived as more mature, empathetic, and better learners; but illness at medical school was recognised to impede learning.
The majority of the medical students and newly qualified doctors we studied reported personal illness experiences, and these experiences were associated with lower undergraduate examination results, higher anxiety, and lower preparedness. However reflection on such experiences may have improved professional attitudes such as empathy and compassion for patients. Future research is warranted in this area.
PMCID: PMC2211477  PMID: 18053231
14.  Patients’ views on changes in doctor-patient communication between 1982 and 2001: a mixed-methods study 
BMC Family Practice  2012;13:80.
Doctor-patient communication has been influenced over time by factors such as the rise of evidence-based medicine and a growing emphasis on patient-centred care. Despite disputes in the literature on the tension between evidence-based medicine and patient-centered medicine, patients’ views on what constitutes high quality of doctor-patient communication are seldom an explicit topic for research. The aim of this study is to examine whether analogue patients (lay people judging videotaped consultations) perceive shifts in the quality of doctor-patient communication over a twenty-year period.
Analogue patients (N = 108) assessed 189 videotaped general practice consultations from two periods (1982–1984 and 2000–2001). They provided ratings on three dimensions (scale 1–10) and gave written feedback. With a mixed-methods research design, we examined these assessments quantitatively (in relation to observed communication coded with RIAS) and qualitatively.
1) The quantitative analyses showed that biomedical communication and rapport building were positively associated with the quality assessments of videotaped consultations from the first period, but not from the second. Psychosocial communication and personal remarks were related to positive quality assessments of both periods; 2) the qualitative analyses showed that in both periods, participants provided the same balance between positive and negative comments. Listening, giving support, and showing respect were considered equally important in both periods. We identified shifts in the participants’ observations on how GPs explained things to the patient, the division of roles and responsibilities, and the emphasis on problem-focused communication (first period) versus solution-focused communication (last period).
Analogue patients recognize shifts in the quality of doctor-patient communication from two different periods, including a shift from problem-focused communication to solution-focused communication, and they value an egalitarian doctor-patient relationship. The two research methods were complementary; based on the quantitative analyses we found shifts in communication, which we confirmed and specified in our qualitative analyses.
PMCID: PMC3460773  PMID: 22873783
Quality of care; Doctor-patient communication; Analogue patients; General practice; Video observation; Mixed-methods design
15.  Don’t Forget the Doctor: Gastroenterologists’ Preferences on the Development of mHealth Tools for Inflammatory Bowel Disease 
JMIR mHealth and uHealth  2015;3(1):e5.
Inflammatory bowel disease (IBD) encompasses a number of disorders of the gastrointestinal tract. Treatment for IBD is lifelong and complex, and the majority of IBD patients seek information on the Internet. However, research has found existing digital resources to be of questionable quality and that patients find content lacking. Gastroenterologists are frontline sources of information for North American IBD patients, but their opinions and preferences for digital content, design, and utility have not been investigated. The purpose of this study is to systematically explore gastroenterologists’ perceptions of, and design preferences for, mHealth tools.
Our goal was to critically assess these issues and elicit expert feedback by seeking consensus with Canadian gastroenterologists.
Using a qualitative approach, a closed meeting with 7 gastroenterologists was audio recorded and field notes taken. To synthesize results, an anonymous questionnaire was collected at the end of the session. Participant-led discussion themes included methodological approaches to non-adherence, concordance, patient-centricity, and attributes of digital tools that would be actively supported and promoted.
Survey results indicated that 4 of the 7 gastroenterologists had experienced patients bringing digital resources to a visit, but 5 found digital patient resources to be inaccurate or irrelevant. All participants agreed that digital tools were of increasing importance and could be leveraged to aid in consultations and save time. When asked to assess digital attributes that they would be confident to refer patients to, all seven indicated that the inclusion of evidence-based facts were of greatest importance. Patient peer-support networks were deemed an asset but only if closely monitored by experts. When asked about interventions, nearly all (6/7) preferred tools that addressed a mix of compliance and concordance, and only one supported the development of tools that focused on compliance. Participants confirmed that they would actively refer patients and other physicians to digital resources. However, while a number of digital IBD tools exist, gastroenterologists would be reluctant to endorse them.
Gastroenterologists appear eager to use digital resources that they believe benefit the physician-patient relationship, but despite the trend of patient-centric tools that focus on concordance (shared decision making and enlightened communication between patients and their health care providers), they would prefer digital tools that highlight compliance (patient following orders). This concordance gap highlights an issue of disparity in digital health: patients may not use tools that physicians promote, and physicians may not endorse tools that patients will use. Further research investigating the concordance gap, and tensions between physician preferences and patient needs, is required.
PMCID: PMC4319145  PMID: 25608628
mHealth; adherence; concordance; compliance; shared decision making; therapeutic alliance; gastroenterology; IBD; ulcerative colitis
16.  The Import of Trust in Regular Providers to Trust in Cancer Physicians among White, African American, and Hispanic Breast Cancer Patients 
Interpersonal trust is an important component of the patient-doctor relationship. Little is known about patients’ trust in the multiple providers seen when confronting serious illness.
To characterize breast cancer patients’ trust in their regular providers, diagnosing physicians, and cancer treatment team and examine whether high trust in one’s regular provider confers high trust to cancer physicians.
In-person interviews.
704 white, black, and Hispanic breast cancer patients, age 30 to 79, with a first primary in situ or invasive breast cancer who reported having a regular provider.
We measure trust in: (1) regular provider, (2) diagnosing doctors, and (3) cancer treatment team. Other variables include demographic variables, preventive health care, comorbidities, time with regular provider, time since diagnosis, cancer stage, and treatment modality.
Sixty-five percent of patients reported high trust in their regular provider, 84% indicated high trust in their diagnosing doctors, and 83% reported high trust in their treatment team. Women who reported high trust in their regular provider were significantly more likely to be very trusting of diagnosing doctors (OR: 3.44, 95% CI: 2.27–5.21) and cancer treatment team (OR: 3.09, 95% CI: 2.02–4.72 ). Black women were significantly less likely to be very trusting of their regular doctor (OR: 0.58, 95% CI: 0.38–0.88) and cancer treatment team (OR: 0.45, 95% CI: 0.25–0.80). English-speaking Hispanic women were significantly less trusting of their diagnosing doctors (OR: 0.29, 95% CI: 0.11–0.80).
Our results suggest that patients are very trusting of their breast cancer providers. This is an important finding given that research with other populations has shown an association between trust and patient satisfaction and treatment adherence. Our findings also suggest that a trusting relationship with a regular provider facilitates trusting relationships with specialists. Additional work is needed to increase interpersonal trust among black women.
PMCID: PMC3024096  PMID: 20811783
breast cancer; doctor-patient relationships; primary care; specialty care
17.  Colorectal cancer screening, perceived discrimination, and low-income and trust in doctors: a survey of minority patients 
BMC Public Health  2009;9:363.
Completion of colorectal cancer (CRC) screening testing is lower among low-income and minority groups than the population as a whole. Given the multiple cancer screening health disparities known to exist within the U.S., this study investigated the relationship between perceived discrimination, trust in most doctors, and completion of Fecal Occult Blood Testing (FOBT) among a low-income, minority primary care population in an urban setting.
We recruited a convenience sample of adults over age 40 (n = 282) from a federally qualified community health center (70% African American). Participants completed a survey which included measures of trust in most doctors, perceived discrimination, demographics and report of cancer screening.
Participants reported high levels of trust in most doctors, regardless of sex, race, education or income. High trust was associated with low perceived discrimination (p < 0.01). The trend was for older participants to express more trust (p = 0.09) and less perceived discrimination (p < 0.01). Neither trust nor discrimination was associated with race or education. Trust was higher among participants over 50 who were up-to-date on FOBT screening vs. those who were not (31 vs. 29 (median), p < 0.05 by T-test). Among those over 50, up-to-date FOBT screening was nearly associated with high trust (p < 0.06; 95% CI 0.99, 1.28) and low perceived discrimination (p < 0.01; 95% CI 0.76, 0.96). Nevertheless, in multivariate-modeling, age and income explained FOBT completion better than race, trust and discrimination.
Perceived discrimination was related to income, but not race, suggesting that discrimination is not unique to minorities, but common to those in poverty. Since trust in most doctors trended toward being related to age, FOBT screening could be negatively influenced by low trust and perceived discrimination in health care settings. A failure to address these issues in middle-aged, low income individuals could exacerbate future disparities in CRC screening.
PMCID: PMC2761405  PMID: 19781085
18.  What happens when patients know more than their doctors? Experiences of health interactions after diabetes patient education: a qualitative patient-led study 
BMJ Open  2013;3(11):e003583.
To explore the impact of patient education on the lives of people with diabetes, including the effect on interactions with doctors and other healthcare professionals.
Qualitative user-led study using longitudinal interviews and 146 h of participant observation. Data were analysed using a narrative approach.
21 patients with type 1 diabetes, those either about to attend a patient education course or those who had completed the course in the previous 10 years.
Established patient education centres in three UK teaching hospitals teaching the Dose Adjustment for Normal Eating (DAFNE) course.
Both postcourse and several years later, most participants spoke of the experience of taking part in education as life-changingly positive. It helped them understand how to gain control over a very complex disease and freed them from dependence on medical advice and restrictive regimes. However, interactions within the health system following patient education could be fraught. Participants emerged from the course with greater condition-specific knowledge than many of the healthcare professionals they encountered. When these professionals did not understand what their patients were trying to do and were uncomfortable trusting their expertise, there could be serious consequences for these patients' ability to continue effective self-management.
Patients who have in-depth knowledge of their condition encounter problems when their expertise is seen as inappropriate in standard healthcare interactions, and expertise taught to patients in one branch of medicine can be considered non-compliant by those who are not specialists in that field. Although patient education can give people confidence in their own self-management skills, it cannot solve the power imbalance that remains when a generalist healthcare professional, however well meaning, blocks access to medication and supplies needed to manage chronic diseases successfully. There is a role for those involved in primary and hospital care, including those supporting and training healthcare professionals, to recognise these problems and find ways to acknowledge and respect chronic patients' biomedical and practical expertise.
PMCID: PMC3831109  PMID: 24231459
Medical Education & Training; Primary Care
19.  Promoting medical competencies through international exchange programs: benefits on communication and effective doctor-patient relationships 
BMC Medical Education  2014;14:43.
Universities are increasingly organizing international exchange programs to meet the requirements of growing globalisation in the field of health care. Analyses based on the programs’ fundamental theoretical background are needed to confirm the learning value for participants. This study investigated the extent of sociocultural learning in an exchange program and how sociocultural learning affects the acquisition of domain-specific competencies.
Sociocultural learning theories were applied to study the learning effect for German medical students from the LMU Munich, Munich, Germany, of participation in the medical exchange program with Jimma University, Jimma, Ethiopia. First, we performed a qualitative study consisting of interviews with five of the first program participants. The results were used to develop a questionnaire for the subsequent, quantitative study, in which 29 program participants and 23 matched controls performed self-assessments of competencies as defined in the Tuning Project for Health Professionals. The two interrelated studies were combined to answer three different research questions.
The participants rated their competence significantly higher than the control group in the fields of doctor-patient relationships and communication in a medical context. Participant responses in the two interrelated studies supported the link between the findings and the suggested theoretical background.
Overall, we found that the exchange program affected the areas of doctor-patient relationships and effective communication in a medical context. Vygotsky’s sociocultural learning theory contributed to explaining the learning mechanisms of the exchange program.
PMCID: PMC3945959  PMID: 24589133
Medical education; Sociocultural learning; Vygotsky; International cooperation; Internationalization on universities; Outcomes of exchange programs; Global health education
20.  Doctors' emotional reactions to recent death of a patient: cross sectional study of hospital doctors 
BMJ : British Medical Journal  2003;327(7408):185.
Objectives: To describe doctors' emotional reactions to the recent death of an “average” patient and to explore the effects of level of training on doctors' reactions.
Design: Cross sectional study using quantitative and qualitative data.
Setting: Two academic teaching hospitals in the United States.
Participants: 188 doctors (attending physicians (equivalent to UK consultants), residents (equivalent to UK senior house officers), and interns (equivalent to UK junior house officers)) who cared for 68 patients who died in the hospital.
Main outcome measures: Doctors' experiences in providing care, their emotional reactions to the patient's death, and their use of coping and social resources to manage their emotions.
Results: Most doctors (139/188, 74%) reported satisfying experiences in caring for a dying patient. Doctors reported moderate levels of emotional impact (mean 4.7 (SD 2.4) on a 0-10 scale) from the death. Women and those doctors who had cared for the patient for a longer time experienced stronger emotional reactions. Level of training was not related to emotional reactions, but interns reported needing significantly more emotional support than attending physicians. Although most junior doctors discussed the patient's death with an attending physician, less than a quarter of interns and residents found senior teaching staff (attending physicians) to be the most helpful source of support.
Conclusions: Doctors who spend a longer time caring for their patients get to know them better but this also makes them more vulnerable to feelings of loss when these patients die. Medical teams may benefit from debriefing within the department to give junior doctors an opportunity to share emotional responses and reflect on the patient's death.
PMCID: PMC166122  PMID: 12881257
21.  Trust in Physicians Among Rural Medicaid-Enrolled Smokers 
Associations have been found between trusting patient-physician relationships and use of preventive care and a greater adherence to prescribed care. The objectives of this study were to assess the level of trust rural Medicaid smokers have in their physicians and whether trust was related to patient characteristics or physician behavior.
This was a cross-sectional study of smokers who were enrolled in a tobacco dependence treatment program. Participants were rural Medicaid-enrolled adults, age 18 and older, who were current smokers. Participants were enrolled from 8 primary care clinics as they came in for an appointment with their physician. The Trust in Physician Scale was completed at the baseline visit. One week later, an interview was conducted with the smoker to determine whether the physician provided tobacco dependence treatment counseling at the visit. Mixed models were used to model the relationship between trust and participant characteristics and physician behaviors.
Medicaid smokers in this study exhibited a high level of trust in their health care provider, as levels were similar to those reported in the general population of patients. Trust was significantly higher among individuals with better self-reported health.
Rural Medicaid smokers appeared to have similar levels of trust in their physician as other patients. Future research should explore the role trust plays in shaping interactions between underserved populations and physicians within the context of smoking cessation counseling.
PMCID: PMC3994402  PMID: 24689546
epidemiology; Medicaid; observational data; rural; tobacco dependence treatment
22.  Details for Manuscript Number SSM-D-06-01956R1 “Physicians” Communication and Perceptions of Patients: Is it How They Look, How They Talk, or is it Just the Doctor?” 
Social science & medicine (1982)  2007;65(3):586-598.
Although physicians’ communication style and perceptions affect outcomes, few studies have examined how these perceptions relate to the way physicians communicate with patients. Moreover, while any number of factors may affect the communication process, few studies have analyzed these effects collectively in order to identify the most powerful influences on physician communication and perceptions. Adopting an ecological approach, this investigation examined: (a) the relationships of physicians’ patient-centered communication (informative, supportive, partnership-building) and affect (positive, contentious) on their perceptions of the patient, and (b) the degree to which communication and perceptions were affected by the physicians’ characteristics, patients’ demographic characteristics, physician-patient concordance, and the patient’s communication. Physicians (N = 29) and patients (N = 207) from 10 outpatient settings in the United States participated in the study. From audio-recordings of these visits, coders rated the physicians’ communication and affect as well as the patients’ participation and affect. Doctors were more patient-centered with patients they perceived as better communicators, more satisfied, and more likely to adhere. Physicians displayed more patient-centered communication and more favorably perceived patients who expressed positive affect, were more involved, and who were less contentious. Physicians were more contentious with black patients, whom they also perceived as less effective communicators and less satisfied. Finally, physicians who reported a patient-centered orientation to the doctor-patient relationship also were more patient-centered in their communication. The results suggest that reciprocity and mutual influence have a strong effect on these interactions in that more positive (or negative) communication from one participant leads to similar responses from the other. Physicians’ encounters with black patients revealed communicative difficulties that may lower quality of care for these patients.
PMCID: PMC2811428  PMID: 17462801
USA; physician-patient communication; physician perceptions; racial inequalities; patient participation
23.  Trust in the Medical Profession: Conceptual and Measurement Issues 
Health Services Research  2002;37(5):1419-1439.
To develop and test a multi-item measure for general trust in physicians, in contrast with trust in a specific physician.
Data Sources
Random national telephone survey of 502 adult subjects with a regular physician and source of payment.
Study Design
Based on a multidimensional conceptual model, a large pool of candidate items was generated, tested, and revised using focus groups, expert reviewers, and pilot testing. The scale was analyzed for its factor structure, internal consistency, construct validity, and other psychometric properties.
Principal Findings
The resulting 11-item scale measuring trust in physicians generally is consistent with most aspects of the conceptual model except that it does not include the dimension of confidentiality. This scale has a single-factor structure, good internal consistency (alpha=.89), and good response variability (range=11–54; mean=33.5; SD=6.9). This scale is related to satisfaction with care, trust in one's physician, following doctors' recommendations, having no prior disputes with physicians, not having sought second opinions, and not having changed doctors. No association was found with race/ethnicity. While general trust and interpersonal trust are qualitatively similar, they are only moderately correlated with each other and general trust is substantially lower.
Emerging research on patients' trust has focused on interpersonal trust in a specific, known physician. Trust in physicians in general is also important and differs significantly from interpersonal physician trust. General physician trust potentially has a strong influence on important behaviors and attitudes, and on the formation of interpersonal physician trust.
PMCID: PMC1464022  PMID: 12479504
Trust; medical profession; scale development
24.  Impact of Patient–Doctor Race Concordance on Rates of Weight-Related Counseling in Visits by Black and White Obese Individuals 
Obesity (Silver Spring, Md.)  2011;20(3):562-570.
The objective of this study was to assess the impact of patient-provider race concordance on weight-related counseling among visits by obese patients. We hypothesized that race concordance would be positively associated with weight-related counseling. We used clinical encounter data obtained from the 2005–2007 National Ambulatory Medical Care Surveys (NAMCS). The sample size included 2,231 visits of black and white obese individuals (ages 20 and older) to their black and white physicians from the specialties of general/family practice and general internal medicine. Three outcome measures of weight-related counseling were explored: weight reduction, diet/nutrition, and exercise. Logistic regression was used to model the outcome variables of interest. Wald tests were used to statistically compare whether physicians of each race provided counseling at different rates for obese patients of different races. We did not observe a positive association between patient–physician race concordance and weight-related counseling. We found that visits by black obese patients to white doctors had a lower odds of exercise counseling as compared to visits by white obese patients to white doctors (odds ratio (OR) = 0.54; 95% confidence interval (CI): 0.31, 0.95), and visits by black obese patients to black physicians had lower odds of receiving weight-reduction counseling than visits among white obese patients seeing black physicians (OR = 0.34; 95% CI: 0.13, 0.90). Black obese patients receive less exercise counseling than white obese patients in visits to white physicians and may be less likely than white obese patients to receive weight-reduction counseling in visits to black physicians.
PMCID: PMC3786341  PMID: 21233803
25.  How Well Do Doctors Know their Patients? Factors Affecting Physician Understanding of Patients’ Health Beliefs 
An important feature of patient-centered care is physician understanding of their patients’ health beliefs and values.
Determine physicians’ awareness of patients’ health beliefs as well as communication, relationship, and demographic factors associated with better physician understanding of patients’ illness perspectives.
Cross-sectional, observational study.
A convenience sample of 207 patients and 29 primary care physicians from 10 outpatient clinics.
After their consultation, patients and physicians independently completed the CONNECT instrument, a measure that assesses beliefs about the degree to which the patient’s condition has a biological cause, is the patient’s fault, is one the patient can control, has meaning for the patient, can be treated with natural remedies, and patient preferences for a partnership with the physician. Physicians completed the measure again on how they thought the patient responded. Active patient participation (frequency of questions, concerns, acts of assertiveness) was coded from audio-recordings of the consultations. Physicians’ answers for how they thought the patient responded to the health belief measure were compared to their patients’ actual responses. Degree of physician understanding of patients’ health beliefs was computed as the absolute difference between patients’ health beliefs and physicians’ perception of patients’ health beliefs.
Physicians’ perceptions of their patients’ health beliefs differed significantly (P < 0.001) from patients’ actual beliefs. Physicians also thought patients’ beliefs were more aligned with their own. Physicians had a better understanding of the degree to which patients believed their health conditions had personal meaning (p = 0.001), would benefit from natural remedies (p = 0.049), were conditions the patient could control (p = 0.001), and wanted a partnership with the doctor (p = 0.014) when patients more often asked questions, expressed concerns, and stated their opinions. Physicians were poorer judges of patients’ beliefs when patients were African-American (desire for partnership) (p = 0.013), Hispanic (meaning) (p = 0.075), or of a different race (sense of control) (p = 0.024).
Physicians were not good judges of patient’s health beliefs, but had a substantially better understanding when patients more actively participated in the consultation. Strategies for increasing physicians’ awareness of patients’ health beliefs include preconsultation assessment of patients’ beliefs, implementing culturally appropriate patient activation programs, and greater use of partnership-building to encourage active patient participation.
PMCID: PMC3024116  PMID: 20652759
physician-patient relationship; racial concordance; patient-centered communication; patient participation; disparities

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