Elsevier

Social Science & Medicine

Volume 47, Issue 8, October 1998, Pages 1077-1087
Social Science & Medicine

Which aspects of general practitioners' behaviour determine patients' evaluations of care?

https://doi.org/10.1016/S0277-9536(98)00138-5Get rights and content

Abstract

This qualitative study explored those behaviours of a general practitioner which were used by patients in their evaluations of 14 aspects of general practice care. Thirty patients were interviewed immediately after visiting their general practitioner. Interview transcripts were analyzed by two authors, who independently marked general practitioners' behaviours used by patients. Then, these text fragments were categorised into task or affective behaviours according to an existing taxonomy of doctor behaviour in consultations. The results showed that patients reported using task oriented behaviours when they evaluated task oriented aspects of general practice care. However, when they evaluated affective aspects they reported using both affective behaviours and task behaviours, although the latter to a lesser extent. The evaluations of “tell you all you wanted to know about your illness”, “explain the purpose and the course of the treatment”, “pay attention to your feelings” and “kind and attentive” are clearly linked to specific general practitioners' behaviour. Therefore, evaluations of these aspects can be interpreted straightforwardly. Evaluation of the aspects “GP understands you”, “having faith in your GP” and “were you involved in decisions about your medical treatment?” were based on a large variety of physician behaviours which may lead to interpretation problems. Thus, this study gives some important considerations for a better understanding of patients' evaluations of general practice care.

Introduction

A patient visits her general practitioner. She says that she started to cough three days earlier, followed the next day by a runny nose, sore throat, headache and fever. She asks for antibiotic treatment. Her general practitioner examines her throat, listens to her lungs and looks into her ears. The general practitioner explains that her lungs do not show any sign of infection, that she has a slightly inflamed throat and that no enlarged lymph nodes were found. To her request for antibiotic treatment her general practitioner replies that the combination of a runny nose, sore throat and absence of enlarged lymph nodes means that she has an upper respiratory tract infection caused by a virus and that an antibiotic will not help.

Finally, when the consultation has ended, the general practitioner asks the patient if she would be willing to cooperate in a study on the quality of the care provided in the practice she is visiting. She says she is happy to do this and receives a lengthy questionnaire. It asks her to judge a number of aspects of care, including medical care, relationship with her general practitioner, communication, information and support. She replies, as do other patients in this practice. The results are analysed by a research institute and the general practitioner receives a report of patients' evaluations of care.

Looking at this report the general practitioner remembers this patient with her cold and thinks: was it possible for this patient to evaluate my skills to distinguish a virus infection from a bacterial infection, or to evaluate my skills in explaining to her why I did not prescribe an antibiotic? How should I interpret the evaluations of care? Why is she satisfied, or not satisfied with the care I provided? Was it the fact that I listened to her lungs? Was it the fact that I explained to her how long her complaint would last? What aspect of my behaviour was important for her when she filled in the questionnaire?

As the views of patients are given more and more importance (Secretaries of State for Social Services, 1987; KNMG, 1990; Netherlands Health Research Council, 1990; WHO, 1990; Donabedian, 1992) patient satisfaction is increasingly given attention as an outcome measure of health care delivery (Maxwell, 1984; Ross et al., 1993; Susman, 1994). Performing a patient survey is a frequently used method for measuring patient satisfaction (Hall and Dornan, 1988: Wensing et al., 1994). However, there are still many problems related to such an approach. For instance, in many instruments patients were not involved in the selection of aspects of care included (Wensing et al., 1994). Furthermore, instruments were often “home-made” and not validated (Hall and Dornan, 1988; Hearnshaw et al., 1996). Little is known about what determines patients' evaluations of care. Are patients able to give differentiated evaluations on aspects of care or are patients' evaluations determined by some sort of generalised emotional response? Fitzpatrick and Hopkins (1983)conducted a qualitative research and “were struck by a lack of fit, in many respects, between patients' own accounts of their experiences and the assumptions about patients contained in satisfaction research”.

Theoretical descriptions of the evaluation process are rare and inconsistent. For example, it has been argued that patients do not distinguish between the interpersonal and technical aspects of care (Like and Zyzanski, 1987). Several authors (Ben-Sira, 1976, Ben-Sira, 1980; Larsen and Rootman, 1976; Segall and Burnett, 1980) suggest that this is because patients are not able to judge the technical competence of a doctor and therefore base their evaluations of the instrumental skills of a doctor on his or her affective behaviour. Other authors (Willson and McNamara, 1982; Hall et al., 1987) believe that patients are able to judge instrumental skills and that affective interpretations of these instrumental skills are made, which in turn influence evaluations of affective behaviour. Both views can be explained as “halo effects” whereby “single striking impressions of another person colour and shape all other judgements made about them” (Fitzpatrick, 1991). However, the supposed halo effect may have two different directions: affective behaviour may carry technical significance or instrumental behaviour may carry affective significance. In contrast, it has been argued that patients have no problems distinguishing interpersonal and technical aspects of care (Rees Lewis, 1994).

When interpreting the results of a patient evaluation survey, a practitioner might assume that a patient who evaluates the practitioner's competence or courtesy does indeed think of competence and courtesy, respectively. As long as it is unclear which aspect of behaviour determine which patients' evaluations of general practice care, such assumptions are risky. This qualitative, explorative study was undertaken to answer the question: Which aspects of general practitioners' behaviour are decisive for patients' evaluations of aspects of general practice care? Do patients indeed differentiate between different aspects of care?

Section snippets

Methods

Patients were recruited from two general practices in the Netherlands in May 1996. One practice, run by three general practitioners, was situated in a rural area. The other practice, run by two general practitioners, was situated in a large city. Purposive sampling was applied in order to achieve variety in age, gender, and education (Pope and Mays, 1995). Thirty-three patients were approached.

For this study 14 specific aspects of general practice care were selected, using the following

Study population

In all, 30 patients out of 33 agreed to be interviewed after their consultation with the general practitioner. Three patients refused to participate due to lack of time. Twenty-one patients were female, nine were male. The mean age was 43 y (minimum 18, maximum 88). Nineteen patients were from the rural practice, 11 from the city practice. The mean interview duration was 20 min (minimum 15, maximum 35 min). Although not the purpose of this study, it was noted that patients' evaluations of care

Discussion

This study explored which aspects of a physician's behaviour are related to patients' evaluations of care. The results give some important suggestions for a better understanding of these evaluations. In general, patients did differentiate between task and affective oriented aspects, thus contradicting Like and Zyzanski (1987)and in accordance with Rees Lewis (1994). Affective-oriented aspects were determined both by affective oriented behaviour and by task-oriented behaviour, although the

Acknowledgements

This study was performed with grants of the European Commission (Biomed 2 Concerted Action (EUROPEP), the Netherlands Organisation for Scientific Research (NWO) and a Dutch Health Care Insurer (VGZ). We want to thank the two helpful referees reviewing the manuscript of this study.

References (38)

  • C.P. Bradley

    Turning anecdotes into data. The critical incident technique

    Family Practice

    (1992)
  • I. Cromarty

    What do patients think about during their consultations? A qualitative study

    British Journal of General Practice

    (1996)
  • A. Donabedian

    The Lichfield Lecture — quality assurance in health care: consumers' role

    Quality in Health Care

    (1992)
  • W.R. Dunn et al.

    The critical incident technique. A brief guide

    Medical Teacher

    (1986)
  • Festinger, L. (1957) A Theory of Cognitive Dissonance. Harper and Row, New...
  • R. Fitzpatrick et al.

    Problems in the conceptual framework of patient satisfaction research: an empirical exploration

    Sociology of Health and Illness

    (1983)
  • R. Fitzpatrick

    Surveys of patient satisfaction. I. Important general considerations

    BMJ

    (1991)
  • J.C. Flanagan

    The critical incident technique

    Psychological Bulletin

    (1954)
  • J.A. Hall et al.

    Meta-analysis of correlates of provider behavior in medical encounters

    Medical Care

    (1988)
  • Cited by (0)

    View full text