BMJ Qual Saf 20:885-893 doi:10.1136/bmjqs-2011-000021
  • Original research

The ability of a behaviour-specific patient questionnaire to identify poorly performing doctors

  1. Pål Gulbrandsen1,6
  1. 1HØKH Research Centre, Akershus University Hospital, Lørenskog, Norway
  2. 2Department of Medicine, Tufts University School of Medicine; and Blue Cross Blue Shield of Massachusetts, Boston, Massachusetts, USA
  3. 3National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  4. 4Center for Evaluation, Harvard Medical School, Boston, Massachusetts, USA
  5. 5Department of Behavioural Sciences, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
  6. 6Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway
  1. Correspondence to Dr Bård Fossli Jensen, Akershus University Hospital, HØKH Research Centre, Postboks 95, 1478 Lørenskog, Norway; b.f.jensen{at}
  1. Contributors Bård Fossli Jensen designed the study, collected most data, organised and interpreted them, did most of the analyses, and drafted the manuscript. Pål Gulbrandsen developed 4HPQ, designed the study, collected some data, interpreted the data, and drafted the manuscript. Fredrik A. Dahl designed the statistical analyses, assured correct analytical procedures, and interpreted the data. Dana Gelb Safran developed 4HPQ, interpreted the data, and drafted the manuscript. Andrew Garratt interpreted the data and drafted the manuscript. Edward Krupat developed the 4HCS evaluation, developed 4HPQ, and interpreted the data. Arnstein Finset developed 4HPQ, designed the study, drafted the manuscript, and interpreted the data. All authors revised the manuscript for important intellectual content and approved the final version. Bård Fossli Jensen and Fredrik A. Dahl had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Accepted 6 July 2011
  • Published Online First 17 August 2011


Background Doctors' ability to communicate with patients varies. Patient questionnaires are often used to assess doctors' communication skills.

Objective To investigate whether the Four Habits Patient Questionnaire (4HPQ) can be used to assess the different skill levels of doctors.

Design A cross-sectional study of 497 hospital encounters with 71 doctors. Encounters were videotaped and patients completed three post-visit questionnaires.

Setting A 500-bed general teaching hospital in Norway.

Main outcome The proportion of video-observed between-doctor variance that could be predicted by 4HPQ.

Results There were strong correlations between all patient-reported outcomes (range 0.71–0.80 at the doctor level, p<0.01). 4HPQ correlated significantly with video-observed behaviour at the doctor level (Pearson's r=0.42, p<0.01) and the encounter level (Pearson's r=0.27, p<0.01). The proportion of between-doctor variance not detectable by 4HPQ was 88%. The reason for this discordance was large within-doctor between-encounter variance observed in the videos, and small between-patient variance in patient reports. The maximum positive predictive value for the identification of poorly performing doctors (92%) was achieved with a cut-off score for 4HPQ of 82% (ie, patient assessments were concordant with expert observers for these doctors).

Conclusion Using a patient-reported questionnaire of doctors' communication skills, favourable assessments of doctors by patients were mostly discordant with the views of expert observers. Only very poor performance identified by patients was in agreement with the views of expert observers. The results suggest that patient reports alone may not be sufficient to identify all doctors whose communication skills need improvement training.


  • Linked article 000323.

  • Disclosures: Bayer Pharma and the Norwegian Chiropractor Association have paid Pål Gulbrandsen and Arnstein Finset/Bård Fossli Jensen respectively for giving lectures on the Four Habits model. The Norwegian Association for General Practitioners paid Pål Gulbrandsen and Bård Fossli Jensen for running a communication skills course during their annual meeting.

  • Funding The study was funded by the Regional Health Enterprise for Southeast Norway. The funding body did not influence any part of the scientific process.

  • Competing interests None.

  • Ethics approval The study was approved by the Regional Committee for Medical Research Ethics of Southeast Norway (1.2007.356).

  • Provenance and peer review Not commissioned; externally peer reviewed.