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Patient satisfaction with physician communication

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Title:
Patient satisfaction with physician communication a mixed methods approach
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Allen, Stephanie
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English
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xi, 135 leaves : ; 28 cm

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Patient satisfaction ( lcsh )
Physician and patient ( lcsh )
Interpersonal communication ( lcsh )
Interpersonal communication ( fast )
Patient satisfaction ( fast )
Physician and patient ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Includes bibliographical references (leaves 131-135).
Statement of Responsibility:
by Stephanie Allen.

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University of Florida
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All applicable rights reserved by the source institution and holding location.
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Full Text
PATIENT SATISFACTION WITH PHYSICIAN COMMUNICATION:
A MIXED METHODS APPROACH by
Stephanie Allen
B.A. Metropolitan State College of Denver, 2005
A thesis submitted to the
University of Colorado at Denver and Health Sciences Center in partial fulfillment of the requirements for the degree of Masters of Arts Sociology
2007


2007 by Stephanie Allen All rights reserved.


This thesis for Master of Arts
degree by Stephanie Allen has been approved by


Andrea Haar
/Q/sT /JO o 7
Date


Allen, Stephanie J. (M.A Sociology)
Patient Satisfaction with Physician Communication: A Mixed Methods Approach Thesis directed by Associate Professor Candan Duran-Aydintug
ABSTRACT
When people become ill or need to seek medical help for any reason, they turn to medical doctors to help them feel better physically, mentally, and emotionally. People confide in physicians to diagnose an illness or confirm that they are physically healthy, and expect their physicians to listen to any concerns they may have. This study is a mixed methods study on how satisfied patients are with their primary care physicians communication style. The research question explored in this study is, Are patients satisfied with their physicians communication style? The quantitative data in this study comes from the 2003-2004 Community Tracking Study Household Survey by the Center for Studying Health System Change. In addition to quantitative data, data were collected from semi-structured interviews of 15 participants (8 males, 7 females), 18 years and older. The results from this study show that patients are overall satisfied with how their primary care physician communicates with them. Patients are mostly satisfied when their physicians listen to them, explain things in a way they can understand, and take the time to ensure that their medical needs have been met. According to the participants interviewed, communication is one of the, if not the most, important aspect of the physician/patient relationship.
This abstract accurately represents the content of the candidates thesis. I recommend its publication.


DEDICATION
I dedicate this thesis to anyone who has a dream to follow. No matter what it is in life, if it is your passion, follow your heart and do not settle for anything less than what you love to do. Money is a luxury but it does not always create happiness. No matter the hard work and/or sacrifice, if it is something you love, it is worth every bit of sacrifice in the long run because you will be happy and content with who you are and the life you live. You get one shot at life so take it and embrace it!


ACKNOWLEDGEMENT
First, I want to begin by thanking my thesis committee members. To my thesis advisor, professor, mentor, and friend, Candan Duran-Aydintug, thank you for your guidance, laughter, and for challenging me the past 2 years. Thank you for always believing in me, supporting me, and giving me opportunities that have made me a better student and person since starting this program. I would like to thank Andrea Haar for always giving me different perspectives to enhance the quality of my research and for always being there to give me advice. Thank you for always believing in me and giving me such great opportunities that will help me succeed in the future. To Martha, thank you for your support and teachings throughout both my undergraduate and graduate years. I am honored that you were willing and able to serve on my thesis committee in graduate school. You have been a great educator, supervisor, and friend, and I could not have made it where I am today without your help. I would also like to thank all of those who participated in my research. Thank you all for sharing your stories with me.
To my mom and dad, your love and encouragement have helped me stay on track with my career goals and without your support and teachings, I would never have found my passion nor succeeded in life. Thank you! To my brothers, Brandon and Jay, and to their wives, Crystal and Karen, thank you all for being there to get me out of the house every once in a while, and for your continued support with my educational goals. To my graduate school friends, Supryia, Tracesea, Bill, Nick, Liz H., Liz D., David, and Vickie, I am grateful to have met all of you and thank you for the fun times and support the past 2 years.
To all of my former professors, now colleagues and friends from Metro State College, thank you all for providing me with such encouragement and for giving me the tools as an undergraduate to succeed in graduate school. To Tod, Rae, Jack, Jon, Jim, Jay, Art, Gesemia, Melissa, Cathy, and Barb, thank you all for teachings, your encouragement, and for lending your ear and support when I needed it most. To Linda, big 7, you have always believed in me and your continued support and guidance has given me such great confidence as a student and person. Thank you for the laughs and all you have done for me. I could not have made it where I am today without all of you in my life.
Lastly, I want to thank the person who got me started in this field, Aileen. You inspired me after just a few weeks of taking your Introduction to Sociology course


that this was the field for me. You have been a great mentor and friend and I cannot thank you enough for always being there for me. You have helped me not only grow as a student but as a person. I can never repay you for all you have done for me but remember, you get a kidney! You are truly an inspiration.


TABLE OF CONTENTS
Tables................................................. ..x
CHAPTER
1. INTRODUCTION..............................................1
2. REVIEW OF THE LITERATURE........................... 4
Satisfaction with Physician Communication.......... 4
Medical School Socialization and Patient Interaction...8
Physician Communication Styles........................10
Biological Sex and Physician Communication.......... .13
Race and Ethnicity....................................16
Trust............................................ ...17
Structural Functionalism and Social Exchange Theory...19
Hypotheses.......................................... 24
3. METHODOLOGY: QUANTITATIVE DATA...........................26
Dependent Variables................................ .27
Independent Variables.............................. 28
Demographic Variables........................... 30
4. RESULTS.......................................... 33
Linear Regression Modeling for Verbal Communication...33
Vll


Linear Regression Modeling for Non-Verbal Communication.38
Linear Regression Modeling for Satisfaction with Choice of Primary Care Physician,,.............................. ...41
5. METHODOLOGY: QUALITATIVE DATA..........................48
Sampling...................................... 49
6. RESULTS.......................................... 52
Importance of Non-Verbal and Verbal Communication from Physicians...................................... 52
The Importance of Trust in a Physician..................60
Overall Satisfaction with Physician Communication.......67
Characteristics of an Ideal Physician.............70
7. DISCUSSION....................................... 75
8. CONCLUSIONS.......................................... 87
APPENDIX
A. TABLES FOR QUANTITATIVE DATA......................... 95
B. CONSENT FORM...................................... 120
C. HUMAN SUBJECTS RESEARCH PROTOCOL......................122
D. BACKGROUND QUESTIONS............................ .123
E. INTERVIEW QUESTIONS FOR INSURED PARTICIPANTS..........125
F. INTERVIEW QUESTIONS FOR UNINSURED PARTICIPANTS...............127
viii


G, PARTICIPANTS RESPONSES............... ................129
REFERENCES...,...........................................131
IX


LIST OF TABLES
Table
4.1.. .
4.2.. .
4.3.. .
4.4.. .
4.5.. .
4.6.. .
4.7.. .
4.8.. .
4.9.. .
4.10..
4.11..
4.12..
4.13..
4.14..
4.15..
4.16.. 4.17.
..34
..39
..42
..96
..97
..98
..99
100
101
102
103
104
105
106
107
108 109
x


4.18
4.19
4.20
4.21
4.22
4.23
4.24
4.25
4.26
4.27
5.1..
6.1..
110
111
112
113
114
115
116
117
118 119 ..50 127
xi


CHAPTER 1
INTRODUCTION
When people become ill or need to seek medical help for any reason, they turn to either medicine or physicians to help them feel better physically, mentally, and emotionally. People confide in their physicians to get diagnosed with an illness or to confirm that they, are physically healthy, and expect their physicians to listen to any concerns they may have. Physicians can communicate in such ways that make or break patient satisfaction. This study is a concurrent mixed methods study on patient satisfaction with their primary care physicians communication style. The research question explored in this study is, Are patients satisfied with how physicians communication with them? The quantitative data in this study come from the 2003-2004 Community Tracking Study Household Survey by the Center for Studying Health System Change.
Qualitative data are used to supplement the quantitative data in this study. This will be a phemenological study on patients experiences with their primary care physicians communication styles. The data for part of this study are gathered from semi-structured interviews with 15 participants, 8 males and 7 females, who are 18 years and older. An interview schedule was used for all participants, however, each participant was asked additional questions for probing or to gain an
1


understanding for other questions that raised during the interviews. All interviews were conducted in the metropolitan Denver area. Participants selected for this study include both those who reported having health insurance and those who were uninsured. Uninsured participants were asked questions about previous primary care physicians, and expectations they have, in general, as patients that would reach their level of satisfaction with physician communication. Participants who did have health insurance were asked questions about their current primary care physician and questions about their expectations to reach their highest perceived level of satisfaction with a primary care physician.
This study is important to conduct to understand whether patients feel that physicians are providing them adequate information, are listening to their concerns, and providing them with the best care possible. Previous studies are limited in including patients who do not have health insurance and what will make them satisfied as patients. Also, this study is unique in that very few studies have been conducted with a mixed methodology, so not only will this study provide insight on patient satisfaction with physician communication at a macro level but also at a micro level. Patient satisfaction with physicians is extremely important to study because satisfaction can affect health care utilization. The structural functionalist paradigm and social exchange theory are used to determine what effects
2


physician/patient communication and patient satisfaction have on the current balance of the health care system.
The results of this study compile the data from both the data set and interviews with participants to determine how satisfied patients are with how their physicians communicate with them, why they are or are not satisfied, and what patients want from their physician to reach their highest level of satisfaction from care.
3


CHAPTER 2
REVIEW OF THE LITERATURE Satisfaction with Physician Communication One of the most important factors in determining patient satisfaction in health care is physician communication (Weiss and Lonnquist 2006). According to the American Medical Association (1999), every patient reacts to an illness differently, and therefore, satisfaction with physician communication is going to vary with each patient. A study titled, Consumer Complaint Department, published different reasonspeople report being dissatisfied with their physicians, including their physicians communication (American Medical Association 1999). Out of 688 respondents surveyed, 128 reported being dissatisfied with their physicians. When looking specifically at physician communication, only 15 percent of the respondents were dissatisfied with their physicians communication style (American Medical Association 1999). Weiss and Lonnquist (2006) argue that most people are satisfied with their primary care physician based on other survey research that has been conducted.
Not all studies have shown that patients are satisfied with their physicians communication style. According to Lavin, Haug, Belgrave, and Breslau (1987:259), .. .64 percent of public respondents agreed that people are beginning
4


to lose faith in doctors and over 60 percent of doctors declared that patients were more demanding. Levinson, Stiles, Inui, and Engle (1993) reported that demanding and controlling patients contributes to physicians own frustration with the communication process between themselves and their patients. While patients report dissatisfaction with their physician because of the way they communicate, physicians argue that some of the blame rests with the patients.
Patient dissatisfaction with how their physician communicates with them includes a number of factors that have been reported, including physicians talking down to patients, and using medical terminology that patients are unfamiliar with (Weiss and Lonnquist 2006). Another factor that patients report being dissatisfied with is whether their physician lets them express themselves. When physicians do not allow for this type of communication to take place, patients feel angry, upset, or leave the physicians office with the feeling that their physician does not care. According to Weiss and Lonnquist (2006:254), Going after just the facts they provide no opening for patients to talk about their concerns or how they perceive current problems related to other events in their lives. They may interrupt patients or otherwise signal a lack of interest of what is being said. Even when physicians just go after the facts, the information that physicians provide their patients with is not always understood or is good enough (Davis 1963; Faden, Becker, Lewis,
5


Freeman, and Faden 1981; Waitzkin 1985; Waitzkin 1984). Waitzkin (1985:82) argues that when it comes to patients perception of physician communication, A variety of studies, in both the U.S. and Great Britain, show that patients tend to be more dissatisfied about the information that they receive from their physicians than about any other aspect of medical care, except possibly the high costs and waiting time. Effective communication from physicians is essential and patients rely on their physicians for explanations of their medical care to obtain a clear understanding of their health. While medical terminology and explanations may make sense to physicians, it is important that they follow up with patients to ensure they understand their communication by asking patients questions, and letting patients ask questions, and/or allowing them to express their concerns during a visit.
Patients who are dissatisfied and approach their physicians about their dissatisfaction are often found to be young, educated, and find that their physician has made a prior mistake in the care they received from them (Haug and Lavin 1981). Haug and Lavin (1981) found in a study they conducted with both patients and physicians when physicians make multiple mistakes, younger and more educated patients will confront that physicians and place demands on them. They
6


found that physicians are not willing to meet the demands of their patients, and are more likely to persuade their patients to comply with them.
Physicians can communicate in such a way that yields positive satisfaction of health care for patients. The American Medical Association (1999:25) reports nine different things that can help improve patient satisfaction: provide patients a clear explanation of diagnosis, medications and illness; respect their patients opinions; acknowledge their patients concerns; be honest in reporting test results, whether they are normal or abnormal; provide full and open answers; discuss different treatment options; direction in seeking expert advice or second opinion options; a willingness to concur on decisions and treatments; coordination with other service providers.
Other factors, such as addressing patients by their first name and not interrupting patients while they are talking, also makes a physician be positively effective in the health care they provide (American Medical Association 1999). While these are tips that come from the American Medical Association, it is important to examine the background of physician training in medical school and whether these communication techniques are learned or not.
7


Medical School Socialization and Patient Interaction
The first two years of medical school are where students learn the basic sciences and mostly spend their time in classrooms, and studying for exams. Medical students study the basics of health sciences disciplines, such as biology, physiology, and cram to pass exams so they can advance to the next level of their training (Conrad 1988). So much knowledge is required of these students that many have difficulties keeping up with the pace. While these students are required to learn book material there are few courses offered where students are trained on how to communicate with patients, especially in their first two years of medical school. Even in the third and fourth years of medical school where their curriculum is based around application On patients for the most part, students are still not trained on how to communicate with patients. In fact, students are trained to depersonalize themselves while treating patients (Weiss and Lonnquist 2006), and report that they are not trained how to talk with patients who are intelligent or articulate (Lavin, et al. 1987; Mizrahi 1986). Weiss and Lonnquist (2006:185) argued, Crucial aspects of the actual practice of medicine are sometimes given little or no attention.. Understanding the importance of sociocultural influences on patient behavior, the development of interpersonal skills, and reflection on ethical questions are rarely highlighted. Talking with patients is not as easy as some may
8


think. Learning how to communicate medical terminology in a way patients can understand, understanding their cultural background, and how to communicate medical information in a way that patients can fully comprehend and feel at ease during their visit with their physician takes practice and time to learn, and should be considered an essential part of the training process.
While working on cadavers in medical school, students are told to make jokes, which is one example, of how they are socialized to detach themselves from patients (Weiss and Lonnquist 2006). They are socialized to focus on curing diseases and there is less of .an emphasis on developing interpersonal relationships with their patients. Renee Fox (1989) coined this type of depersonalization as, emotional numbness where medical students who become physicians learn to personally and emotionally detach from their patients resulting in not making eye contact,, not listening to their patients needs and/or concerns. This is not as important to physicians because their main focus is on biomedical issues of patients, not on creating relationships with them. In fact, while discussing a patients medical condition and the proper procedures to treat them, physicians sometimes communicate with one another in front of their patients and make no attempt to include the patients into their discussion. Overall, physicians are
9


socialized in such a w^y that communication with their patients is devalued and de-emphasized.
Physician Communication Styles
Physicians differ in their communication styles in that some physicians prefer to be dominant over their patients and maintain control, while other physicians prefer to work with patients as partners. Various communication styles have emerged from studies conducted on physician communication styles and patient preference.
Buller and Buller (1987) conducted a quantitative study about physician communication styles and how these affect patient satisfaction. They showed that while most patients reported satisfaction with physicians who were of the affiliation style, meaning they were empathetic, sympathetic, listened to their patients, and established a positive relationship between their patients and themselves, how patients really viewed the importance of physician communication was based upon the type of illness they had. They found that patients who were diagnosed with acute illnesses while visiting their physicians were more critical of their physicians communication style than those diagnosed with chronic illnesses. They argued that patients with chronic illnesses, such as cancer, were accustomed to medical procedures and terminology and therefore, were less critical of the
10


communication style of their physicians. This was also because patients with chronic illnesses were more focused on getting well and therefore, the communication style of their physician was not as important as finding a cure. The results of this study showed that those physicians who practiced the affiliation style were more likely to be female versus the control style physicians who were more likely to be male. Overall, patients reported being more satisfied with the affiliation style than a control style, where physicians take control over the health care relations, regardless of the patients illnesses.
Street, Krupat, Bell, Kravitz, and Haidet (2003) conducted a stratified case-controlled study where they observed the relationship between physicians and patients by identifying two behavioral styles. The first style they identified was called active patient participant where both patients and physicians were equally engaging in the relationship and making the patients health care decisions together. The second style they observed was a control style where physicians had the control over their patients health care decisions with no input from patients. The results of their study showed that patients who were of the active patient participant style had more engagement in the relationship by being able to ask their questions, and express their concerns than those patients who had a physician be in control of the relationship. Their results also showed that those patients who
11


were more actively involved during medical visits actually influenced their physicians to engage in a mutual relationship, and therefore, this relationship was considered a physician partnership building. Lavin et al. (1987) argue that physician partnership, rather than the form of social control of physicians over patients, is preferred among patients.
Overall, the trend appears to be that patients are more satisfied with physicians when physicians listen, are empathetic, sympathetic, let patients ask questions, and let patients have an input with their health care. Hall, Roter, and Rand (1981) conducted a qualitative study on communication between patients and physicians and found that patients reported that being content with their physician is related to their physicians communication style Haug and Lavin (1981) reported that results from their study with patients and physicians showed that patients who are young believe that they have the right to be a partner in medical decisions when it concerns their health, and that physicians should not possess all of the control. Those who are older support a more directive communication style because traditionally, this is how they have been socialized (Swenson, Buell, Zettler, White, Ruston, and Bernard 2002). Here, we have a clear distinction between generations in terms of socialization. Older generations prefer the traditional, social control of physicians over patients, while the younger generations
12


prefer a partnership with their physician. There is also a distinction between educational attainment levels of patients. Patients who have lower educational attainment levels are often unfamiliar with health care literature and preventative care, and prefer the dominance of physicians to make decisions regarding their health care, rather than those who obtain a higher educational attainment level (Swenson et al. 2002). Patients who know about other options are more likely to present them to their physicians, giving them more of an opportunity to engage in a partner relationship with their physician, rather than someone who may not obtain as much knowledge.
Biological Sex and Physician Communication Patients report different views on male physicians compared to female physicians. Female physicians are more likely to be family physicians, and they are viewed as being more empathetic, sympathetic, humane, and willing to listen to their patients more than their male counterpart (Martin, Arnold and Parker 1988). These characteristics are related to higher health care satisfaction. Researchers have also found that female physicians are more likely than male physicians to let their patients ask questions, and to give their patients the opportunity to ask questions and express concerns (Bylund and Makoul 2002). Female physicians are reported to obtain more interpersonal skills, while male physicians obtain more of a
13


social control approach. Weitzman, Chang, and Reynoso (2004) reported similar results of a study they did titled, Middle-aged and Older Latino American Women in the Patient-Doctor Interaction. The results of their study indicated that those female patients under the age of 65 were more likely to be satisfied with communication and the health care they received if they were either in control or mutually involved with their physician during their visit. These females were also more likely to be highly educated.
Weitzman et al. (2004) argue that the difference in physician preference among age cohorts could be due to traditional gender roles, or more specifically, the patriarchy that has traditionally dominated the medical field. Their results indicated that the older generations of females preferred to seek medical advice from male physicians than female physicians, regardless of the quality of interaction/communication that takes place due to the historical patriarchy of the medical field.
With this understanding, it could be argued that the younger and more educated population may have more satisfaction with physicians who are more friendly and willing to engage in a physician/partner relationship, which female physicians are more likely to be rather than male physicians. Those who are older and less educated are more satisfied with physicians who maintain the control,
14


which is how males have traditionally communicated with patients. Also, males dominated the medical field for decades and because of these factors, older patients prefer male physicians because this is how they have been socialized. They have been socialized that patients are subordinates and that physicians have the control, and therefore, that is the communication style they are most satisfied with.
Wolosin and Gesell (2006) found in their secondary data analysis that neither the biological sex of physicians or patients has a direct effect on patient satisfaction. Overall, it comes down to the individual characteristics of patients and physicians.
Weiss and Lonnquist (2006) report that one-third to one-half of patients have a preference of their physicians biological sex. However, they argue that this preference is more likely to occur when it comes to patients needing a physical exam. Patients are more likely prefer seeing physicians of their same biological sex to perform a physical exam rather than physicians of the opposite sex because they feel more comfortable. For example, females are more likely to prefer female doctors for gynecological issues, and males prefer male physicians for their annual exams. However, Weiss and Lonnquist (2006) note that for basic medical care, patients are less likely to have a preference of a physicians biological sex.
In addition to gender studies of physicians, studies have also been conducted about the biological sex of the patient and how that affects the
15


relationship between physicians and their patients. Physicians have reported that they have more difficulties with female patients because they are much more demanding, emotional, and expect more time with their physician (Bernstein and Kane 1991; Weiss and Lonnquist 2006). As mentioned before, physicians are not satisfied when patients are demanding and controlling, and this can have just as much of an effect on how physicians communicate with their patients, and can ultimately effect the satisfaction of both the patient and physician.
Race and Ethnicity
The race/ethnicity of the physician has an effect on how satisfied patients are with their physician (LaVeist and Nuru-Jeter 2002). Some patients have reported that they prefer a physician of their own race/ethnicity because of the quality of care they receive. They report that when they seek medical assistance from a physician of their own race/ethnicity that their physician is more catering to their cultural beliefs, and they receive a better quality of care than they would have from a physician of another race/ethnicity (LaVeist and Nuru-Jeter 2002). This is an indication that patients are more likely to prefer seeing a physician with their same ethnic background because in that case, more effective communication may take place. A physician with the same ethnic background may have more of a cultural understanding or empathy with these patients, and understand how to
16


communicate with these patients, which would result in greater satisfaction of health care for their patients (Spalter-Roth, Lowenthal and Rubio 2005).
Trust
Establishing rapport with a physician is critical for satisfaction of health care, and is a key component to satisfaction with physician communication. Trust involves many different components of communication from physicians, including providing patients with thorough medical information, and information they can understand. Weiss and Lonnquist (2006:252-253) argue that, Patients do not feel comfortable with the physician, do not feel free to talk openly about their worries and concerns, have questions that go unasked or unanswered, and do not understand information that is being provided. Trust involves physicians listening to patients, asking them questions and encouraging their patients to ask questions, and most importantly, taking care of their medical needs (Henderson 1981). Mechanic (2001:201) argues that Trust is related to high quality of communication and interaction. He also argues that when patients trust their physicians it results in the likelihood that patients will continue to see the same physicians.
Minorities in the U.S. have reported receiving inadequate health care from physicians, and they feel that this happens because of their own race/ethnicity (Ban-2004). For example, in the Commonwealth Funds 2001 Health Care Quality
17


Survey, African Americans reported feeling that had they been another race/ethnicity, such as non-Hispanic White, that they would receive better quality of care (Collins, Hughes, Doty, Ives, Edwards and Tenny 2002). Cooper, Roter, Johnson, Ford, Steinwach and Powe (2003) argued that because of history, African Americans lack trust in medical physicians, and are not always convinced that they are receiving the best quality of care and communication. However, a recent study by Stepanikova, Mollbom, Cook, Thom, and Kramer (2006) showed that when it came to trusting their physician, there were no differences in race/ethnicity to indicate that one race trusts their physician more over another race/ethnic group. However, they did note that their sample came from only those who saw their physician within the last 12 months of data collection, and it did not include those without health insurance. Race/ethnicity as it relates to satisfaction with physician communication is under-researched and needs to be further studied to gain a better understand of this relationship.
Another important factor that should be mentioned is that when patients trust their physicians, it does have an effect on how serious they take their physicians medical advice. Studies have shown that patients who report that they trust their physician are more likely to follow their medical advice (Mechanic 2001). This is important because following medical advice and instructions can be
18


detrimental to ones health. Should a.patient chose not to follow the advice of their physician because they do not trust them, complications of health could occur As mentioned before though, when patients know that their physician has made a medical mistake, they are likely to be more demanding and controlling over their health care, and do not want their physician to have control. Patients who know their physicians have made a mistake are not only less likely to take their medical advice seriously, but are also less likely to continue a relationship with these physicians.
Structural Functionalism and Social Exchange Theory Structural functionalism looks at the operations, interdependency, and stability of social systems. This paradigm attempts to explain social behavior as an effort to establish and maintain structural consensus through institutional equilibrium (Matcha 2000:14). For this research, the medical field is the social system and one of its subsystems, the patient/physician interaction, is what is being researched. Part of the patient/physician interaction includes the process of communication between the two. How physicians communicate with their patients has a tremendous impact on patient satisfaction of not only with them, but with the medical field. Patient satisfaction is a component of this subsystem that continually upholds the functioning of medical clinics, and ultimately the functioning of the
19


medical field.. Patients who are dissatisfied with their physicians are likely to seek out other physicians until they find one they are satisfied with. Physicians are taught mostly in medical school about the anatomy and physiology of the human body and less on interpersonal skills with patients. Therefore, it is important to understand how physicians with this background communicate with patients and affects patient satisfaction.
According to the functionalist perspective, individuals have functions, or roles, they perform that contributes to the stability of the whole social system (Matcha 2000). Physicians have functions, which includes communication with their patients. As previously mentioned, some of the types of communication that makes patients satisfied with their physicians communication includes asking questions, letting patients express their thoughts and emotions, and making eye contact. Research has shown that patients are different in that some patients prefer a partnership between themselves and their physicians while others prefer their physicians to maintain the control. Regardless of patient preference, it is important for those patients to find physicians who meet their satisfaction criteria and successfully integrate them into the relationship with their physicians. Patients who are not satisfied are likely to seek out other alternative physicians, or even alternative health care services if their needs are not being met, which can pose as a
20


threat to the stability of medical institutions, such as family clinics. Matcha (2004:14) adds, Functionalist theory offers a view of society in which equilibrium is expected to exist between its components and parts. Patient satisfaction is a crucial element because without it, patients are likely to seek other alternatives, which threatens to cause the equilibrium out of balance with patients. Without patients, physicians cannot practice medicine, which ultimately effects the entire medical system.
William Cockerham (2006:98) argues that, Functionalist theory focuses on the influence of the larger society on individuals. Patients who Eire young, and have higher educational attainment levels are more likely to prefer a partner relationship with their physicians, while people who are older, and/or less educated have a preference for physicians who make the health care decisions for them. Are physicians accommodating the differences with these patients? How are physicians compensating for patients to integrate them within their social system? When values are different between patients and physicians, this is a threat to the functioning of their social system by losing patients to other physicians or other alternative health care options. Macionis (2002) argues that some physicians just expect patients to follow their orders, but this seems to be an expectation that is becoming outdated. Patients are educating themselves more about health care, and
21


some are engaging in preventative health care, and the trend seems to be going in the direction that patients are not just going to follow their doctors orders. In the section about trust, it had been shown that patients are less likely to follow their physicians orders, especially when there is a lack of trust in that relationship. Therefore, the communication between patients and physicians is crucial to satisfaction, and ultimately crucial to maintain an equilibrium or stability of a social system. If physicians are not effectively communicating with patients in a way they can understand and feel comfortable, that will ultimately cause problems between patients and physicians.
Looking at the relationship at a micro-level, understanding the physician/patient communication process from social exchange theory is important because this theory look at how each member of a group interacts with each other. George C. Homans (1974) looked at social exchange as a relationship between group members and what rewards and punishments come out of those relationships. He argues that people who receive more rewards than punishments in a group are more than likely going to form group solidarity and continue those relationships. Patients who begin seeing their physicians are going to look at the interaction with their physicians and ask themselves whether or not they want to continue seeing the same physicians. They will weigh rewards, such as effective communication,
22


and/or punishments, ineffective communication, and decide whether or not to continue seeing the same physicians. The more satisfied they are with how their physicians communicate with them, they more likely they will continue that relationship with their physician. However, as Peter Blau (1964) argues, the more punishments or costs there are in a relationship, in this case with the physician, the more likely that relationship will be terminated by their patients. Physicians also need benefits or rewards as well because when patients decorum is accepted by a physician, the more likely a physician will want to continue to help their patients. If patients decorum is inappropriate to the physician, the communication process may be shortened. If patients are satisfied, more than likely the physician will be satisfied. However, if there is an imbalance with one member 6r the other, that relationship will become undesirable and possibly terminated.
How does functionalism and social exchange theory tie into one another? When patients are satisfied with how their physicians communicate with them, the more likely they will continue seeing the same physicians, will listen and follow the advice provided by their physicians, and the more likely they will utilize health care services. This in turn will help to uphold the equilibrium with patients, physicians, and the medical field. Ultimately, if patients are dissatisfied with communication from physicians, these relationships can terminate which may pose
23


a threat to the medical field because patients may choose alternative health care options. If patients feel an imbalance with the relationship for too long, they will find another physician to get that balance back.
This research will focus on how satisfied patients are with how their physicians communicate with them from both a macro and micro perspective. Two components of the following sections will show the results from macro and micro level research respectively. The first section shows readers the results complied from the 2003-2004 Community Tracking Household Study using several linear regression analyses followed by the results from 15 interviews I conducted. Based on the analysis and patterns of those results, structural functionalism and social exchange theory will be applied to determine whether the patient/physician subsystem is in balance, or at risk of collapsing.
Hypotheses
Hi: Patients who trust their physicians to meet their medical needs will rate their physicians explanation and listening positively, and will be satisfied with their choice of primary care physician.
H2: Patients who are older will be more likely to rate their physicians explanations and listening positively, and will be satisfied with their choice of primary care physician than younger patients.
H3: Females are more likely to rate their physicians explanations and listening negatively and are more dissatisfied with their choice of primary care physician.
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PL: Patients who report a higher family income will rate their physicians explanations and listening positively, and will be satisfied with their choice of primary care physician than those who report a lower annual family income.
H5; Patients who see the same provider are more satisfied with their physicians explanations, listening, and choice of primary care physician than those who do not see the same physician.
Patients who think their physician performs unnecessary tests will rate their physicians explanations and listening as bad, and be dissatisfied with their choice of primary care physician.
H7: Patients who rate the thoroughness and carefulness of their exam positively, will rate their physicians explanations and listening positively, and will be satisfied with their choice of primary care physician.
Hg: Patients who are satisfied with their primary care physician will rate their physicians explanations and listening positively.
H9: White, non-Hispanic patients will be more satisfied with their physicians explanations, listening, and choice of primary care physician than those who identify themselves as being African American, non-Hispanic, and Hispanic.
Hio'- Patients who have a college degree or beyond will rate their physicians explanations and listening positively and will be satisfied with choice of primary care physician.
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CHAPTER 3
METHODOLOGY: QUANTITATIVE DATA
Data for this section come from the 2003-04 Center for Studying Health System Change's Community Tracking Study Household Survey (CTS). This was a longitudinal study that began in 1996, funded by the Robert Wood Johnson Foundation. Researchers have collected data for four different rounds in two-year intervals (1996-1997; 1998-1999; 2000-2001; 2003-2004) from 60 CTS sites, 51 metropolitan and 9 non-metropolitan areas, in the 48 contiguous states in the United States. This is a nationally representative sample, and participants in households were originally randomly selected using random digit dialing techniques. In the 20Q3-2004 study, participants from the 2000-2001 (third round) study were included, as well as the phone numbers that were not utilized in third round of data collection. The researchers also accounted for the households that did not have telephones or had substantial interruptions with a probability sample. To collect their data, the researchers utilized a computer-assisted telephone interview.
The total sample size was 46,587 respondents in this dataset; however, 39,206 were included in this study. This fourth round of study did not include 5,700-6,100 respondents who were included in the third round of data collection.
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Topics included in this study include, but are not limited to health care satisfaction, health insurance coverage, health care utilization, as well as demographic questions, such as age, biological sex, education, annual family income, and race/ethnicity.
Dependent Variables
The first dependent variable in this study, communication, is conceptualized with two different questions. These questions are in reference to participants who had a physician that they visited for medical reasons in last 12 months. The first question represents non-verbal communication. Based on their visit with their physician, the respondents were asked, How would you rate how well your doctor listened to you? Would you say it was: 1. Poor; 2. Fair; 3.. Good; 4. Very Good; 5. Excellent, 7. N/A, not examined or treated;-8. Dont Know; -7. Refused; -1. Inapplicable. The data for the responses of N/A, not examined or treated, Dont Know, Refused, and Inapplicable, were considered missing data. The answer choices poor and fair were recoded as negative, and good, very good, and excellent as positive for crosstabulations.
The second communication indicator represents verbal communication.
The question asks, How would you rate how well the doctor explained things in a way you could understand? Would you say it was: 1. Poor; 2. Fair; 3. Good; 4.
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Very Good; 5. Excellent; 7. N/A, not examined or treated; *8. Dont Know; -7. Refused; -1. Inapplicable; The answer choices poor and fair were recoded as negative, and good, very good, and excellent as positive for crosstabulations.
The second dependent variable was satisfaction with the choice of primary care physician. There was no question explicitly given for this variable; however, the respondents were asked to select one of the following answer choices about their choice of primary care physician: 1. Very Satisfied; 2. Somewhat Satisfied; 3. Neither Satisfied/Dissatisfied; 4. Somewhat Dissatisfied; 5, Very Dissatisfied; -9. Not Ascertained; -1. Inapplicable. The response categories 1 and 2, and 4 and 5, were later recoded into two nominal measurements: 1. Satisfied; 2. Dissatisfied for crossfabulations. The responses -9 and -1 were coded as missing data.
Independent Variables
The first independent indicator, satisfaction with physicians, was operationalized using three indicators. The first satisfaction indicator is in reference to whether the respondents see the same physician/nurse/provider. The question asks, Do(es) [you/fill NAME] usually see the same (doctor/nurse/provider) each time (you/he/she) go(es) there? This question was operationalized by respondents answering: 0. No; l.Yes; -8. Dont Know;
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-7. Refuse; -1. Inapplicable. The responses -8, -7, and -1 were coded as missing data.
The second satisfaction indicator is a statement about satisfaction with choice of physician, which is also used as a dependent variable. Respondents were asked to select one of the following response categories: 1. Very Satisfied;
2. Somewhat Satisfied; 3..Neither Satisfied/Dissatisfied; 4. Somewhat Dissatisfied; 5. Very Dissatisfied; -9. Not Ascertained; -1. Inapplicable. The responses -9 and -1 were coded as missing data.
The last satisfaction indicator is a statement that the respondents were to select one response about a visit they had with their physician in the last 12 months for either a check-up or illness. The statement reads, Still thinking about this visit in [fill MONTH], how would you rate the thoroughness and carefulness of the examination and treatment you received? Would you say it was: 1. Poor; 2. Fair;
3. Good; 4. Very Good; 5. Excellent. The responses N/A, not examined or treated, Dont Know, Refused, and Inapplicable Were coded as missing data.
The second independent variable used in this study is trust, which was conceptualized using two different indicators The first indicator is a statement about trust that the respondents were supposed to answer whether they agree or
29


disagree with the statement. The statement is, I trust my doctor to put my medical needs above all other considerations when treating my medical problems. Respondents were to select their answer on a Likert scale of: 1. Strongly Agree; 2. Somewhat Agree; 3. Neither Agree/Disagree; 4. Somewhat Disagree; 5.
Strongly Disagree; 7. N/A;-9. Not Ascertained; -8. Dont Know; -7. Refused; -1. Inapplicable Responses 7,-8,-7, and -1 were coded as missing data.
The second trust indicator is a statement respondents were to answer regarding a visit with a physician in the past 12 months. The statement is, I sometimes think that my doctor might perform unnecessary tests or procedures. Respondents were to answer from the following responses: 1. Strongly Agree, 2. Somewhat Agree; 3. Neither Agree/Disagree; 4. Somewhat Disagree; 5. Strongly Disagree. The responses, 7. N/A; -9. Not Ascertained; -8. Dont Know; -7. Refused; -1. Inapplicable, were coded as missing data.
Demographic Variables
The first demographic variable was age, and the question asks, Beginning with [fill HOUSEHOLDERS NAME], what is his/her age? The response categories were: 0-17; 18-24; 25-34; 35-54; 55-64; 65-90; 91: top code. Age was recoded into equal intervals, beginning with the age of 18 years old. The responses
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categories are: 1. 18-28 years old; 2. 29-39 years old; 3. 40-50 years old; 4. 51-61 years old; 5. 62-72 years old; 6. 73 years and older.
The second demographic variable was Education, and the question asked, What is the highest grade or year of school [fill NAME] completed? The response categories, 6, 7-11, 12,13-15, 16, 17-18, 19 (top code) were recoded into an ordinal scale: 1. Less than high school; 2. High School Diploma; 3. Some College, Associates Degree or other Specialty Degree; 4. Bachelors Degree; 5. Post-Secondary Degree.
Sex was operationalized by asking the question, Is [fill HOUSEHOLDER] male or female? 1. Male; 2. Female. These responses were later recoded into dichotomous variables for linear regression modeling as: 0. Male; 1. Female.
Race/ethnicity was operationalized by the respondents selecting the categories of, White, non-Hispanic; African American,; non-Hispanic, Hispanic; All other non-Hispanic. Each operational measurement was recoded into dichotomous variables for linear regression: 0. White-non-Hispanic; 1. Not White, non-Hispanic; 0. African American, non-Hispanic; 1. Not African American, non-Hispanic; 0. Hispanic; 1. Not Hispanic; 0. All other non-Hispanic; 1. Not all other, non-Hispanic. The variables, White, non-Hispanic,
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African American, non-Hispanic, and Hispanic were used in this study because they were the most representative in this sample.
Family Income was used and operationalized by asking respondents the question, During 2002, what was your familys total income for all sources, before taxes and other deductions? The response categories were: $0; $1-4,999; $5,000-$9,999; $10,000-$ 19,999; $20,000-$29,999; $30,000-$39,999; $40,000-$49,999; $50,000-$99,999; $100,000-$149,999. The categories were recoded into: $0-$9,999; $10,000-$ 19,999; $20,000-$29,999; $30,000-$39,999; $40,000-$49,999; $50,000-$59,999; $60,000-$69,999; $70,000-$79,999; $80,000-$89,999; $90,000 and above.
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CHAPTER 4
RESULTS
The first statistical test I used for my variables was descriptive statistics to check for normal distribution. The variables, satisfaction with choice of primary care physician, trusts doctor to meet medical needs, and, doctor performs unnecessary tests, were above or below the -1.0 and 1.0 range for both skewness and kurtosis, and I took a log for each variable to ensure normal distribution.
Linear Regression Modeling for Verbal Communication
Linear regressions were generated for each dependent variable and the independent, variables to check for both significance and what type of relationships are occurring between the variables. Cross-tabulation statistics follow the regression statistics to give readers further understanding of the relationship between the dependent and independent variables. Crosstabulation tables can be found in the Appendix.
Linear regression was generated for the verbal communication dependent variable (how well respondents felt their doctor explained things they could understand), showed that the variables biological sex and race/ethnicity were not statistically significant,
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Table 4.1
Linear Regression Statistics for Verbal Communication
Variable Name B Beta Significance Tolerance N
Trust Doctor (log) -.136 -.059 .000* .761 25,116
Age -.017 -.028 .000* .923 25,116
Family Income .006 .018 .000* .774 25,116
Same Provider .039 .013 .005* .945 25,116
Education .026 .032 .000* .810 25,116
Unnecessary Tests (log) ,099 .040 .000* .900 25,116
Thorough Exam .618 .630 .000* .803 25,116
Satisfied with Physician (log) -.196 -.087 .000* .719 25,116

NOT SIGNIFICANT
Sex .015 .008 .083* .980 25,116
Race 25,116
African American -.012 -.004 .606* .316 25,116
Hispanic -.003 -.001 .915* .393 25,116
White, non-Hispanic -.029 -.013 .161* .229 25,116
*P< .05
Trusting doctors to meet.needs was significant at .000. The standardized beta coefficient was -.059, and the unstandardized beta coefficient was -.136, meaning that when patients distrust their physician to meet their medical needs, verbal communication decreases by -.136. This relationship showed that those respondents who distrusted their physician to meet medical needs and rated their physicians explanations as negative was 6.1 percent. The pattern shows that even
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when distrusting their physician, they tended to rate their physicians explanation more positively than negatively (see table 4.4).
Age of the respondent showed to be statistically significant (.000). The standardized beta was -.028, and the unstandardized beta coefficient was -.017, meaning that the younger the respondent the more likely he/she were to be dissatisfied with how their physician verbally communicated with. Nearly 45 percent of the respondents were between the ages of 40 and 61. Respondents who rated their physicians explanations as negative, the largest age group to report this was the 40-50 year old age group at 23.5 percent. This same age group and percentage also rated their physicians explanations as positive. Overall, nearly 94 percent rated their physicians explanations as positive (see table 4.5).
Family Income was statistically significant (.000), with a standardized beta coefficient of .018, and an unstandardized beta coefficient of .006. As income increases, there is a .006 increase of physician explanation. The highest percentage of income group shown in the crosstabulations were those who earned an annual income of $90,000 and above at 14.6 percent. The income group who rated their physicians explanations as negative the highest was the $0-$9,999 income group (17.0 percent). The lowest income group who rated their physicians explanations as negative were the $80,000-$89,999 group at 3.8 percent. Those who rated their
35


physicians explanations as positive the highest was the $90,000 and above income group at 15.7 percent (see table 4.6).
Seeing the Same Provider was statistically significant at .005, with a standardized beta coefficient of .013, and an unstandardized beta coefficient of .039. These results indicate that as one continues to see the same provider, the verbal communication from physicians increases by .039. Nearly 88 percent of the respondents reported that they see the same provider or physician for their medical needs. When compared with how they rate their physicians explanations, those who rated their physicians explanations as negative but still see the same provider, 79.4 percent rated their explanations as negative compared to 20.6 percent who do not see the same provider. Of those who rated their physicians explanation as positive, 88.4 percent see the same provider compared to 11.6 percent who do not see the same provider (see table 4.7).
Education was significant at .000, with a standardized beta coefficient of .032 and an unstandardized beta coefficient of .026, meaning that as educational attainment level increases, an increase of verbal communication occurs at .026. Education was compared with how respondents rated their physicians explanations, and overall, the majority of respondents had a high school diploma as their highest earned degree. Those who earned a high school diploma reported the
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highest percentage of negative explanations from their physician (38.5 %) and positive explanations (33.7 %) than any other educational group. Nearly 94 percent rated their physicians explanations as positive (see table 4.8).
The variable Doctor Performs Unnecessary Tests was significant at .000, and the standardized beta coefficient was .040, and the unstandardized beta coefficient was .099. This means that as one unit increases in doctor performing unnecessary tests, the verbal communication variable increases by .099. Over 73 percent of respondents disagreed that their physician performs unnecessary tests compared to just over 4.1 percent who strongly agreed. Of those who agreed that their physician performs unnecessary tests, nearly 81 percent of the respondents still rated their physicians explanations as being positive (see table 4.9).
Thoroughness and Carefulness of the Exam was statistically significant at .000, with a standardized beta coefficient of .630, and an unstandardized beta coefficient of .618, meaning that as the thoroughness and carefulness of the exam increases, the verbal communication increases by .618. Over 92 percent of the respondents rated the thoroughness or carefulness of their examination from good to excellent (see table 4.10).
Lastly, Satisfaction with Choice of Primary Care Physician was significant at .000, with a standardized beta coefficient of-.087 and a standardized beta
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coefficient of -.196. This means that as choice of primary care physician increases one unit, the verbal communication decreases-.087. Over 93 percent of respondents reported that they were satisfied with their choice of primary care physician.; When looking at how they rated their physicians explanations and satisfaction, nearly 72 percent of the respondents who rated their explanations as negatively said they were satisfied with their choice of their primary care physician. Those who, rated their physicians explanations as positively, nearly 95 percent were also satisfied with their choice of their primary care physician (see table 4.11).
Linear Regression Modeling for Non-Verbal Communication A linear regression model was generated for the non-verbal communication dependent variable, {How would you rate how well your doctor listened to you?). The variables that showed no relationship to the dependent variable were Race/ethnicity, Age, Biological Sex, Family income, and Education.
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Table 4.2
Linear Regression Statistics for Non-Verbal Communication
Variable Name B Beta Significance Tolerance N
Trust Doctor (log) -.124 -.053 .000* .760 25,103
Same Provider .045 .014 .001* .945 25,103
Unnecessary Tests (log) .081 .032 .000* .900 25,103
Thorough Exam .705 .698 .000* .803 25,103
Satisfied with Physician (log) -.198 -.086 .000* .718 25,103

NOT SIGNIFICANT
Age -.001 -.002 .621* .924 25,103
Sex .009 .005 .262* .980 25,103
Family Income .003 .008 .078* .774 25,103
Education .005 .006 ,162* .810 25,103
Race 25,103
African American -.028 -.009 .209* .316 25,103
Hispanic -.028 -.008 .244* .393 25,103
White, non-Hispanic -.029 -.012 .146* .229 25,103
*P<.05
Trusting the Doctor to Meet Medical Needs was found to be significant at .000 with a standardized beta coefficient of -.053, and an unstandardized beta coefficient of -.124. These statistics show that as people distrust their physician, the non-verbal communication decreases by .053. The crosstabulations show that respondents who strongly disagreed they trust their physician to meet their medical needs were still likely to rate their physicians listening positively (70.8%) (see table 4.12).
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.705, meaning that as the thoroughness and carefulness of the exam increases by one unit, so does the non-verbal communication by .705. This relationship showed that 97 percent of respondents rated their physician from good to excellent in thoroughness and carefulness of an examination (see table 4.15).
Lastly, Satisfaction with Choice of Primary Care Physician, was statistically significant (.000) with a standardized beta coefficient of -.086, and an unstandardized beta coefficient of -.198. These statistics show that as people are dissatisfied with choice if primary care physician, non-verbal communication decreases by .198. This relationship showed that 93.4 percent of respondents are satisfied to some degree. Of those who are dissatisfied, only 28.5 percent rated their physician negatively when it comes to listening to them (see table 4.16). Linear Regression Modeling for Satisfaction with Choice of Physician Linear regression was generated for the third dependent variable, Satisfaction with Choice of Primary Care Physician. Only one variable was not found to be significant and that was those who reported being of a Hispanic race/ethnicity (.309).
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Table 4.3
Linear Regression Statistics for Satisfaction
Variable Name B Beta Significance Toleran ce N
Trust Doctor (log) .645 .315 .000* .849 25,078
Age -.022 -.040 .000* .925 25,078
Sex .033 .020 .000* .980 25,078
Family Income -.005 -.018 .004.* .774 25,078
Same Provider -.164 -.061 .000* .950 25,078
Unnecessary Tests (log) -.217 o V 00 .000* .908 25,078
Thorough Exam -.082 -.094 .000* .950 25,078
Doc. Explanation -.053 -.060 .000* .364 25,078
Doc. Listening -.094 -.109 .000* .302 25,078
Education .004 .011 .058* .810 25,078
Race 25,078
African American .091 .033 .001* .316 25,078
Hispanic .028 .009 .309* .393 25,078
White, non-Hispanic .085 .042 .000* .229 25,078
*P< 05
Trusting Doctor to Meet Medical Needs was statistically significant (.000) with a standardized beta coefficient of .315, and an unstandardized beta coefficient of .645. These statistics show that trusting a physician does increase patients satisfaction with their choice of their primary care physician. Nearly 94 percent of respondents reported that they trust their doctor to meet their medical needs compared to nearly 6 percent who disagreed. Of those who reported they were satisfied with their choice of primary care physician, 95.7 percent also agreed that they trust their doctor to meet their medical needs. Of those who disagreed with
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the statement that they trust their physician, 43.9 percent reported being dissatisfied with their choice of primary care physician (see table 4.17).
Age was significant at .000, with a standardized beta coefficient of -.040, and an unstandardized beta coefficient of -.022. This means that age increases by one unit, and satisfaction with choice of primary care physician decreases by .022. The breakdown of age shows that the age group most satisfied with choice of their primary care physician is the 40-50 years old age group (23.9%). Overall, 93 percent of these respondents reported being satisfied with their choice of primary care physician. Of those who are dissatisfied, the age group 40-50 years old had the highest percentage (27%) followed by the 29-39 years old age group (23.1%) (see table 4.18).
The Biological Sex of the respondent was significant (.000) with a standardized beta coefficient of .020, and an unstandardized beta coefficient of .033, meaning that biological sex increases by one unit, and satisfaction with choice of primary care physician increases by .033. Nearly 55 percent of females and just over 45 percent of males responded to this question. Of the males who answered this question, 93.7 percent were satisfied with their choice of their primary care physician. Only 6.3 percent of males reported that they were dissatisfied. Of the females who responded to this question, 93.1 percent reported they were satisfied
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with their choice of primary care physician, and 6.9 percent were dissatisfied. Comparing males to females, 54.6 percent of females were satisfied and 45.4 percent of males were satisfied. Nearly 43 percent of males were dissatisfied compared to over 57 percent of females (see table 4.19).
The next variable, Family Income, was significant (.004) with a standardized beta coefficient of -.018 and a standardized beta coefficient of -.005. This means that as one unit of family income increases, satisfaction with choice of primary care physician decreases. Total family income showed that the income group of $90,000 and above had the highest percentage of satisfaction with choice of primary care physician (14.6%). The group that reported the highest percentage of dissatisfaction was the $10,000-$ 19,999 age group (16.5%) followed by the $0-$9,999 age group (16.4%) (see table 4.20).
Seeing the Same Provider was statistically significant at .000. The standardized beta coefficient was -.061 and the unstandardized beta coefficient was -.164, meaning that when people do not see the same provider, satisfaction with choice of primary care physician decreases by 164. The majority of respondents answered Yes that they usually see the same provider or physician for their medical needs (86.5%). Respondents who answered No to this question still rated their choice of primary care physician as being satisfied (88.2%) compared to being
44


dissatisfied (11.8%). Over 87 percent who are satisfied usually see the same provider or physician compared to those who answered No, but are still satisfied (12.7%). Of those respondents who are dissatisfied, 27.2 percent do not see the same provider or physician compared to 72.8 percent who answered that they do (see table 4.21).
Doctor Performs Unnecessary Tests was significant (.000), but had both a negative standardized beta coefficient (-.098), and negative unstandardized beta coefficient (-.217). This means that as doctors perform unnecessary tests, satisfaction with choice of primary care physician will decrease by .217. The results showed that only 12.2 percent agree with this statement to some extent. Those who strongly agreed with this statement indicated they were still satisfied with their choice of primary care physician (79.2%) rather than dissatisfied (20.8%) (see table 4.22).
The variable, Thoroughness and Carefulness of Exam, was statistically significant at .000, with a standardized beta coefficient of -.094 and a standardized beta coefficient of -.082. This means that the decrease of thoroughness and carefulness of exam will decrease satisfaction with choice of primary care physician. Lastly, respondents who were satisfied with the thoroughness and carefulness of their exam from their physician was 94.1 percent. Those
45


respondents who were dissatisfied with their physician, rated the thoroughness and carefulness of their exam highest as being good (26.9%) followed by fair (23.9%) (see table 4.23).
For the respondents who answered the question rating how well their physician explains things, the results showed a standardized beta coefficient of -.060 and an unstandardized beta coefficient of -.053, which means that when physicians explanation is negative, physician satisfaction decreases. Overall, respondents are satisfied with their choice of primary care physician (94.1%) and rated how well their physician explains things they can understand from good to excellent (95.4%). Of those who are dissatisfied with choice of physician, just nearly 40 percent rated their physicians explanations as poor (see table 4.24).
Linear regression results also showed that as patients negatively rate how well their physician listens to them, their satisfaction is affected because the results show a beta coefficient of -.109 and an unstandardized beta coefficient of -.094. Therefore, satisfaction with choice of physician decreases by -.094. Nearly 95 percent of respondents rated how well their physician listens from good to excellent compared to poor (1.0%). Those who rated how well their physician listens as poor responded that they were still satisfied (58.8%) with their choice of physician compared to dissatisfied (42.1%) (see table 4.25).
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Linear regression results found significant relationships with both non-Hispanic Whites (.000) and African Americans (.000) with satisfaction of choice of primary care physician. The breakdown of race/ethnicity shows that the majority of respondents are White, non-Hispanic (74.3%), followed by African American, non-Hispanic (11.4%), Hispanic (9.6%), and All other non-Hispanic (4.8%). Non-Hispanic whites responded with higher rates of satisfaction (74.9%) compared to African Americans (11.2%) and Hispanics (9.2%). When looking at the data within the individual race/ethnic groups, all groups are more satisfied than dissatisfied with their choice of primary care physician (see table 4.26).
Lastly, Education was significantly related to satisfaction with choice of primary care physician. The results showed the standardized beta coefficient as .013 and an unstandardized beta coefficient of .009. These statistics show that as there is an increase in education, there is also an increase in satisfaction with choice of primary care physician. The respondents with the highest degree, which was post-baccalaureate degree, were most satisfied with their choice of primary care physician (93.7%) compared to those who were most dissatisfied, which were those who had less than a high school education (9.3%) (see table 4.27).
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CHAPTER 5
METHODOLOGY: QUALITATIVE DATA
In addition to quantitative research, interviews were conducted to determine how satisfied patients are with how their physician communicates with them. Prior to conducting the interviews, permission was obtained by the Human Subjects Committee of the University of Colorado at Denver and Health Sciences Center. After approval was obtained, I conducted 6 pilot interviews before conducting actual interviews for this study. To construct questions for my interview, I worked with my thesis committee chair.
This part of my study is a phemenological approach to understand how patients interact with their physicians, how satisfied they are with their physicians verbal and non-verbal communication, how much they trust their physicians, who their ideal physician would be, and overall, how satisfied they are with their physicians. These questions stemmed from the questions asked in the Community Tracking Household Survey that I utilized for the quantitative section of this research. Each participant was initially contacted face-to-face, via the telephone, or via e-mail and asked for permission to participate in this study.
This research was conducted during a four-month period in the year 2007. For this study I utilized an interview schedule for each participant, and used
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probing during the process of interviewing when necessary. Each participant was interviewed face-to-face in the greater Metropolitan area of Denver, Colorado, with the exception of one interview that was conducted via the telephone with a person who lives in Virginia. All interviews were conducted in quiet, private locations for the purpose of limited distractions. A total of 7 interviews were conducted in the participants homes, 7 were conducted on a college campus, and lastly, one was conducted via the telephone. Each participant was given a consent form to review and sign along with asking to complete a demographic background questionnaire. All participants were briefed both before the interview and the day of the interview regarding what my study was about, and each interviewee provided consent on tape to tape-record each interview. All participants were given code names in their transcription for confidentiality purposes. All interviews were transcribed verbatim by myself, and are locked away to protect all participants confidentiality.
Sampling
Initially 22 participants were asked and agreed to participate in this study. Two withdrew for medical reasons, 2 decided not to participate, and the remaining 3 did not respond to follow-up contact to set up interview time and location. The total sample size for this study was 15.
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Table 5.1
Participants Demographic Backgrounds
Variable Frequency Percentage
Age of Participants
18-28 years 8 53.3
29-39 years 3 20.0
40-50 years 0 0.00
51-61 years 3 20.0
62-72 years 1 6.7
Education
Less than high school 0 0.00
High School Diploma 1 6.7
Some College/Associates Degree/Other Degree 4 26.7
Bachelors Degree 6 40.0
Post-baccalaurate Degree 4 26.7
Gender
Males 8 53.3
Females 7 46.7
Annual Family Income
$0-$9,999 4 28.6
$10,000-19,999 0 0.0
$20,000-$29,999 1 7.1
$30,000-$39,999 2 14.3
$40,000-$49,999 2 14.3
$50,000-$59,999 2 14.3
$60,000-$69,999 1 7.1
$70,000-$79,999 1 7.1
$80,000-$89,999 0 0.0
$90,000 and above 1 7.1
Race/Ethnicity
Non-Hispanic White 13 86.7
Hispanic/Latino of any race 2 13.3
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To find these participants, I utilized the snowball sampling method by asking people I knew for recommendations for people they knew who might be willing to let me interview them about their experiences with their physician(s). The participants I interviewed come from a variety of backgrounds. A total of 8 males and 7 females were interviewed. The mean age range of the participants interviewed was 29-39 years. Forty percent of the participants had a bachelors degree, while nearly 27 percent had either some college or associates degree or a post-baccalaureate degree, and nearly 7 percent had a high school diploma. The median income group for these participants was they reported an annual individual income of $30,000-$39,999. Lastly, the majority of the participants were non-Hispanic white (13) and 2 people indicated that they were Hispanic or Latino of any race. All participants were at least age 18 or over. Two participants did not have health insurance, however, provided information about their former physicians and were asked questions regarding expectations they have as patients and what they will look for when selecting physicians in the future. Sixty percent of the participants with a physician had a male physician. The mean number of years these participants had their primary care physician was 8.7 years. All demographic information was computed using SPSS.
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CHAPTER 6
RESULTS
Importance of Non-Verbal and Verbal Communication from Physicians
Each participant was asked how important it was to them for their physician to listen to them and how well their physician actually listened to them. Overall, most of the participants agreed that it was very important for their physician to listen to them and for the most part, they stated that their physician did listen to them during their visits. One participant, Kaylee, commented,
Oh I think it is the utmost important because obviously youre taking the time to put your personal health in the hands of somebody else. I think that the least they can do is listen to you. Um, I think theres probably not anything more important then a doctor listening to your concerns, you know, whats going on with your body, so. Who knows your body more than yourself so, very important.
Other participants who agreed that it was important for their physician to listen to them said that it was important because they know their own bodies and how their own bodies feel. To get an understanding of what is happening with a patients health, it is important for them to listen to what the patient has to say.
One participant, Emma, said,
.. .shell give you the answer, the right answer, so she must be listening.
In addition to being given an answer from their physician, another indication that they know their physician is listening is by their non-verbal
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communication, such as nodding of the head when the participants were communicating with them; eye contact was important in that it appeared as though their physician were focusing on them. Lastly, an important indication was that their physician does not interrupt them while they are communicating with them. Ricardo has had his physician for approximately 10-years and when asked about how he knew that his physician was listening to him, he said,
Hes a very good listener and uh, you know, he, you know, he gives you attention, you know. You can tell by his body language and his eye contact hes right there and he doesnt interrupt you or cut you off or something like that like some other physicians do.
Out of all the participants interviewed, only two were dissatisfied with the listening style of their physician. What both of these participants had in common was that their physicians did not listen to their concerns. Mackenzie is a 28-year old female who is uninsured. For her medical treatment, she thinks that it is very important for physicians to listen to their patients. Mackenzie has sought out medical treatment from a specific clinic for the past 3 years. Her last experience at this medical clinic with her physician was frustrating enough that she decided to leave this clinic. Her last visit with her physician included her having a pap smear done. When Mackenzie received the results from her physician, her physician told her that her exam was abnormal and would require surgery. Mackenzie said that
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she researched the results online and when she approached her physician about her research, her physician did not listen to her. Here is what Mackenzie told me,
I started, you know, researching, cause she was saying that I had um, I forget, some kind of abnormal cells, and as I began researching and learning, what she said I was having and how high test results come back wrong, she basically discounted me. Discounted my knowledge, discounted my research. Like whatever I told her she was like, no. You know, she basically ignored my concerns, so, um. She was just rude.
Mackenzie did not have the surgery and had another pap smear done by a different organization specifically designed to provide medical care to women who were uninsured. The results came back as normal and she explains what came out of that visit,
.. .1 was treated more holistically at the second clinic compared to first because as I was explaining with the first clinic, and how they change my birth control pills, how it screwed up my cycle, how I bled for three weeks straight, and all this other stuff, they were like, That doesnt matter, which was bologna. But when I went to, um, the second clinic, and I actually had a male physician, so it was a little embarrassing, but, um, when I went there, I explained to him and they treated me holistically. They were like, You know what, were going to take that into consideration. We understand, you know, that birth control effects whats going on down there, and your diet and your stress level. I had a second pap smear done and it came back normal. And um, so I wont ever go back to the first clinic.
Ahna was another participant who was extremely satisfied with her OBGYN but extremely dissatisfied with her primary care physician. She reported similar experiences as Mackenize as to why she felt as though her physician did not listen to her, and felt as though her physician ordered unnecessary tests. She
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describes a situation where she was sick and her parents pressured her into visiting her physician.
.. .approximately uh a year and a half ago, maybe, give or take, I went in, uh, had a bad cold, you know, parents kind of pushed me to go in and I was pretty sure it was just a bad cold. Well, um, the, my doctor thought that, you know, they heard something in my lungs and were absolutely, 100 percent certain that I had a blood clot in my lungs because I was a smoker. Um, you know that was kind of their thing. Everything that was wrong with me was related to the fact that I smoke. And so they sent me clear across town, while I was sick, to get a CAT scan done where they found, you know, there was no blood clot in my lung. It was, you know, mucus. I was sick. And then, uh, so that kind of made me question it, when they were sending me across town to get a CAT scan when theres really nothing else could lead that I was, had a blood clot, other than the fact that I was sick, and you know, had, you know, kind of swampy lungs at the time, and that I was a smoker. And so, kind of, it kind of made me feel like it was a wild goose chase to make me go out there and do that, and what furthered that was my insurance company denied the claim and a frivolous claim.
Ahna described in the interview that when she is sick, she would rather not visit her physician unless she absolutely has to because her physician does not listen to her or takes her seriously. She told me,
I dread going, um, to that specific, uh, uh, doctor which is why if I have problems, even though they might be slightly outside the scope of my OBGYN, I will approach her first about it, and ask her her opinion, and then if she believes that I should see, um, my primary care, uh, doctor about that specific problem, then she will refer me to them. But shes, I would rather talk to her about any issues that Im having, rather than going to my primary care physician.
Ahna described her last visit with her primary care physician when she saw her for a problem with her legs. She explains that her physician was not very good at listening to her when describing what was going on with her body, and
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completely disregarded any research that she had done. She describes her physicians listening as,
If I had any concerns, she just kind of blew them off as, Well, youre fine. And um, especially I had an experience where I have uh, some issues with my legs and uh, a type of, uh, scar tissue tumor, which is completely benign, but when I asked her about it and I told her, you know, that I had researched it online on Web MD because its a popular search engine thats there to kind of help you out. Shes like, Well, that doesnt really make sense and that couldnt be what it is and you know search engines like that arent really useful to you. They just make you about things that are really, you know nothing to worry about, and as it turned out, what I had read online was actually what I had at the time. It wasnt what she thought it was. She had referred me out to a dermatologist to get it checked out who relayed the information back to me that it was indeed what I found online and it wasnt what she originally thought it would be.
She then added,
.. .she wasnt very supportive or very apologetic about the fact that she disregarded what I had thought it was going to be, and disregarded, kind of, my concerns about it, and which is why I havent really havent been back there.
I asked Ahna how the breakdown of communication made her feel and her response was,
As a patient, it, it makes me like I cant trust that physician because theyre not, they werent able to communicate with me. They didnt really listen to my concerns, and I feel that, that if theyre not listening to my concerns, theyre not really able to properly treat me as a patient; shes not treating me as a whole patient.
Even though both of these participants have had negative experiences with physicians in the past, both have reported that they currently have a physician that they are satisfied with. Overall, the participants from this study agree that having
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their physicians listen to them is very important and they are satisfied in the way that their physicians listens to them while they are talking. Most participants indicated that their physician gives them advice or lets them communicate without interruption, and allows them to ask for clarification without being upset.
When participants were asked about how important it was for their physician to explain things in a way that they could understand, all participants agreed that it is very important. When asked how well their physician explains things that they can understand, only two participants disliked how their physicians explained things. The participants who were dissatisfied were Ahna and a male named Seth. As mentioned before, Ahna is dissatisfied with her primary care physician. When asked about her physicians explanations, she told me,
My primary care provider is not very good about explaining things. Uh, she used very technical terminology and she wasnt very good at explaining anything to me...
She also described in her interview that in addition to using medical terminology, her physician also does not clarify herself when asked to.
Seth on the other hand describes his situation a little bit differently. Seth sought out assistance in an emergency room because he did not have health insurance at the time he needed medical attention. He describes his situation with the medical personnel in the emergency room.
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I mean I had to get to the specialist to find out what I had. I mean, the physician wasnt able to tell me but then again, its. I was in the emergency room and I dont think that even going there you dont see the physician, you see a P.A. or a nurse, or something like that, so. I guess I dont think I actually saw the physician. I think it was the P.A. that told me. Um, but he wasnt able to explain it to me either way. He said, Here, just go see a specialist. Tell me which one you want to go see, and I had to go digging around to find one, um...
Seths situation is different than the other stories told during this study. Not only did he describe his situation of his physician not accurately telling him what was wrong with him, but also there was a breakdown in communication as to who he should see as a specialist for his problem. Seth had to take it upon himself to find a specialist without any recommendations. When I asked Seth about how he felt about this situation, he replied,
Yeah. Id say its a pretty big breakdown, um, because not only did he misdiagnose me, he, you know, just said, Go see a neurologist, saying, you know, One that specializes in this. One that specializes in that or, whatever. He just said, Go do this, so yeah, it was a complete breakdown of communication.
He added,
Yeah. I think I was pretty frustrated but again, I always go in not expecting a lot anyway. So, if you dont expect a lot, you cant get that disappointed [laughter].
Overall, Ahna and Seth are disappointed in their physicians because there was a breakdown in communication. Ahna does not think her physician explains things in terms she can understand and refuses to break it down to her understanding. Seth on the other hand experienced not only a physician
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misdiagnosing something that he had, but also he was not given an accurate explanation or referral of whom to see for his medical problems.
The participants who were satisfied with their physicians explanations agree that they have a physician who breaks down medical terminology in a way that they can understand. In addition to explaining things, some participants indicated that their physician will either sit down with them or provide them with printed out information for them to take home, look over, and ask any questions based on that additional literature. Physician explanations were described as Easy to understand, to User friendly. One participant, Luke, told me when asked about his physicians explanations,
I never left the doctor's office feeling like I, I didnt know what was going
on, so.
Ricardo described in detail of how well his physician explains things,
Well when he explains things, hes, he uh, like when, for example, like when I went in for, the last time I was there I was there for when I hurt my foot and he was just very explicit saying as like, Well, explained how he went through the x-rays and didnt see any bone damage. He was just saying that it could be soft tissue damage and the fact that he said, you know, You might want to keep it elevated and, you know, pack it with ice the first 48 hours and, you know, just go easy on it and crutches may be a good idea, he said to keep the weight off of it, you know, and um, you know, that, hes just very plain the way he says it, you know.
In addition to just the explanation, both Ricardo and another participant named Spike explained that when they receive test results back, their physician will
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mail them the results with attached notes explaining what the results of their tests mean, which has increased both of their satisfaction with their physicians communication style. Ricardo described his situation when he receives his test results in the mail from his physician,
For example, like when I have my annual physical, hell complete blood tests and then hell review it and write some comments, just the general comments saying, Everything was fine, you know, Youre doing well. Maybe some, some particular measure thats a little high, he may something about that but, but he always puts general comments saying, Youre doing fine, or something like that. So, and the fact that hes personal, going to the trouble to write a note on it, and he puts it on top of the lab results, is pretty good. In fact Ive never seen a physician do that before.
For these participants, getting clear and thorough explanations of test results also factors in to how satisfied they are with their physicians communication styles.
The Importance of Trust in a Physician Each participant was asked a series of questions regarding trust of their physician. Participants were asked, How important is it for you to trust your physician?, On a scale from 1-10, with 10 being that you absolutely trust your physician, where would you rate your physician and why?, and What does it take for you to trust your physician? Out of all the participants who answered this question, all participants agreed that it is important for them to trust their physician and that they do trust their physician. Participants responded that it is one of the
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most important aspects of the physician/patient relationship because without trust, patients will not follow their physicians orders and more than likely will not stay with that physician. Aaron is a 27-year old male and when asked how important it was for him to trust his physician, he responded,
I think that it helps the, you know, how things go, not necessarily with your body, but you know, theyre there to put you at ease and if they put you at ease, youre trusting that individual. Uh, so I mean, I think its extremely important. If your, if you, if you dont trust them, then youre gonna feel a little apprehensive to share things with them and to really, you know, get to the, the bottom of whats going on, so I mean, I think its extremely important.
Aaron also said that part of the trust process is the physician having good bedside manners.
.. .1 think a lot of dealing with, with patients and such, a lot of it is bedside manner. If you got good bedside manner, you know, if you got good bedside manner you can put somebody at ease.
Aaron was asked earlier in the interview what feelings he has before visiting his physician, and he responded that he has, White Coat Syndrome, or that he is anxious when he is around his physician. For Aaron, part of decreasing his anxiety is trusting his physician, and the decision that his physician makes regarding his medical treatment.
Other participants responded that part of trusting their physician is the communication style of their physician. The important parts of communication is both that they have a physician that explains thing to them in a way that they can
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understand as well as knowing that their physician is listening to them. Participants responded that if their physician cannot explain things to them, it could be that their physician does not really know what they are talking about and will be skeptical to believe what they say. When it comes to listening, this is important with trust because as patients, they are describing to their physician what is wrong, and the physician has to be listening to know how to treat them medically. Ricardo describes why trust is related to the communication process with his physician.
What I liked about him is that he communicated with me, you know, again, he was on a first name basis with me too. He was just very good, so um. Uh, I think the most important thing has been the communication and what I feel is their competence. They are able to diagnose what the illness or what the, you know, accident or something that youve had. So, you know, competency, and communication.
Adam also indicates how important communication is with his physician and trusting his physician by saying,
Well, um, it, it all comes down to faith. Um, and I have to, whenever I go in there, um, I have to place absolute faith into a doctor and say, This is whats going on, you know, This is effecting my life and I dont how to fix it, um, which is why theyre there. Theyre, they go through all the training to fix those kinds of problems, so trust is an absolute. Um, if I dont have that trust, I wont go to that doctor. Um, it comes right down to that. If I dont think youre going to do whats best for me, um, you know; if youve got some other thing in mind or youre just not getting it, then Ill find someone else. Um, so trust is an absolute and faith is an absolute.
Both Ricardo and Adam describe that communicating with their physician and receiving communication are important because of diagnoses and as previously
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mentioned, other respondents agreed that if they do not trust their physician, they are not likely to continue that relationship with them because if they are not taken seriously as patients, then they will not take their physicians diagnoses seriously either. As Emma states clearly in her interview when asked about trust,
Whats the point? If you dont trust them, then whats the point in even going then, wasting the time and the money and everything else cause youre not going to probably respect them.
One participant, Bill, told me that he trusts his physician, but he does not follow his orders. In his words,
I have no reason to distrust him. I trust what my physician recommends, but I just do not do what he recommends. I hope it doesnt come back to haunt me.
When asked why he does not follow what his physician recommends, he replied to me that he is stubborn and does not like to take prescription medication. However, not following doctors orders does not have any reflection on his physician; rather it is what he chooses to do as a patient.
Out of the 11 participants who rated how much they trust their physician, on average, they rated that trust at an 8.5 (see table 6.1). When asked why they rated their physician as they did, some respondents indicated that they trust their physician 100 percent based on their experiences with their physician, and that they have no reason not to trust them 100 percent yet. Other participants rated their physician lower mainly because they say that they could never trust any physician
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100 percent. Some participants said that because physicians are human beings, they are prone to error and that alone makes it difficult to trust their physician completely. Other participants said that physicians are never completely honest with their patients and therefore, they can never absolutely trust their physician. Overall, these participants rated that they trust their physician, but no matter what physician they see, they will never completely trust any of them 100 percent due to these two reasons.
In addition to asking how they rate their trust in their physician, I also asked each participant what it takes for them to trust their physician. Adam replied,
Ive got to walk in the door. That, that understanding is already there... Um, so when I walk in the door, I know that I can trust them, um, until I am proven wrong, which as of so far, Ive never been proven wrong as far as that, you know, meeting a doctor. You know, Im sure that theres problems, theres issues, miscommunication, whatever, um, I still have faith in that doctor. Um, you know, even though, you know, there was some stuff that we werent seeing, you know, I didnt have a problem with that, overall. There was no lack of trust there. So, yeah, trust is instant and absolute until proven otherwise.
For Adam, trust is something that is instant unless he is proven otherwise and what is different about his response than any of the other participants is that he is the only participant who said that it is instant, and the only participant who responded that while there may be miscommunication, it is not a good enough reason for him not to trust his physician. The other respondents who responded about communication felt that this was an important characteristic that a physician
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should have. For Adam, as long as he is treated for his medical problems, communication is not as important as a factor in trusting his physician.
Most other participants responded that trust is something that is built up over a period of time, or based on experience with their physician. However, while the time spent with their physician may not lead to complete trust in their physicians abilities, it builds up that rating of trust within their physician. Maria, a 27-year old female, indicated that the only way she thinks people could absolutely trust their physician is if they have them for an extended period of time, such as from childhood through adulthood. I interviewed a female named Jennifer who has had the same physician since she was a child, or for nearly 30 years, and says,
I wouldnt uh, theres no reason not, for me not to trust him that Ive never experienced, no. Like I said, Ive been going to him forever, so um, you know... hes a general practitioner and I trust that if somethings wrong with me and I, I, and I trust him to listen and I trust him to make a choice.
Luke has also had his physician since he was a child, and he agrees that the trust has been built up over a long period of time. However, he does not fully trust his physician because he says that they do not always know what is going on or how to treat their patients.
Overall, these respondents said that they trust their physician to meet their medical needs but this trust is built up over an extended period of time. As Luke said in his interview,
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Uh, well, its just like, to me its like with any relationship. You got to spend time with them, you know, you gotta, theres, to me, there are some doctors you go to and they just want to get you in and out, and there are other doctors that, you know, will ask you whats going on in your life and kind of get to know you a little bit. So, I dont know, I guess going to see your doctor, uh, regularly is probably the best, best solution.
In addition to communication and experience, a physician ordering necessary tests is another criterion of trust in a physician. Most participants agreed that their physician orders necessary tests and some are consulted before these tests are conducted. In the aforementioned question about communication, Ahnas physician made her get tests that she did not feel were necessary, which actually decreased her satisfaction with communication for that physician because her physician dismissed her concerns. This is one reason why Ahna does not seek out medical attention from this physician unless she absolutely has to, and does not trust this physician. All the other respondents did feel as though the tests were mostly necessary and trusted that their physician because most of the tests were common sense, such as in Spikes case when he was getting his ribs x-rayed after a car accident, he replied,
He [his physician] made the decision but it was pretty straightforward anyway. I mean, if Ive got a broken rib, hes not going to take an x-ray of my foot. I dont think? [laughter].
In summing up trust, overall time period is an important factor when it comes to trusting ones physician, but for these respondents, no matter what
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physician they currently have or will have in the future, they will never trust them completely because they are prone to making mistakes with diagnoses. Communication is another important indicator of trust because if their physician cannot explain what is happening with the patient, the treatment options, or is really listening to their patient, it will reflect the overall care that the patient receives. Without trust, some of these participants will choose to seek alternative options until they find a physician that they can trust and without that trust, satisfaction with their physician and communication will decrease.
Overall Satisfaction with Physician Communication Participants were specifically asked, How satisfied are you with the way your physician communicates with you? and the majority of the respondents responded that they were satisfied. Both Mackenzie and Ahna were dissatisfied with their physicians and changed physicians, and are now satisfied. They participants are satisfied for a variety of reasons, including they now have physicians that accept research they look up on the internet about their health, and their physicians listen to them and lets them as patients explain what is going on with their own bodies. Other satisfaction responses included that their physician takes the time to spend with them so that they are not rushed, and that they feel as though they leave their physicians office with all the information they need to take
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care of their medical needs. Ricardo said that the most important thing regarding satisfaction is the line of communication,
Hes been able to explain to me and also to speak to me on a, on an equal level and plus the fact is that he has, I can build a level of trust with a person so thats both not only kind of a professional assessment but its also kind of an intuitive assessment on whether I can, you know, feel that theres that confidence or trust involved there.
Taylor was also satisfied with his physicians communication. Taylor has had the same physician for about 20-years and when asked how satisfied he was with his physicians communication, he replied,
Very, very. Um, uh, it's, it's not run-on, but it's thorough, and, you know, it's just about right. He knows, I think thats evolved. I think that initially he was not as thorough with explaining things to me but I, I kept drawing him out and asking questions, and now his explanations are much more complete. I think they've changed over the years.
When Taylor was describing his trust in his physician, he said that this was something that was built up over time which also had to do with the way his physician communicated with him. Taylor responded that at first his physician was not always complete in his explanations but as the relationship grew, this began to change as well as the trust, which is all related to his satisfaction with his physicians communication, and his overall satisfaction with him.
Jennifer, who has had the same physician since she was a child, responded that while she was satisfied with the way her physician communicates with her, she
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was often rushed through the appointment. On average, she responded that her physician gives her 5-10 minutes of his time and while that is not enough time for her to ask all of her questions, she is satisfied with the answers that he gives her. Other interviewees replied that not being rushed through an appointment by their physician was another important factor that plays in how satisfied with how their physician communicates with them.
Seeking alternative options, or admitting that they do not have the answer but can refer them to someone who would know is another factor that plays in the satisfaction process with these participants. When their physician admits that they do not know what something is or how to treat someone, they like that their physician is honest enough not to pretend that they have all of the answers. However, they also are satisfied when their physician will go out of their way to find additional information or contact someone who may know more information to give them to help treat their medical problems.
Lastly, the way that they receive test results is important to some of the participants. Two of the participants, Spike and Ricardo, receive test results in the mail and their physicians will write comments explaining what the results mean. Both of them told me that this was very important in the communication process because they understand what is going on with their bodies and find it to be more
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personable, which is something that makes them satisfied. Other interviewees said that when it comes to test results, as long as whomever is calling them with the results is competent to answer questions that they might have, it does not matter who calls them with the results. Also, it is important that they are able to contact their physician to ask them questions instead of playing phone-tag between the nurse, physician, and themselves.
Overall, these participants are satisfied with the way their physician communicates with them and if they could change anything about it, those who felt as though they are not given enough time would like to be given enough time with their physician.
Characteristics of an Ideal Physician
Each participant was asked to describe who their ideal physician would be. Three participants answered this question saying that they either had or were close to having their ideal physician. Not one participant said that the race/ethnicity of the physician is important. For some, the biological sex of their physician was important when it came to anatomy. Forty-percent of the respondents indicated that they had a preference for whom they see as a physician in terms of biological sex, and most responded that they are more comfortable with a physician of their same biological Sex (see table 6.1). Only one participant, Abby, said that in some
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cases, she prefers a male physician, especially when it comes to selecting an OBGYN.
I switched from one doctor to another, um, with my second pregnancy.
They had referred me to one doctor and she was female and I was having, um, preterm labor, which I always did with both of my, and she was like, Oh these are just Braxton Hicks. They dont hurt that bad. Because she had had kids, so she wasnt very sympathetic and she wasnt really listening to me. Well, I immediately switched her [laughter] Im like, I dont like her. So I went to a doctor that was really listening because how can she say Braxton Hicks dont hurt? It might not have hurt her but they were definitely hurting me, you know? So, um, I dont know. Maybe gender does play a role. I think it, when you, this is why, when people ask me, Do you like female OBs? Or do you like male OBs? Im like, I would much rather have a male, and they say, Why? and Im like, Because a male has never gone through child labor. So they are so sympathetic. And theyre like, Okay, how can we make you feel more comfortable? How can we... and thats what you want, so. Whereas females, theyre more like, Oh, this is natural. This is a natural part of life, you know, Women have had babies for... and you dont want to hear that! You want to hear, Can I get you another pillow? [laughter].
Abby later responded that when it comes to general issues of care, it does not matter whether her physician is male or female, which was the consensus among most of the participants. When they had to select a physician for physicals, they prefer to select a physician of their own biological sex because they believe that there is more of an understanding of what is going on, and that it is more comfortable talking to someone of the same biological sex. However, three participants said they prefer a physician of their own biological sex, regardless of
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what the reason is to see their physician. Maria responded to this question by saying,
I just prefer a female. It just think it makes it easier to ask, you know, personal questions, like theyre understanding, um, maybe like what I might be going through or saying, or, um, easier to approach, I think, than a male.
When asked about the physicians age, over 33 percent of the respondents said that age is an important consideration for their ideal physician (see table 6.1). Of this 33 percent, these participants all responded that they want a physician who has experience and is older but not so old that they are ready to retire.
Other characteristics that the participants described about their ideal physician included location of their physician. Nearly 47 percent of the participants said that their ideal physician would be in a close location for convenience of getting to and from their doctors office from their homes (see table 6.1). Another characteristic from four of the participants was that their ideal physician would treat them holistically. This response did not seem to make a difference when it came to age group because this came from a variation of different age groups. However, the participants either had a college degree or had some college and therefore, education could play a role in seeking alternative health care choices. Mackenzie describes her ideal physician as,
Um, my ideal physician is someone that is holistic. Somebody that would actually listen to me, my thoughts, and my concerns and if there was something
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wrong, obviously Im one of those people thatll probably research the heck out of it. And, um, to address my concerns and just treat me like a person. Not, you know, dont brush me off, dont, um, discredit me if Im wrong. Explain to me this is how it actually works, dont treat me like Im an idiot.
Over 73 percent of the respondents said that their ideal physician would have good communication skills, which included their physician listening to them, lets them explain things to their physician without being interrupted or rushed, and that their physician is personable within that communication, but gets down to business with limited personal conversation (see table 6.1). Aaron described his ideal physician as someone who is personable, someone who listens, and is someone he trusts.
Uh, I guess my ideal physician is, uh, you know, it doesnt have anything to do with, you know, race or ethnicity or, you know, sex or anything like that. Its just a doc that, you know, listens to you, and uh, you know to me whats kind of important is that you want the type of doc to me, that when you walk in, they know who you are. You know, and it seems like anymore, the docs that you have are just, I mean theyve got so many patients that they deal with that they dont, they dont know who you are, and youre a, youre a file [laughter], so I think that that, ideally, thats the type of doctor I would love to have is one thats, you know, thats spends time with you, getting to know you, and, and, you know, essentially, I guess, grows old with you and they, you know, they, um, you know you talked about trust earlier, someone that you trust, you know follows up and makes sure that things are, you know, going well. Sometimes going above and beyond.
Ricardo takes this a step further and includes competence in his description.
.. .the one who has the trust, who has the communication, who I think is knowledgeable about the topic, who can uh, suggest alternatives rather than just a set regimen, so. Its when they have the pros and cons on a variety of methods and I like that. I dont like the cut and dry approach, you know? Competence more
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than anything; competence is important and competence includes communication, communicative capability ability to explain to you, you know, if they cant explain to you, you know, then its kind of like its, its kind of sad, I think.
Overall, these participants ideally would select a physician who makes time for their patients, respects them, listens to them, and explains things to them in a way that they can understand. They should be able to trust them, have competence in their job, be personable yet also know when to be professional, and suggest alternative health care options other than medication. One personal quality that some participants mentioned was their physician calling them by their first name and jotting notes that reminds their physician of who their patients are and follows up on some of the personal things about their patients. Some of these participants would prefer a physician of their own biological Sex or of the opposite, yet most do not really have a preference. The race/ethnicity of the physician has no bearing on these participants. A few participants would select a physician who is approximately middle age because if the physician is too young, they may be inexperienced yet they do not want a physician who is so old that they are ready to retire.
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CHAPTER 7
DISCUSSION
Linear regression results show that the first hypothesis was not completely supported. It was hypothesized that patients who trust their physicians to meet their medical needs would rate their physicians explanations and listening as good, and be satisfied with choice of their physician. While there was a relationship between trust, and their physicians listening and being satisfied with their primary care physician, a significant relationship between trusting their physicians to meet their medical needs and physicians explanations was not found. The relationship that the analyses did show was that when people do not trust their physicians to meet their medical needs, they are also less likely to report that their physician is listening to them. When interviewing participants to determine how important it was to trust their physician, not only did all of the interviewees agree that trust is important, but many of them also included their physicians explanations as part of that trust component. These participants said that if a physician cannot explain something to them, then trust issues arise because their physician may not be completely honest which would be why they cannot explain something. However, another issue would be that if a patient is not understanding their physicians explanations, then they will not understand what is going on with their bodies,
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how to treat it, and will seek out another professional who has a comprehensive style of explanation. As noted in the literature review, Mechanic (2001) argued that those who do not trust their physician will not be likely to continue that relationship with that physician. The discrepancy with the quantitative data could be that the questions from the data set referred to their visit with their physician in the last 12 months whereas the participants were asked about trust with their physician in general, regardless of length of time with their physician. The discrepancy could also be due to since the question from the data set asked about their visit in the last 12-months, their physician explaining things may not have been that important with trust during their last visit.
Linear regression did not completely support the second hypothesis. A relationship was found between age of respondent and physicians explanations and satisfaction with choice of primary care physician, but no relationship was found between age and physician listening to the patients. The results indicate that the younger patients are, the more likely they are to report being dissatisfied with their choice of primary care physician. Patients who are younger tend to not have health insurance, and literature has shown that patients who are younger tend to be more aggressive with their physician by wanting to be a partner with their physician, and confront their physician when they make multiple mistakes. These results are
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consistent with the literature by Haug and Lavin (1981), however, it is unclear as to why non-verbal communication would not be found as significant. The younger participants interviewed in this study were more likely to be uninsured and have had experiences where they have been unhappy with explanations that physicians have given them in the past. When each participant was asked whether their age played a factor in how they were treated, 11 participants said that when they were younger, they felt as though their physician was more likely to talk and listen to their parents when they were in the room instead of them, which would make age a significant factor when asking about their physicians listening. However, the discrepancy between age and their physician listening could be that the respondents from the data set never saw age as an issue because maybe they have not had the same physician for an extended period of time and it would be difficult to assess whether or not age really played a factor in that non-verbal communication. For explanations from their physician, this could be consistent with the level of understanding each age group plays. Some respondents said that when their physician talked to them when they were a child, their physician talked to them as a child in words that they could understand. As far as age and satisfaction with choice of physician, the younger the respondent was, the more experiences they had
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of being dissatisfied with a primary care physician in the past, but all were satisfied with who they currently consider as a primary care physician.
Female patients have been viewed by physicians that they are more difficult because they are less likely to listen, and female patients tend to report more dissatisfaction than male patients (Berstein and Kane 1991; Weiss and Lonnquist 2006). The results of this study showed that while no relationship was determined between biological sex of the patients and physician explanations and listening, and a relationship was found between biological sex and satisfaction with choice of physician. When looking further in the cross-tabulation tables to see what this relationship showed, females showed to be more dissatisfied (59%) with choice of physician than males (41%) (see table 4.19). Therefore, this hypothesis is partially supported. All interviewees were asked whether they felt as though their gender played a role in how their physician treated them and only one participant said yes. Most participants said that they felt their age played more of a factor than their biological sex. When it came down to level of satisfaction, more females were dissatisfied with a physician in their recent past than the males, but their biological Sex and satisfaction with choice of physician did not seem to play a role with these participants. Overall, these participants said it was more important as to how their
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physicians communicated and interacted with them rather than the biological Sex of their physicians that effected their satisfaction.
The results for family income and physician explanations, listening, and satisfaction with choice of primary care physician showed a relationship with both explanation and choice of physician, but not with listening. Those respondents who reported the lowest annual family income of this group ($0-$9,999) were more likely to rate their physicians explanations as poor (see table 4.6) and be less satisfied with their choice of physician (see table 4.20). Those who reported a higher annual family income were more likely to be satisfied with their choice of physician and their explanations. In the interviews, those who did report a higher annual income reported being satisfied with their primary care physician and their explanations; however, income was never a factor that came up when they were responding to the questions about satisfaction with their physician listening, explaining things, and satisfaction with choice of physician. It is very difficult to determine whether income of the participant has an effect on how physicians communicate with patients since most physicians do not have knowledge of their patients annual income. There is a deficiency in the literature about the relationship between annual income and patient satisfaction with physician communication and it could be because it is very difficult to determine. These
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participants focused mainly on who their physicians were and their relationship to them. Their responses to satisfaction were more based on the overall communication from their physicians rather than their own demographic characteristics, and their physicians demographics that determined their satisfaction. What would have to be determined for respondents in the data set is who people are defining as their primary care physician or who the physician was they rated for explanations. Patients who are of the lower class are least likely to have health insurance and seek places, such as emergency rooms, for medical attention. Emergency rooms are limited with physicians, and patients tend to be more dissatisfied with the care they receive there than at a physicians office because physicians do not have as much time to spend with patients in emergency rooms. This is an area where further research that needs to be conducted to find out why these patients are dissatisfied. This hypothesis was not completely supported.
The fifth hypothesis was supported. A relationship was found with respondents seeing the same provider and rating their physicians explanations and listening as good, and being satisfied with choice of primary care physician. This was also consistent with what was found in the interviews. The mean number of years the respondent have seen their physician was nearly 9 years. For those who have seen the same physician, they were satisfied with their physicians
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communication style and with them overall. This makes sense because patients who are dissatisfied are less likely to see the same physician over and over, and if they are dissatisfied, chances are slim that rating their physicians explanations and listening as good. A few interviewees said that they would not continue seeing the same physician if they were not satisfied with them and their communication. Therefore, people are more likely to continue seeing the same physician if overall, they are satisfied with their treatment and communication.
The sixth hypothesis was also supported. A significant relationship was determined with linear regression when looking at Doctor Performing Unnecessary Tests and how well their physician explained, listened, and satisfaction with choice of primary care physician. Respondents mostly disagreed that their physician performed unnecessary tests and were more likely to rate their physicians explanations and listening as good to excellent. This is also a consistent finding with the interviews. All but one participant agreed that their physician did not run unnecessary tests because the tests that were run were pretty straightforward. Ahna was in a situation where she did not want a chest x-ray but was told by her doctor that she had to have one, so she did. These participants did say that they would want to be consulted by their physician if they needed additional tests run outside of the normal tests because they are ultimately paying
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for those tests and do not want any surprises. One participant, Aaron, said that he felt physicians do not run enough tests and would like to have more done for more accurate results and further investigation into his health.
Significant relationships were determined between how thorough and careful physicians were with exams and how they rated physicians explanations, listening, and satisfaction with choice of physician. Respondents rated their physicians thoroughness and carefulness nearly 100 percent excellent, and rated them highly on their explanations and listening. The participants mean time that they were given to see their physician was nearly 19 minutes and all but 1 person said that they felt it was enough time for their physician to examine them and to have a satisfactory conversation with their physician. Jennifer felt as though her physician rushed her in and out during her appointments but said she was understanding of his position, and felt that in the time he did give her that she left mostly satisfied with his services. The examination process includes that communication process and makes sense that a relationship would be determined based on what the interviewees said. This hypothesis was supported.
The eighth hypothesis was supported that when the respondents were satisfied with verbal and non-verbal communication, they were satisfied with their physicians. Respondents who were satisfied with their choice of physician highly
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rated their explanations and listening. Respondents who were satisfied with explanations and listening were more satisfied with their choice of primary care physician. The more dissatisfied a patient was, the lower they rated their physicians communication. The results from the regression analysis are consistent with the responses from the interviewees. Overall, the participants were satisfied with their current choice of primary care physician and had positive things to say about their physicians listening and explanation styles. The two participants who described dissatisfaction with their previous physicians were dissatisfied with their communication. They said that their physicians did not listen to the research they had conducted and did not treat them as though their concerns were important. The communication process to these participants was essential to the satisfaction of their physician, and communication was an important aspect when describing their ideal physician.
Results showed a relationship only when looking at African Americans and White populations in relation to satisfaction with choice of primary care physician. Overwhelmingly, the respondents were white and showed both highest rates of satisfaction and dissatisfaction with choice of primary care physician. However, when comparing African Americans to Whites, Whites were more satisfied (78.1%) than African Americans (10.2%) with their choice of primary care physician (see
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table 4.26). These results could be skewed because of the larger sample size of whites compared to the other race/ethnic groups. However, as noted in the literature review, studies have shown that African Americans are more distrusting of physicians (Collins et al. 2002). This hypothesis was supported with the quantitative data but cannot be determined with the qualitative data. No African Americans were included in the interviews, however, each participant was asked whether they felt as though their race played a role in the way their physician communicated with them and not one participant answered that it did. This is an area that needs to be studied in future research.
Lastly, educational attainment level of the respondents was statistically significant when compared with physician explanations and satisfaction with choice of primary care physician. No relationship was found between educational attainment level of the respondents and physicians listening. The results show that the lower the educational attainment level, the lower the rating of explanations and satisfaction with choice of primary care physician. As noted in the literature review, there are differences in educational attainment level that could effect satisfaction with how their physicians communicate with them. Those who are less educated may have more limited knowledge of how to interact or communicate with their physician, which could effect their satisfaction. These patients prefer
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their physician to take control over their health care because of their limited knowledge and because they may have been socialized to listen to authority rather than negotiate with their physician (Weitzman et al. 2004). Those who are more educated may have a more efficient communicative relationship with their physicians because they may have developed those skills that someone with a lower educational attainment level may not have been exposed to. Annette Lareau (2003) found in her study with both middle and working and lower class families that middle class children were socialized with negotiation skills that will help them be more effective when communicating with others, including physicians. Working and lower class children were socialized to listen and respect authority rather than to negotiate or try to take charge. This type of socialization can carry with these children into adulthood, which would affect their communication with others, including physicians. Overall, the interviewees had a bachelors degree and indicated that they were somewhat knowledgeable about medical terminology and care that may have helped with the communication process. However, none of the interviewees said that they felt their educational background was an important component of their relationship with their physician. However, it did seem to come down to the physician themselves and their own way of communicating with patients. When each participant was asked about whether or not their age,
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biological sex, or race played a role in that communication process with their physician most responded that these things did not play a role. However, one participant, Maria, did say that when she sees her physician, she is usually coming from her job that requires her to wear scrubs. She said that because she works in the medical profession that it creates some conversation with her physician, but overall, this was not a reason why she was satisfied with her physician or her communication. This hypothesis was not completely supported. It could be with the respondents from the data set that maybe they do not think their own educational background reflects on their physicians non-verbal communication, which would be consistent with some of the findings from the interviews. Again, it may just come down to the personality of the physician and how well they listen, in general, regardless of patient background.
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CHAPTER 8
CONCLUSIONS
The results of this study are consistent with the existing literature that patients, in general, are satisfied with the way their physicians communicate with them. Patients are satisfied when their physicians take the time to listen to them while they are talking because this is an indication that their physicians are taking the time to care about their health, and shows that they are taking patients health seriously. Patients are also satisfied when their physician is consistently explaining things to them in a way that they can understand because when patients do not understand what their physician is telling them, they are less likely to understand what their health status is and may not follow doctors orders in treating their health. As I found with my interviews, people will more than likely seek other alternative health care options or other physicians for health care if they are dissatisfied with the way that they are being treated and communicated to. Insufficient communication from physicians seems to lead to lack of trust, which will ultimately lead to discontinuing the relationship with their physician.
As shown in the literature review, there are different communication styles of physicians, including affiliative and control styles, and physician partnership building and active patient participant. With the results of this study, the pattern
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shows that patients are different in what they are looking for in a physician and that it comes down to the quality of communication and interaction that they receive from their physician. Some patients preferred qualities from an affiliative style while others preferred more of a control style. Education and/or income may play as factors in who is more comfortable with which communication style but this needs to be researched further. Socializing children with language skills could effect which physician communication style will leave them satisfied as adults. For these participants in this study, they want to be communicated to in a way that they can understand, that they listen, and that their health care needs are taken care of. They said that they do not want to be treated with disrespect, and that they want their questions answered during their visit. They want to leave the doctors office feeling as though their physician took the time to take care of their medical needs. The participants in this study were mostly satisfied with their physician because they found physicians that satisfy their medical needs and were effectively communicated to. If patients prefer one communication style over another, they are more likely to shop around for physicians until they find one that meets their needs.
When applying all of this to the structural functionalism theory and social exchange theory, when communication and satisfaction is unequal between patients and physicians, the relationship is at risk to be terminated. As Peter Blau argued,
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when there are more costs than benefits to a relationship, a person may choose to terminate that relationship. When a physician is not effective in the way they communicate, this creates an imbalance in the relationship with their patients and ultimately the imbalance of the medical field. Patients who are dissatisfied will seek out other physicians or choose an alternative holistic healing method. When the interviewees were asked what characteristics their ideal physician would have, many of these people included communication as not only a characteristic, but a very important component to the patient/physician relationship. The communication process leads to trust and effective health care treatment, and people will more than likely utilize health care services when they are satisfied. Ahna told me in her interview that she dreads going in to see her primary care physician because of the way that she gets treated. She rates her satisfaction with that communication very low and will not see that physician unless she absolutely has to. People who are uncomfortable in any given situation will tend to avoid it, and this would be no exception for patients seeing their physician. The current medical field does not appear to be imbalanced since most patients are reporting satisfaction with their primary care physician; however, this study does show that the communication process weighs heavily on that satisfaction, and physicians need
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Full Text

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2004 Community Tracking Study Household Survey

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Introduction to Sociology

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2003-2004 Community Tracking Study Household Survey

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Consumer Complaint Department, most

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ot

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2003-2004 Community Tracking Household Study

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2003-04 Center for Studying Health Change Community Tracking Study Household Survey

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poor andfair negative, good, very good, excellent

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poor fair negative, good, very gOQd, excellent

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trust,

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N/A; trust N/A; age, Age

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Education, Sex Racelethnicitywas

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Family Income

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satisfaction with choice of primary care physician, doctor to meet medical needs, doctor performs unnecessary tests., biological sex race/ethnicity

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NOT SIGNIFICANT Trusting doctor s to meet-needs negative

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Age negative, positive positive Family Income negative negative

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positive Seeing the Same Provider negative negative positive, Education

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of.negative positive positive Doctor Performs Unnecessary Tests positive Thoroughness and Carefulness of the Exam Satisfaction with Choice of Primary Care Physician

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negatively positively, (How would you rate how well your doctor listened to you?). Race!ethnicity,Age, Biological Sex, Family income, and Education

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NOt SIGNIFICANT Trusting the Doctor to Meet Medical Needs

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"good to excellent" Satisfaction with Choice of Primary Care Physician negatively Satisfaction with Choice of Primary Care Physician.

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Trusting Doctor to Meet Medical Needs

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Age Biological Sex satisfied dissatisfied. satisfied

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dissatisfied. satisfied satisfied. Family Income, Seeing the Same Provider Yes No satisfied

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satisfied No, satisfied Doctor Performs Unnecessary Tests Thoroughness and Carefulness of Exam, satisfied with

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good fair (23.9%) good excellent poor good to excellent poor poor satisfied dissatisfied

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White, non-Hispanic African American, non-Hispanic Hispanic All other non-Hispanic Education

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Community Tracking Household Survey

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Doctor Performing Unnecessary Tests

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expedited process,

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Physician-Patient Relations: A Guide to Improving Satisfaction. Journal of General Internal Medicine Medical Care Exchange and Power in Social Life. Journal of Health and Social Behavior Patient Education and Counseling Medical Sociology, h Edition. The Commonwealth Fund: Journal of Health and Social Behavior

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Annuals of Internal Medicine (http://OPsychiatry in Medicine Medical Care The Sociology of Medicine: A Participants Observer's View. Journal of Health and Social Behavior Journal of Health and Social Behavior Physician-patient communication: readings and recommendations. Social Behavior: Its Elementary Forms.

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Journal of Health and Social Behavior Journal of Health and Social Behavior Medical Care Society: The Basics, 6th edition. Journal of Health and Social Behavior Medical Sociology. The Sociology of Health and Illness: Critical Perspectives. 6th Edition. Getting Rid of Patients: Contradictions in the Socialization of Physicians. America's Health Care System: A Comprehensive Portrait.

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American Sociological Association Journal of General Internal Medicine Journal of Health and Social Behavior Journal of General Internal Medicine Journal of Health and Social Behavior International Journal of Health Services The Sociology of Health, Healing and Illness.

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Journal o/Cross-Cultural Gerontology Quality Management Health Care