PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (1062691)

Clipboard (0)
None

Related Articles

1.  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
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.
doi:10.1155/2013/478498
PMCID: PMC3652207  PMID: 23691317
3.  Holding relationships in primary care: a qualitative exploration of doctors' and patients' perceptions 
The British Journal of General Practice  2011;61(589):e484-e491.
Background
Ongoing doctor-patient relationships are integral to the patient-centred ideals of UK general practice, particularly for patients with chronic conditions or complex health problems. ‘Holding’, a doctor-patient relationship defined as establishing and maintaining a trusting, constant, reliable relationship that is concerned with ongoing support without expectation of cure, has previously been suggested as a management strategy for such patients.
Aim
To explore urban GPs' and patients' experiences of the management of chronic illness, with a particular focus on holding relationships.
Design and setting
A qualitative study in urban and suburban areas of north west England.
Method
Participating GPs recruited registered patients with chronic illness with whom they felt they had established a holding relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.
Results
GP responders considered holding to be a small but routine part of theirwork. Benefits described included providing support to patients but also containing demands on secondary care. Patient responders, all with complex ongoing needs, described the relationship with their GP as a reassuring, positive, and securing partnership. Both GP and patient responders emphasised the importance of pre-existing knowledge of past life-story, and valued holding as a potential tool for changing health-related behaviour. Difficulties with holding work included fears of dependency, and problems of access.
Conclusion
Holding relationships are a routine part of general practice, valued by both GPs and patients. Naming and valuing holding work may legitimise this activity in the management of people with chronic and complex health problems.
doi:10.3399/bjgp11X588457
PMCID: PMC3145532  PMID: 21801542
chronic illness; doctor-patient relations; continuity of care; qualitative research
4.  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.
Background
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.
Aim
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.
Method
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.
Results
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.
Conclusion
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.
doi:10.3399/bjgp12X636119
PMCID: PMC3310034  PMID: 22520915
decision making; evidence-based practice; patient compliance; physician-patient relations; professional practice
5.  An exploration of the value of the personal doctor-patient relationship in general practice. 
BACKGROUND: Within the context of general practice, continuity of care creates an opportunity for a personal doctor-patient relationship to develop which has been associated with significant benefits for patients and general practitioners (GPs). Continuity of care is, however, threatened by trends in the organisational development of primary health care in the United Kingdom and its intrinsic role within general practice is currently the subject of debate. AIMS: To determine how many patients report having a personal doctor and when this is most valued, to compare the value of a personal doctor-patient relationship with that of convenience, and to relate these findings to a range of patient, GP, and practice variables. DESIGN OF STUDY: Cross sectional postal questionnaire study. SETTING: Nine hundred and ninety-six randomly selected adult patients from a stratified random sample of 18 practices and 284 GP principals in Oxfordshire. METHOD: Qualitative interviews with patients and GPs were conducted and used to derive a parallel patient and GP questionnaire. Each patient (100 from each practice) was invited to complete a questionnaire to evaluate their experience and views concerning personal care. All GP principals currently practising in Oxfordshire were sent a similar questionnaire, which also included demographic variables. RESULTS: Overall, 75% of patients reported having at least one personal GP. The number of patients reporting a personal GP in each practice varied from 53% to 92%. Having a personal doctor-patient relationship was highly valued by patients and GPs, in particular for more serious, psychological and family issues when 77-88% of patients and 80-98% of GPs valued a personal relationship more than a convenient appointment. For minor illness it had much less value. CONCLUSIONS: Patients and GPs particularly value a personal doctor-patient relationship for more serious or for psychological problems. Whether a patient has a personal GP is associated with their perception of its importance and with factors which create an opportunity for a relationship to evolve.
PMCID: PMC1314098  PMID: 11593831
6.  Patient satisfaction with healthcare provided by family doctors: primary dimensions and an attempt at typology 
Background
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.
Methods
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.
Results
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.
Conclusion
To improve the quality of healthcare, family doctors should take special care to ensure the quality of their interactions with patients.
doi:10.1186/1472-6963-9-63
PMCID: PMC2678111  PMID: 19371417
7.  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.
doi:10.1016/j.socscimed.2007.03.036
PMCID: PMC2811428  PMID: 17462801
USA; physician-patient communication; physician perceptions; racial inequalities; patient participation
8.  Doctor Discontent 
OBJECTIVE
To examine the differences in physician satisfaction associated with open- versus closed-model practice settings and to evaluate changes in physician satisfaction between 1986 and 1997. Open-model practices refer to those in which physicians accept patients from multiple health plans and insurers (i.e., do not have an exclusive arrangement with any single health plan). Closed-model practices refer to those wherein physicians have an exclusive relationship with a single health plan (i.e., staff- or group-model HMO).
DESIGN
Two cross-sectional surveys of physicians; one conducted in 1986 (Medical Outcomes Study) and one conducted in 1997 (Study of Primary Care Performance in Massachusetts).
SETTING
Primary care practices in Massachusetts.
PARTICIPANTS
General internists and family practitioners in Massachusetts.
MEASUREMENTS
Seven measures of physician satisfaction, including satisfaction with quality of care, the potential to achieve professional goals, time spent with individual patients, total earnings from practice, degree of personal autonomy, leisure time, and incentives for high quality.
RESULTS
Physicians in open- versus closed-model practices differed significantly in several aspects of their professional satisfaction. In 1997, open-model physicians were less satisfied than closed-model physicians with their total earnings, leisure time, and incentives for high quality. Open-model physicians reported significantly more difficulty with authorization procedures and reported more denials for care. Overall, physicians in 1997 were less satisfied in every aspect of their professional life than 1986 physicians. Differences were significant in three areas: time spent with individual patients, autonomy, and leisure time (P ≤ .05). Among open-model physicians, satisfaction with autonomy and time with individual patients were significantly lower in 1997 than 1986 (P ≤ .01). Among closed-model physicians, satisfaction with total earnings and with potential to achieve professional goals were significantly lower in 1997 than in 1986 (P ≤ .01).
CONCLUSIONS
This study finds that the state of physician satisfaction in Massachusetts is extremely low, with the majority of physicians dissatisfied with the amount of time they have with individual patients, their leisure time, and their incentives for high quality. Satisfaction with most areas of practice declined significantly between 1986 and 1997. Open-model physicians were less satisfied than closed-model physicians in most aspects of practices.
doi:10.1046/j.1525-1497.2001.016007452.x
PMCID: PMC1495236
health maintenance organizations; job satisfaction; physicians' practice patterns; United States; professional autonomy
9.  Instrumental and socioemotional communications in doctor-patient interactions in urban and rural clinics 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1472-6963-13-261
PMCID: PMC3734115  PMID: 23835062
Physicians; Family practice; Rural clinics; Urban clinics; Patient-physician communication; Patient-physician interaction
10.  Sanctions against sexual abuse of patients by doctors: sex differences in attitudes among young family physicians. 
OBJECTIVE: To explore attitudes of new-to-practice certified family physicians in Ontario concerning sanctions against sexual abuse of patients by physicians and to assess the importance of concern about accusations of sexual abuse in influencing clinical decisions. DESIGN: Qualitative study and cross-sectional survey. SETTING: Ontario. PARTICIPANTS: Focus groups: 34 physicians who completed family medicine residency training between 1984 and 1989 participated in seven focus groups between June and October 1992. Survey: all certificants of the College of Family Physicians of Canada who received certification between 1989 and 1991 and were currently practising in Ontario. Of the 564 eligible physicians 395 (184 men and 211 women) responded, for an overall response rate of 70.0%. The response rates among the male and female physicians were 70.5% and 69.6% respectively. OUTCOME MEASURES: Physicians' attitudes toward restricting physical examinations done by physicians to same-sex patients, mandatory reporting of sexual impropriety and loss of licence in cases of sexual violation and the perceived importance of concern about accusations of sexual abuse as an influence on clinical decisions. RESULTS: During the focus groups male physicians in particular expressed concerns about the effect on their practice patterns of the current climate regarding sexual abuse of patients. Female physicians were less concerned about possible accusations of sexual abuse but expressed concerns regarding possible sexualization of the clinical encounter by male patients. In the survey equal proportions of men (163 [93.7%]) and women (191 [92.3%]) disagreed with restricting examinations to same-sex patients. The women were more likely than the men to agree that all suspected cases of sexual impropriety committed by other physicians should be reported (121 [58.7%] v. 86 [50.0%]), whereas the men were more likely to disagree (48 [27.9%] v. 32 [15.5%]) (p = 0.008). The women were also more likely than the men to agree that physicians should lose their licence permanently if they were found guilty of sexual violation (125 [62.2%] v. 73 [43.5%]), whereas the men were more likely to disagree (61 [36.3%] v. 37 [18.4%]) (p < 0.001). Almost half of the men (80 [46.5%]) but only 28 women (14.1%) reported that concerns about accusations of sexual abuse were of importance in their clinical decisions (p < 0.001). CONCLUSIONS: Young female family physicians practising in Ontario are much more likely than their male counterparts to endorse permanent loss of licence for physicians who sexually abuse patients and are significantly less concerned about accusations against themselves. Neither sex endorses only same-sex examinations by physicians. Educational approaches to protect patients while ensuring that appropriate care continues to be delivered are essential.
PMCID: PMC1338055  PMID: 7600468
11.  Impoverished Diabetic Patients Whose Doctors Facilitate Their Participation in Medical Decision Making Are More Satisfied with Their Care 
OBJECTIVE
Greater participation in medical decision making is generally advocated for patients, and often advocated for those with diabetes. Although some studies suggest that diabetic patients prefer to participate less in decision making than do healthy patients, the empirical relationship between such participation and diabetic patients' satisfaction with their care is currently unknown. We sought to characterize the relationship between aspects of diabetic patients' participation in medical decision making and their satisfaction with care.
DESIGN
Cross-sectional observational study.
SETTING
A general medical county hospital–affiliated clinic.
PARTICIPANTS
One hundred ninety-eight patients with type 2 diabetes.
MAIN MEASURES
Interviews conducted prior to the doctor visit assessed patients' desire to participate in medical decision making, baseline satisfaction (using a standardized measure), and sociodemographic and clinical characteristics. Postvisit interviews of those patients assessed their visit satisfaction and perception of their doctor's facilitation of patient involvement in care. A discrepancy score was computed for each subject to reflect the difference between the previsit stated desire regarding participation and the postvisit report of their experience of participation.
RESULTS
Overall, patients reported low postvisit satisfaction relative to national standards (mean of 70 on a 98-point scale). Patients perceived a high level of facilitation of participation (mean 88 on a 100-point scale). Facilitation of participation and the discrepancy score both independently predicted greater visit satisfaction. In particular, a 13-point (1 SD) increase in the perceived facilitation score resulted in a 12-point (0.87 SD) increase in patient satisfaction, and a 1.22 point increase (1 SD) in the discrepancy score (the extent to which the patient was allowed more participation than, at previsit, he or she desired) resulted in a 6-point (0.5 SD) increase in the satisfaction score, even after controlling for initial desire to participate. For women, but not for men, physician facilitation of participation was a positive predictor of satisfaction; for men, but not women, desire to participate was a significant positive predictor of visit satisfaction.
CONCLUSION
Clinicians may feel reassured that encouraging even initially reluctant patients with diabetes to participate in medical decision making may be associated with increased patient satisfaction. Greater patient participation has the potential to improve diabetic self-care because of the likely positive effect of patient satisfaction on adherence to treatment. Further research to assess the prospective effects of enhancing physician facilitation of patient participation is likely to yield important information for the effective treatment of chronically ill patients.
doi:10.1046/j.1525-1497.2002.20120.x
PMCID: PMC1495130
patient participation; patient satisfaction; doctor-patient communication; diabetes
12.  Is networking different with doctors working part-time? Differences in social networks of part-time and full-time doctors 
Background
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.
Methods
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.
Conclusion
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.
doi:10.1186/1472-6963-8-204
PMCID: PMC2583974  PMID: 18834545
13.  How Well Do Doctors Know their Patients? Factors Affecting Physician Understanding of Patients’ Health Beliefs 
BACKGROUND
An important feature of patient-centered care is physician understanding of their patients’ health beliefs and values.
OBJECTIVE
Determine physicians’ awareness of patients’ health beliefs as well as communication, relationship, and demographic factors associated with better physician understanding of patients’ illness perspectives.
DESIGN
Cross-sectional, observational study.
RESEARCH PARTICIPANTS
A convenience sample of 207 patients and 29 primary care physicians from 10 outpatient clinics.
APPROACH AND MEASURES
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.
KEY RESULTS
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).
CONCLUSIONS
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.
doi:10.1007/s11606-010-1453-3
PMCID: PMC3024116  PMID: 20652759
physician-patient relationship; racial concordance; patient-centered communication; patient participation; disparities
14.  Herbal medicine: women's views, knowledge and interaction with doctors: a qualitative study 
Background
There is growing concern that serious interactions are occurring between prescribed/over the counter and herbal medicines and that there is a lack of disclosure of herbal use by patients to doctors. This study explores women's perspectives about the safety of herbal remedies, herb-drug interactions and communication with doctors about herbal medicines.
Methods
Qualitative, cross-sectional study, with purposive sampling which took place in Cheshire, UK. Eighteen in depth semi-structured interviews were conducted with female herbal medicine users aged 18 years and above.
Results
The large majority did not inform their GPs of their use of herbal medicines. This was due to lack of physician enquiry, perception of importance and fear of a negative response. Several women were not aware that herbal remedies could interact with prescribed or over the counter medicines. Of the women who had experienced adverse effects none had reported them, believing them of low importance.
Conclusion
The women had little knowledge about herb-drug interactions and rarely disclosed use of herbal medicines to their doctor. Doctors' communication and openness regarding herbal medicines needs to improve and there should be increased access to accurate information on herbal medicines in the public and health care domain.
doi:10.1186/1472-6882-6-40
PMCID: PMC1702550  PMID: 17156416
15.  Career shift phenomenon among doctors in tacloban city, philippines: lessons for retention of health workers in developing countries 
Background
At the height of the global demand for nurses in the 1990s, a phenomenon of grave concern arose. A significant number of medical doctors in the Philippines shifted careers in order to seek work as nurses overseas. The obvious implications of such a trend require inquiry as to the reasons for it; hence, this cross-sectional study. The data in the study compared factors such as personal circumstances, job satisfaction/dissatisfaction, perceived benefits versus costs of the alternative job, and the role of social networks/linkages among doctors classified as career shifters and non-shifters.
Methodology
A combined qualitative and quantitative method was utilized in the study. Data gathered came from sixty medical doctors practicing in three major hospitals in Tacloban City, Philippines, and from a special nursing school also located in the same city. Respondents were chosen through a non-probability sampling, specifically through a chain referral sampling owing to the controversial nature of the research. A set of pre-set criteria was used to qualify doctors as shifters and non-shifters. Cross-tabulation was carried out to highlight the differences between the two groups. Finally, the Wilcoxon-Mann-Whitney test was utilized to assess if these differences were significant.
Results
Among the different factors investigated, results of the study indicated that the level of job satisfaction or dissatisfaction and certain socio-demographic factors such as age, length of medical practice, and having children to support, were significantly different among shifters and non-shifters at p ≤ 0.05. This suggested that such factors had a bearing on the intention to shift to a nursing career among physicians.
Conclusion
Taken in the context of the medical profession, it was the level of job satisfaction/dissatisfaction that was the immediate antecedent in the intention to shift careers among medical doctors. Personal factors, specifically age, support of children, and the length of medical practice gained explanatory power when they were linked to job satisfaction or dissatisfaction. On the other hand, factors such as perceived benefits and costs of the alternative job and the impact of social networks did not differ between shifters and non-shifters. It would then indicate that efforts to address the issue of physician retention need to go beyond economic incentives and deal with other sources of satisfaction or dissatisfaction among practicing physicians. Since this was an exploratory study in a particular locale in central Philippines, similar studies in other parts of the country need to be done to gain better understanding of this phenomenon at a national level.
doi:10.1186/1447-056X-10-13
PMCID: PMC3204289  PMID: 21977902
Career-shift; doctors; nurses; immigration/emigration/migration; retention; health workers; job satisfaction/dissatisfaction
16.  What happens when doctors are patients? Qualitative study of GPs 
Background
Current evidence about the experiences of doctors who are unwell is limited to poor quality data.
Aim
To investigate GPs' experiences of significant illness, and how this affects their own subsequent practice.
Design of study
Qualitative study using interpretative phenomenological analysis to conduct and analyse semi-structured interviews with GPs who have experienced significant illness.
Setting
Two primary care trusts in the West of England.
Method
A total of 17 GPs were recruited to take part in semi-structured interviews which were conducted and analysed using interpretative phenomenological analysis
Results
Four main categories emerged from the data. The category, ‘Who cares when doctors are ill?’ embodies the tension between perceptions of medicine as a ‘caring profession’ and as a ‘system’. ‘Being a doctor–patient’ covers the role ambiguity experienced by doctors who experience significant illness. The category ‘Treating doctor–patients’ reveals the fragility of negotiating shared medical care. ‘Impact on practice’ highlights ways in which personal illness can inform GPs' understanding of being a patient and their own consultation style.
Conclusion
Challenging the culture of immunity to illness among GPs may require interventions at both individual and organisational levels. Training and development of doctors should include opportunities to consider personal health issues as well as how to cope with role ambiguity when being a patient and when treating doctor–patients. Guidelines about being and treating doctor–patients need to be developed, and GPs need easy access to an occupational health service.
doi:10.3399/bjgp09X472872
PMCID: PMC2765832  PMID: 19861026
doctor–patients; general practitioners; qualitative interview
17.  A Preliminary Mixed-Method Investigation of Trust and Hidden Signals in Medical Consultations 
PLoS ONE  2014;9(3):e90941.
Background
Several factors influence patients' trust, and trust influences the doctor-patient relationship. Recent literature has investigated the quality of the personal relationship and its dynamics by considering the role of communication and the elements that influence trust giving in the frame of general practitioner (GP) consultations.
Objective
We analysed certain aspects of the interaction between patients and GPs to understand trust formation and maintenance by focusing on communication channels. The impact of socio-demographic variables in trust relationships was also evaluated.
Method
A cross-sectional design using concurrent mixed qualitative and quantitative research methods was employed. One hundred adults were involved in a semi-structured interview composed of both qualitative and quantitative items for descriptive and exploratory purposes. The study was conducted in six community-based departments adjacent to primary care clinics in Trento, Italy.
Results
The findings revealed that patients trusted their GP to a high extent by relying on simple signals that were based on the quality of the one-to-one communication and on behavioural and relational patterns. Patients inferred the ability of their GP by adopting simple heuristics based mainly on the so-called social “honest signals” rather than on content-dependent features. Furthermore, socio-demographic variables affected trust: less literate and elderly people tended to trust more.
Conclusions
This study is unique in attempting to explore the role of simple signals in trust relationships within medical consultation: people shape trust and give meaning to their relationships through a powerful channel of communication that orbits not around words but around social relations. The findings have implications for both clinicians and researchers. For doctors, these results suggest a way of thinking about encounters with patients. For researchers, the findings underline the importance of analysing some new key factors around trust for future investigations in medical practice and education.
doi:10.1371/journal.pone.0090941
PMCID: PMC3949702  PMID: 24618683
18.  Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views 
Quality & safety in health care  2005;14(4):290-294.
Background: The current orthodoxy within patient safety research and policy is characterised by a faith in rules based systems which limit the capacity for individual discretion, and hence fallibility. However, guidelines have been seen as stifling innovation and eroding trust. Our objectives were to explore the attitudes towards guidelines of doctors and nurses working together in surgical teams and to examine the extent to which trusting relationships are maintained in a context governed by explicit rules.
Methods: Fourteen consultant grade surgeons of mixed specialty, 12 consultant anaesthetists, and 15 nurses were selected to reflect a range of roles. Participant observation was combined with semi-structured interviews.
Results: Doctors' views about the contribution of guidelines to safety and to clinical practice differed from those of nurses. Doctors rejected written rules, instead adhering to the unwritten rules of what constitutes acceptable behaviour for members of the medical profession. In contrast, nurses viewed guideline adherence as synonymous with professionalism and criticised doctors for failing to comply with guidelines.
Conclusions: While the creation of a "safety culture" requires a shared set of beliefs, attitudes and norms in relation to what is seen as safe clinical practice, differences of opinion on these issues exist which cannot be easily reconciled since they reflect deeply ingrained beliefs about what constitutes professional conduct. While advocates of standardisation (such as nurses) view doctors as rule breakers, doctors may not necessarily regard guidelines as legitimate or identify with the rules written for them by members of other social groups. Future safety research and policy should attempt to understand the unwritten rules which govern clinical behaviour and examine the ways in which such rules are produced, maintained, and accepted as legitimate.
doi:10.1136/qshc.2005.013912
PMCID: PMC1744048  PMID: 16076795
19.  The effect of training doctors in communication skills on women’s satisfaction with doctor–woman relationship during labour and delivery: a stepped wedge cluster randomised trial in Damascus 
BMJ Open  2013;3(8):e002674.
Objectives
To determine the effect of training residents in interpersonal and communication skills on women’s satisfaction with doctor–woman relationship in labour and delivery rooms.
Design
A stepped wedge cluster randomised trial.
Setting
4 tertiary care teaching maternity hospitals in Damascus, Syria.
Participants
2000 women who gave birth to a living baby in the four study hospitals and consented to participate in the intervention took part in the study. Women with difficult labour and high-risk pregnancies were excluded. All were interviewed at home after discharge.
Interventions
A specially designed training package in communication skills was delivered to all resident doctors at the four hospitals.
Primary outcome measures
The main outcome measure was women’s satisfaction with interpersonal relationships in labour and delivery rooms measured via a series of questions on a Likert scale modified from the Medical Interview Satisfaction Scale.
Results
At the individual level, the mean for the average satisfaction score was 3.23 (SD 0.72) of a possible score of 5 in the control group and 3.42 (SD 0.73) in the intervention group. Using generalised linear mixed models, we were unable to detect a difference between the mean for the average satisfaction score of women in the intervention arm and that of women in the control arm; the 95% CI associated with the effect of the intervention ranged from –0.08 to 0.15.
Conclusions
Despite slight changes in the observed residents’ communication skills, the training package in communication skills does not seem to be associated with higher satisfaction scores of women. This raises the question of whether training individuals without further structural changes in the delivery of care and without further reinforcement of the training can have an impact on improving the quality of doctor–patient communication.
Trial Registration Number
ISRCTN80243969
doi:10.1136/bmjopen-2013-002674
PMCID: PMC3752047  PMID: 23945729
EPIDEMIOLOGY
20.  The Doctor–Patient Relationship and HIV-infected Patients' Satisfaction with Primary Care Physicians 
OBJECTIVE
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.
DESIGN
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.
SETTING
Two urban medical centers in the northeastern United States.
PARTICIPANTS
Patients seeking primary HIV care for the first time.
MEASUREMENTS AND MAIN RESULTS
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.
CONCLUSIONS
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.
doi:10.1046/j.1525-1497.2000.03359.x
PMCID: PMC1495486  PMID: 10940132
HIV; satisfaction; doctor–patient relationship
21.  "Seeing a doctor is just like having a date": a qualitative study on doctor shopping among overactive bladder patients in Hong Kong 
BMC Family Practice  2014;15:27.
Background
Although having a regular primary care provider is noted to be beneficial to health, doctor shopping has been documented as a common treatment seeking behavior among chronically ill patients in different countries. However, little research has been conducted into the reasons behind doctor shopping behavior among patients with overactive bladder, and even less into how this behavior relates to these patients’ illness and social experiences, perceptions, and cultural practices. Therefore, this study examines overactive bladder patients to investigate the reasons behind doctor shopping behavior.
Methods
My study takes a qualitative approach, conducting 30 semi-structured individual interviews, with 30 overactive bladder patients in Hong Kong.
Results
My study found six primary themes that influenced doctor shopping behavior: lack of perceived need, convenience, work-provided medical insurance, unpleasant experiences with doctors, searching for a match doctor, and switching between biomedicine and traditional Chinese medicine. Besides the perceptual factors, participants’ social environment, illness experiences, personal cultural preference, and cultural beliefs also intertwined to generate their doctor shopping behavior. Due to the low perceived need for a regular personal primary care physician, environmental factors such as time, locational convenience, and work-provided medical insurance became decisive in doctor shopping behavior. Patients’ unpleasant illness experiences, stemming from a lack of understanding among many primary care doctors about overactive bladder, contributed to participants’ sense of mismatch with these doctors, which induced them to shop for another doctor.
Conclusions
Overactive bladder is a chronic bladder condition with very limited treatment outcome. Although patients with overactive bladder often require specialty urology treatment, it is usually beneficial for the patients to receive continuous, coordinated, comprehensive, and patient-centered support from their primary care providers. Primary care doctors’ understanding on patients with overactive bladder with empathetic attitudes is important to reduce the motivations of doctor shopping behavior among these patients.
doi:10.1186/1471-2296-15-27
PMCID: PMC3936809  PMID: 24502367
Hong Kong; Doctor shopping; Perceptions; Social environment; Illness and treatment experiences; Personal cultural preference; Cultural beliefs; Overactive bladder patients
22.  Touch in primary care consultations: qualitative investigation of doctors’ and patients’ perceptions 
The British Journal of General Practice  2013;63(609):e283-e290.
Background
Good communication skills are integral to successful doctor–patient relationships. Communication may be verbal or non-verbal, and touch is a significant component, which has received little attention in the primary care literature. Touch may be procedural (part of a clinical task) or expressive (contact unrelated to a procedure/examination).
Aim
To explore GPs’ and patients’ experiences of using touch in consultations.
Design and setting
Qualitative study in urban and semi-rural areas of north-west England.
Method
Participating GPs recruited registered patients with whom they felt they had an ongoing relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.
Results
All participants described the importance of verbal and non-verbal communication in developing relationships. Expressive touch was suggested to improve communication quality by most GPs and all patients. GPs reported a lower threshold for using touch with older patients or those who were bereaved, and with patients of the same sex as themselves. All patient responders felt touch on the hand or forearm was appropriate. GPs described limits to using touch, with some responders rarely using anything other than procedural touch. In contrast, most patient responders believed expressive touch was acceptable, especially in situations of distress. All GP responders feared misinterpretation in their use of touch, but patients were keen that these concerns should not prevent doctors using expressive touch in consultations.
Conclusion
Expressive touch improves interactions between GPs and patients. Increased educational emphasis on the conscious use of expressive touch would enhance clinical communication and, hence, perhaps patient wellbeing and care.
doi:10.3399/bjgp13X665251
PMCID: PMC3609476  PMID: 23540485
communication skills; consultations; non-verbal communication; primary health care; qualitative research; touch
23.  Is personal continuity of care compatible with free choice of doctor? Patients' views on seeing the same doctor. 
While much has been written about the benefits of personal continuity of care there has been little research about the views of patients. In this cross sectional study 111 patients from three group practices (one of which ran a personal list system) were interviewed at home within a week of consulting a general practitioner. Patients were selected randomly from a systematic series of consulting sessions and a semi-structured interview was administered. Patients receiving more personal continuity of care were likely to be older, to have booked their most recent appointment further in advance, to desire personal continuity of care, to have an external health locus of control and to have a lower extroversion score. In the practice with a personal list, patients had a high level of continuity of care, were satisfied and showed little interest in having a choice of doctor. In the combined list practices patients valued their choice of doctor but often could not exercise it enough and they were more critical. They made more suggestions for change than those in the practice with a personal list system, mostly about receptionists and appointments. It is concluded that most patients like to see the same doctor, but they may not be willing to wait two days for this if there is a quicker option. It may be difficult to deliver both personal continuity of care and choice in group practice.
PMCID: PMC1372612  PMID: 8312019
24.  Doctor-patient concordance and patient initiative during episodes of low back pain. 
Doctor-patient concordance and patient initiative were examined in a prospective network interview study, with telephone follow-up, of a cohort of 100 patients presenting with low back pain to their family physician. The average overall rate of concordance was 60% (95% CI = 53 to 66), with the highest rates for radiographic imaging studies and sick leave. No correlation was found between concordance and patient parameters. Subjects initiated an average of two (95% CI = 1.7 to 2.3) diagnostic or therapeutic procedures, the most common of which were for medications (40%), followed by bed rest (26%) and back school (22%). One out of every six subjects initiated a referral to a complementary therapist. Positive correlation was found between patient initiatives and pain severity (P = 0.022) and disability (P = 0.02). There was a negative correlation between the subjects' initiatives and their belief that the physician understood the cause of their pain and its influence on their life (P = 0.02). Overall, those patients who described more pain or disability sought more types of diagnostic and therapeutic measures, while those who felt they had been understood sought less.
PMCID: PMC1313822  PMID: 11127171
25.  The patient–doctor relationship: a synthesis of the qualitative literature on patients' perspectives 
The British Journal of General Practice  2009;59(561):e116-e133.
Background
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.
Aim
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.
Method
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.
Results
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.
Conclusion
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.
doi:10.3399/bjgp09X420248
PMCID: PMC2662123  PMID: 19341547
communication; continuity of patient care; physician–patient relations; qualitative research

Results 1-25 (1062691)