Which aspects of general practitioners' behaviour determine patients' evaluations of 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.
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