The Relationship Between Patient Socioeconomic Status and Patient Satisfaction: Does Patient-Physician Communication Matter?

Home , Erving Goffman

THE RELATIONSHIP BETWEEN PATIENT SOCIOECONOMIC STATUS AND PATIENT SATISFACTION: DOES PATIENT-PHYSICIAN COMMUNICATION MATTER?

A dissertation submitted to Kent State University in partial fulfillment of the requirements for the degree of Doctor of Philosophy

Susan M. Labuda Schrop

December, 2011

Dissertation written by Susan M. Labuda Schrop B.S., University of Akron, 1976 M.S., University of Akron, 1978 Ph.D., Kent State University, 2011

Approved by

______, Chair, Doctoral Dissertation Committee Timothy Gallagher, Ph.D.

______, Co-Chair, Doctoral Dissertation Committee Brian F. Pendleton, Ph.D.

______, Members, Doctoral Dissertation Committee Donna Martsolf, R.N., Ph.D., C.N.S.

______, Christian Ritter, Ph.D.

______, Mark Savickas, Ph.D., P.C.C.

______, Clare Stacey, Ph.D.

Accepted by

______, Chair, Department of Sociology Richard Serpe, Ph.D.

______, Dean, College of Arts and Sciences John R. D. Stalvey, Ph.D.

TABLE OF CONTENTS

LIST OF FIGURES ...... vi

LIST OF TABLES ...... vii

PREFACE AND ACKNOWLEDGEMENTS ...... ix PREFACE ...... ix ACKNOWLEDGEMENTS ...... xi

CHAPTER I. INTRODUCTION AND STATEMENT OF THE PROBLEM ...... 1 INTRODUCTION ...... 1 BACKGROUND ...... 3 The United States Health Care System ...... 3 Health Disparities versus Health Care Disparities ...... 5 The medically uninsured ...... 9 Medicaid ...... 11 Primary Care ...... 13 Patient-Centered Care ...... 16 Patient-Physician Relationship ...... 20 Problem Statement ...... 22

II. THEORETICAL FOUNDATION ...... 23 INTRODUCTION ...... 23 DYADS ...... 27 The Ideas of Georg Simmel ...... 27 The Ideas of George Herbert Mead ...... 29 The Ideas of Erving Goffman ...... 30 THE PATIENT AND PHYSICIAN AS A DYAD...... 35 The Ideas of Talcott Parsons ...... 35 THE PROFESSION OF MEDICINE ...... 37 Physician Socialization ...... 39

III. LITERATURE REVIEW ...... 43 INTRODUCTION ...... 43 SOCIOECONOMIC STATUS AS A FUNDAMENTAL CAUSE OF DISEASE ...... 44 THE PATIENT-PHYSICIAN INTERACTION...... 51 PATIENT SATISFACTION ...... 62 iii

Measuring Patient Satisfaction ...... 63 Factors Affecting Patient Satisfaction ...... 66 Patient characteristics...... 66 Physician characteristics ...... 70 Characteristics of the care delivery site ...... 74 Does patient satisfaction matter? ...... 77 IMPACT OF GENDER AND RACE ON HEALTH AND HEALTH CARE, AND OTHER CONSIDERATIONS ...... 80 SUMMARY ...... 88

IV. RESEARCH QUESTIONS ...... 91 INTRODUCTION ...... 91 GENERAL ISSUE TO BE INVESTIGATED ...... 93 The Gap ...... 93 Filling the Gap ...... 94 Specific Aim ...... 95 HYPOTHESES ...... 96 The Relationship between Patient Socioeconomic Status and Patient-Physician Communication ...... 96 The Relationship between Patient-Physician Communication and Patient Satisfaction...... 98 The Relationship between Patient Socioeconomic Status and Patient Satisfaction ...... 100

V. RESEARCH METHODS ...... 102 INTRODUCTION ...... 102 METHODS ...... 103 Design/Methodology Strategies – The Direct Observation of Primary Care Study ...... 103 Specific aim of the DOPC study ...... 103 Sites and subjects of the DOPC study...... 104 Data collection procedures of the DOPC study ...... 104 Measures used in the DOPC study...... 106 Data security ...... 110 Data analysis techniques for the DOPC study ...... 110 Brief overview of results of the DOPC study ...... 111 Design/Methodology Strategies – The Present Study ...... 113 Specific aim ...... 113 Data ...... 113 Sites and subjects ...... 113 Institutional review board review and approval ...... 114 Conceptualization and operationalization of the variables ...... 114 Creation of scales ...... 118 Creation of scores ...... 118 iv

Creation of other new variables ...... 119 Coding of variables ...... 120 Analysis techniques ...... 122 The relationship between patient socioeconomic status and patient-physician communication ...... 123 The relationship between patient-physician communication and patient satisfaction ...... 124 The relationship between patient socioeconomic status and patient satisfaction ...... 125

VI. RESULTS ...... 127 INTRODUCTION ...... 127 THE STUDY SAMPLE ...... 128 THE RELATIONSHIP BETWEEN PATIENT SOCIOECONOMIC STATUS AND PATIENT-PHYSICIAN COMMUNICATION ...... 134 THE RELATIONSHIP BETWEEN PATIENT-PHYSICIAN COMMUNICATION AND PATIENT SATISFACTION ...... 141 THE RELATIONSHIP BETWEEN PATIENT SOCIOECONOMIC STATUS AND PATIENT SATISFACTION ...... 149 SUMMARY ...... 157

VII. IMPLICATIONS ...... 158 SUMMARY ...... 158 DISCUSSION AND INTERPRETATION OF FINDINGS...... 159 The Relationship between Patient Socioeconomic Status and Patient-Physician Communication ...... 159 The Relationship between Patient-Physician Communication and Patient Satisfaction...... 161 The Relationship between Patient Socioeconomic Status and Patient Satisfaction ...... 163 LIMITATIONS ...... 164 CONTRIBUTIONS ...... 170 FUTURE RESEARCH ...... 170 FINAL COMMENTS ...... 172

BIBLIOGRAPHY ...... 175

APPENDICES ...... 199 A. The Direct Observation of Primary Care Study – Methods ...... 199 B. The Direct Observation of Primary Care Study – Data Fields ...... 213 C. Human Subjects Oversight ...... 244

LIST OF FIGURES

Fig. 1 Factors Influencing Patient Centeredness...... 18

Fig. 2 Factors Influencing Patient-Centered Communication ...... 19

Fig. 3 General Factors Affecting the Delivery of Primary Care ...... 94

Fig. 4 Conceptual Model of the Present Research ...... 95

LIST OF TABLES

Table 1 Variables for Analysis for the Present Study ...... 116

Table 2 Demographic Profile of Medicaid versus Privately Insured Patients ...... 131

Table 3 Visit Profile of Medicaid versus Privately Insured Patients ...... 132

Table 4 Profile of Physicians ...... 133

Table 5 Effect of Insurance Status on Centeredness ...... 138

Table 6 Effect of Insurance Status on Chatting ...... 140

Table 7 Effect of Centeredness on Patient Satisfaction with the Practice Site ...... 144

Table 8 Effect of Centeredness on Patient Satisfaction with the Physician ...... 145

Table 9 Effect of Centeredness on Overall Patient Satisfaction ...... 146

Table 10 Effect of Centeredness on Patient Perception of Having Expectations Met ...... 148

Table 11 Effect of Patient Insurance Status on Patient Satisfaction with the Practice Site ...... 152

Table 12 Effect of Patient Insurance Status on Patient Satisfaction with the Physician ...... 153

Table 13 Effect of Patient Insurance Status on Overall Patient Satisfaction ...... 154

Table 14 Effect of Patient Insurance on Patient Perception of Having Expectations Met ...... 156

Table B.1 Operational Definitions of the Modified Davis Observation Code Used for Direct Observation Coding...... 214

Table B.2 Content of the Direct Observation Checklist ...... 218

Table B.3 Content of the Patient Exit Questionnaire ...... 221 vii

Table B.4 Data Recorded from the Medical Record ...... 226

Table B.5 Content of the Practice Environment Checklist ...... 231

Table B.6 Content of the Physician Questionnaire ...... 237

viii

PREFACE AND ACKNOWLEDGEMENTS

PREFACE

This dissertation provides me with the opportunity to converge three areas that are very important to me – my profession, my health and the health of my family, and my community.

My profession: I have had the privilege of teaching communication skills to first- year medical students for 30 years. I always begin my introduction each year by reinforcing the importance of patient-physician communication skills and emphasizing that knowledge of disease processes is only one of two critical elements in the diagnosis of disease. The second is the patients’ history – not only what symptoms patients are experiencing and what health concerns they and their family members have had in the past, but just as important is who they are as a person – what matters to them and the type of family and community in which they live. This context allows the physician to treat a patient who has a health problem, not treat only the problem. Without excellent communication skills, physicians rarely will be able to elicit a “good” history from a patient, good in the sense that the patient shares meaningful information, information that is necessary for the physician to help solve the patient’s problem. Without that history, problem solving is severely hindered. Further, without the personal context, treatment will not be optimal. The patient comes first – medical professionals are doing what they do because and only because of the patient. For this reason, the patient will be

acknowledged first throughout my dissertation, i.e., the patient-physician relationship rather than the physician-patient relationship.

My health and the health of my family: My health and the health and health care of my family matter to me. I’ve had optimal interactions with physicians, and those that have been dismal. The discerning factor for me has been communication. What I consider to be an optimal interaction – the most satisfying for me – may not always be an interaction that is in my or my family member’s best interest. Those that might not be as satisfying to me, might actually be in my best interest – those during which difficult subjects were discussed or I heard information that I did not want to hear. However, the outcomes were of optimal benefit to my health. On the other hand, there have been dismal interactions wrought with poor communication or miscommunication often without regard for personal needs and/or preferences. Dismal interactions serve no useful purpose for me, my family members, or the physicians themselves.

My community: For many years, I have served in an advocacy role for the poor and the medically underserved. My research has focused on improving preventive health and medical communication. I spend a significant amount of time serving the Ohio

Association of Free Clinics as a member of and secretary to the Board of Directors, as co- chair of the Education Committee, and a regular presenter at their conferences. Several years ago, I had a discussion with my previous department chair regarding services provided in free clinics. I commented that the medically uninsured deserved the same number and quality of health care and services provided in the clinics to which I typically have access. I was shocked when she said that wasn’t necessarily so. After a pause, she

clarified that the underserved need more. Their economic disadvantage puts them at a disadvantage for accessing health-related services at sites other than the free clinics. They need more than primary care at the site – they need additional services that include mental health care, dental care, and social support, among many others. My work with directors and staff at the free clinics and my focus on literacy reinforces that the communication that takes place with those of lower levels of education must be much different – but does it? Physicians need to, and must, talk with all patients in ways that patients can understand, using plain language.

Therein lays the rub. Does the communication that takes place between a patient and a physician differ in any measureable, meaningful way when the patient’s socioeconomic status differs? And, does this difference, if there indeed is one, matter to the patient, his/her satisfaction with the visit, and ultimately health outcomes?

ACKNOWLEDGEMENTS

As difficult as the dissertation was to write, this section was by far the most difficult. It was difficult both to express how deeply grateful I am to those who have tolerated, supported, and mentored me throughout this educational endeavor as well as to remember all those who have made important contributions to this process. Therefore, I offer my thanks in general terms. You know who you are. To my friends and colleagues at NEOMED, thank you for listening to me talk, sometimes incessantly, about my

“school work.” You allowed me to interrupt your work and listened attentively when I discussed topics ranging from Marx to statistics and health disparities, although most

times you probably wanted to get on with your work and for me to get to my desk and to my work. To my family, those with me and those who came before me, you provided the encouragement, space, and support on a 24/7 basis – all hours of the day and night, all days of the week, holidays and vacations included. To my committee, your guidance and support must be unmatched. I would like to believe, but I doubt that it is the case, that no other graduate student shared in the same riches that I have had. I consider myself so fortunate that you have been willing to share your knowledge and wisdom, never failing me. To you, I offer my utmost thanks and appreciation.

xii

CHAPTER I

INTRODUCTION AND STATEMENT OF THE PROBLEM

The modern era in medicine has brought a turning away from a quality of doctor/patient interactions that had persisted over centuries. When there were few efficacious remedies, doctors relied upon the healing power of the doctor/patient relationship. Hippocrates observed “The patient, though conscious that his condition is perilous, may recover his health simply through his contentment with the goodness of the physician.” Balint reaffirmed the importance of the doctor/patient interaction, asserting that by far the most frequently used drug in medical practice is the doctor him- or herself. (Novack 1995:32)

INTRODUCTION

The therapeutic efficacy of the patient-physician interaction plays a central role in medicine. The patient-physician interaction, however, is a naturally asymmetrical relationship (Parsons 1951). Although both interactants in the encounter likely share the common goal of the patient’s good health, many factors can impact the quality and symmetry of the patient-physician interaction, and ultimately health outcomes. These factors include cognitive factors such as patient and physician beliefs about health and health care (e.g., Martin 1983), affective factors such as communication strategies (e.g.,

Ruusuvuori 2001; Stewart 1995), behavioral factors such as how the patient and physician carry out their roles and the structural aspects of the encounter (e.g., Bertakis et al. 1998), and patient characteristics and social factors such as patient socioeconomic status (e.g., Bernheim et al. 2008; Hooper et al. 1982; Meyers et al. 2006). Patients’

socioeconomic status has been linked to a number of disparities in health and health care.

People who are poor have less formal education, lack health insurance, have more difficulty accessing health care services and bear a higher burden of disease than their more wealthy counterparts (Andrulis 1998; Ross and Mirowski 2000). Muenning et al.

(2005) considered the income-associated burden of disease to be the leading cause of morbidity and mortality in the United States.

In a 2007 viewpoint published in the European Journal of Public Health, Mark

Petticrew highlighted that in spite of the fact that health policy makers and researchers recognize the need and call for better evidence on the effects of interventions on health inequalities, there remains a relative absence of rigorous research in this area. While waiting for better evidence to fill the gaps, he stressed the need to make better use of the information we do have, whatever its limitations, regarding the social determinants of health with the objective of ameliorating health inequalities. This dissertation research can identify what new interventions might be appropriate and where they should be directed.

The objective of this dissertation is to examine the relationship between patient socioeconomic status and patient satisfaction and if this relationship is mediated by patient-physician communication, which is a key aspect of patient-centered care. It represents the merging of two disciplines – sociology and medicine – both of which are essential for a comprehensive understanding of health and health care delivery. This chapter presents background information to help ground the dissertation in medicine and sociology. General information about the U.S. health care system is provided followed by

a discussion of the difference between health disparities and health care disparities. The medically uninsured and the Medicaid system of public health insurance are defined followed by definitions of primary health care and patient-centered care. Finally, the patient-physician relationship is introduced followed by the problem statement.

In subsequent chapters, the sociological theoretical foundations of the relationship between and the role of the patient and physician are reviewed, followed by a review of the literature focused on patient-physician communication and patient satisfaction. The knowledge gap is specified followed by the presentation of a model that can help reveal any differences that exist in the delivery of patient-centered care between poor people

(who will be defined in this dissertation as those who have Medicaid insurance) and those who have private insurance coverage. This information is essential to inform health policy as states and the nation move forward with expanding government-sponsored health insurance for poor people, and to structure educational interventions along the entire medical education continuum that will address the role of the physician in improving the health and health care of some of our nation’s most vulnerable citizens, the medically disenfranchised.

BACKGROUND

The United States Health Care System

The United States continues to be the only major capitalist country without a comprehensive national health program. In spite of its international acclaim, the United

States has one of the most dysfunctional health care systems among the countries in its tier, and poor people fare the worst. The U.S. has accepted a piecemeal, incremental

approach to providing for the health care of the nation. The two major problems with our health care system are cost increases and access to health care in our two-tiered health care system – one system for most of us, and one for the poor (Patel and Rushefsky

1999). High costs and insufficient coverage are the key characteristics of the U.S. health care non-system, the most inefficient and inhuman health care system in any developed country (Navarro 1993).

Health, regardless of the country in which a person lives, follows a social gradient, or what Michael Marmot referred to as the status syndrome (Marmot 2004). He emphasized that one’s standing in the social hierarchy and the chances of getting ill are intimately related – the higher one’s standing in the social order, the better one’s health – with the difference between the top and bottom growing for the last generation. Further, he indicated that “these social inequalities in health – the social gradient – are not a footnote to the ‘real’ causes of ill health in countries that are no longer poor; they are the heart of the matter” (Marmot 2004:3). Because the U.S. does not have a health system that provides universal access to primary care and coverage for all, being poor matters more to health and health care access in the United States. The cynical, but unfortunately true, comment regarding health care access in the U.S. is that there is universal access – use of the emergency room for all health care needs, whether they are emergent or not, whether one has health insurance or not (Pendleton, Brian F., personal communication

2007). However, access to primary care is critical for effective and efficient entry into the health care system and achieving and maintaining optimal health. The most important single factor necessary for adequate access to health care is insurance, either private or

public (Geyman 2005), and most people in the U.S. who have health insurance have it through their jobs (Patel and Rushefsky 1999). But, it is important to keep in mind that access to health care does not guarantee good health or equal treatment after access has been gained.

The medically underserved are those persons who are unable to, or have difficulty having their health care needs met because they are uninsured, underinsured, or otherwise lack access to needed care. Although all societies ration health care (Conrad and Brown

1999), how people get sick, die, and the type of health care they receive depends not only on their race and gender, but primarily on the social class to which they belong (Navarro

1993). The U.S. does have social classes, and the poor in the U.S. are more likely to be medically underserved and have less access to primary health care than their more affluent counterparts (Geyman 2005).

Health Disparities versus Health Care Disparities

In the U.S., socioeconomic status is a strong and consistent predictor of morbidity and mortality. Americans in the lower socioeconomic groups suffer disproportionately from almost every disease and show higher rates of mortality than those above them. This association is found considering each of the socioeconomic status indicators – income, education, and occupational status (Adler et al. 1997). This is health disparity –

differences in the incidence, prevalence, mortality, burden of diseases, and other adverse health conditions or outcomes that exist among specific population groups in the United States. Health disparities can affect population groups based on gender, age, ethnicity, socioeconomic status, geography, sexual orientation, disability, or special health care needs, and occur among groups who have persistently experienced historical trauma, social disadvantage, or discrimination, and systematically experience

worse health or greater health risks than more advantaged social groups. (NACDD 2006:N.p.)

The Institute of Medicine (2001) recognized that the U.S. health care system “often lacks the environment, the processes, and the capabilities needed to ensure that services are safe, effective, patient-centered, timely, efficient, and equitable” (p. 25). Unfortunately, the poor fare the worst in their health and in our health care system, and the existence of social inequalities in health pose the most serious challenge to improving the health of the nation (Whitehead and Dahlgren 2006). According to the U.S. Agency for Healthcare

Research and Quality, “racial, ethnic, and socioeconomic disparities are national problems that affect health care at all points in the process, at all sites of care, and for all medical conditions – in fact, disparities are pervasive in our health care system”

(USDHHS AHRQ 2004:N.p.).

Carter-Pokras and Baquet (2002) provided a fairly comprehensive summary of the meaning behind and definitions of health disparities. Although many words can be used to indicate differences in health between groups of people, the term “health disparity” is almost exclusively used in the United States, with “health inequality” and “health inequity” used elsewhere. In the U.S., disparity in the public health context has taken on the implication of injustice. Health disparities can be considered a chain of events with differences in: 1) environment, 2) access to, utilization of, and quality of care, 3) health status, and 4) a particular health outcome that deserves scrutiny.

The majority of the definitions of health disparity focus on the health and health status of groups of people, with health status being the focal point. For example, the

World Health Organization defined health inequalities as “differences in health which are

not only unnecessary and avoidable, but, in addition, are considered unfair and unjust”

(Whitehead 1990:9). Equity in health implies that ideally everyone could attain his/her full health potential, and no one should be disadvantaged from achieving this potential due to social position or other socially determined circumstance (Whitehead and

Dahlgren 2006). Healthy People 2010 (USDHHS 2000) defined health disparities as differences that occur by race and ethnicity, gender, education, income, geographic location, disability status, or sexual orientation. And, in its first attempt at a definition in

1999, the National Institutes of Health defined health disparities as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States” (NCI

2010:N.p.). This definition evolved in 2000, and under United States Public Law 106-

525, also known as the “Minority Health and Health Disparities Research and Education

Act,” the legal definition became: “A population is a health disparity population if there is significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality or survival rates in the population as compared to the health status of the general population” (NCI 2010:N.p.).

Inadequate access to health services is also a critical component of health disparities but is reflected in only one definition reported by Carter-Pokras and Baquet

(2002), that of the U.S. Department of Health Resources and Services Administration,

Workgroup for the Elimination of Health Disparities, and includes “a population-specific difference in the presence of disease, health outcomes, or access to care” (p. 430).

Whitehead and Dahlgren (2006) focused on the human rights perspective and indicated

that adequate access to health services is a very basic right for people and that having access to effective health care ameliorates suffering of the sick, protects and prevents people from developing disease in the first place, and helps people maintain their own health when well. “Without the benefits that access to health services can bring, by improving health and providing freedom from pain and suffering, all other human activities are compromised” (Whitehead and Dahlgren 2006:8). Further, the Institute of

Medicine acknowledged that “In America, there is no guarantee that any individual will receive high-quality care for any particular health problem” (IOM 2001:24), and again, poor people fare the worst.

Although it is acknowledged that differences do exist in access to health care, no definition could be found that addressed inequalities or disparities that exist in the delivery of health care once access has been achieved. This also is health care disparity – the unequal treatment of patients on the basis of one or more of their personal characteristics, unequal treatment that is not justified by the patient’s underlying health condition or treatment preference. This dissertation will focus on the more narrow specification of disparities in health care access – disparities that might be the result of differences in the provision of primary care once access has been gained. Although the focus of this dissertation will be on those persons who are insured by Medicaid, the U.S. government-sponsored health insurance for poor people, an overview of health care for most poor people, the medically uninsured and well as those insured by Medicaid, will be provided because the medically uninsured and underinsured are essentially inseparable when socioeconomic status is considered.

The medically uninsured. The U.S. Medical Expenditure Panel Survey (Chu and

Rhoades 2009) defined the uninsured as people not covered by Medicare, TRICARE

(armed forced-related coverage), Medicaid, other public hospital/physician programs, private hospital/physician insurance (including Medigap), non-comprehensive state- specific programs, or private single service plans. According to the U.S. Census Bureau, the number of uninsured in the U.S. has continued to increase to 46.3 million people, representing 15.4 percent of the population, and among young adults, ages 18 to 24, the number of uninsured increases to nearly 30 percent (Cohen, Martinez, and Ward 2010).

Almost 20 percent of Americans had no health care coverage for at least part of 2009, and almost 11 percent had been uninsured for more than a year prior to the 2009 National

Health Interview Survey (Cohen et al. 2010). The Kaiser Commission on Medicaid and the Uninsured (2010) indicated that due to the deep recession and decline in employer- sponsored health insurance, the number of uninsured grew to 50 million in 2009. In Ohio, the number of uninsured adults, ages 19-64 reached almost 1.2 million in 2010, representing almost 17 percent of adults of that age group (HPIO 2010). Regardless of the specific number, the number of uninsured Americans is large by all estimates.

Although the uninsured are a diverse group, they are more likely to be poor and low income rather than high income, with more than half of the uninsured below 200 percent poverty. The poor and the near poor comprise almost 70 percent of the uninsured population (OHA 2006). Although four out of every five uninsured Americans are from working families (OHA 2006), the uninsured are less likely than other Americans to be working, and if they do work, less likely to work full time, less likely to receive an offer

of health insurance, and less likely to be able to afford an offer of coverage (USDHHS

OASPE 2005).

Robert Ferrer (2001) referred to the U.S. health care system as a system of no- system, one that is an increasingly incoherent system of exclusion that denies care to the uninsured, one of fragmented resources, a netherworld of closed doors and shrinking services, the paradox of which is that this no-system is becoming increasingly systematized. Imbedded in our health care system is a so-called safety net of providers who provide care for the uninsured. Those who are uninsured access primary care through safety-net providers – access to care networks, federally qualified health centers, and free clinics. The simple fact that these resources exist in the U.S. today is due to gaps in the health care delivery system.

Access to care networks are community-based organizations that link those who are uninsured and the working poor to primary and specialty health care services that are already in place throughout the community. Typically, services are provided at no cost to the patients thanks to volunteer efforts of participating physicians and donations of services by local health care facilities. Federally qualified health centers (FQHCs) are both public and private non-profit health care organizations that are funded by the federal government specifically under Section 330 of the Public Health Service Act (USDHHS

HRSA 2010). FQHCs provide comprehensive primary health care services for all, with fees adjusted based on ability to pay. Although FQHCs are intended primarily to serve populations with limited access to health care, they serve the uninsured as well and those who have full health insurance and those insured by Medicaid, receiving enhanced

Medicaid reimbursement. Unlike access to care networks and federally qualified community health centers, free clinics are volunteer-based, safety-net health care organizations that provide a range of medical, dental, pharmacy, and/or behavioral health services to economically disadvantaged individuals who are predominately uninsured

(NAFC 2010), typically at no cost to the patient for primary health care.

The uninsured typically have worse health than those who are privately insured, with 10 percent reporting fair or poor health compared to only 5 percent of those privately insured. They are up to three times more likely to report problems getting needed medical care, even for serious conditions, than their privately insured counterparts, more likely to be hospitalized for avoidable health problems, less likely to receive preventive care, and less likely to receive regular outpatient care (Kaiser 2006).

Extending Medicaid to the uninsured would reduce their mortality rates by 10-15 percent

(Geyman 2005). However, the positive association between socioeconomic status and health is well established (Ross and Mirowsky 2000), and the income-associated burden of disease would still remain as a leading cause of morbidity and mortality in the U.S.

(Muenning et al. 2005).

Medicaid. Some people with limited economic resources are eligible for health care coverage by a government- and state-sponsored program – Medicaid. Medicaid assistance is not available to all poor persons. Medicaid is available only to certain low- income individuals and families who fit into a designated, i.e., eligibility, group that is recognized by federal and state law (USDHHS CMMS 2006). It is important to note that not all low-income individuals are eligible for Medicaid, and entry-level incomes differ

by state. Nationally, Medicaid provides health care services to 19 percent of the total population, 52 million people, including children and many of the nation’s poorest and sickest (Kaiser N.d.). Nationally, 37.6 million adults ages 19-64 are insured by Medicaid including 10 percent of women and 7 percent of the men. The racial and ethnic distribution of the non-elderly insured by Medicaid includes 16.8 million (42 percent) who are white, 8.7 million (22 percent) who are black, and 10.9 million (28 percent) who are Hispanic (Kaiser N.d.).

In Ohio, more than 1.7 million receive Medicaid-supported services on an average monthly basis (ODJFS 2005), including 1.3 million non-elderly adults (Kaiser N.d.).

Ohio’s Medicaid program, a complex system with more than 50 separate categories of eligibility, is the sixth largest in the country in terms of both spending and enrollment. In

Ohio, Medicaid spending for all state agencies reached approximately $12.5 billion in

2005, approximately 25 percent of the entire state budget. Women make up a disproportionate share (57.9 percent) of Ohio’s Medicaid consumers. More than two- thirds of people enrolled in Ohio Medicaid are white, about one-third are black, and about

3 percent are Hispanic, which is 25 percent of all Hispanics in Ohio (Kaiser N.d.).

At both the state and national levels, there are movements to provide health insurance for the uninsured. In the state of Ohio, former Governor Strickland launched the Healthcare Coverage Reform Initiative (ODI 2009). The goal of his administration was to make affordable health insurance available to all Ohioans with an initial target of covering 500,000 more Ohioans by 2011, presumably through a Medicaid-like program.

In theory, this would provide access to necessary primary care services, generally considered to be general internal medicine, general pediatrics, and family medicine.

At the national level, the U.S. Congress passed the Affordable Care Act in March

2010. The Act put comprehensive health insurance reforms into place to “hold insurance companies more accountable, lower health care costs, guarantee more health care choices, and enhance the quality of health care for all Americans” (HealthCare.gov N.d.).

Among the intentions of the legislation is to help those who are currently uninsured by providing them with affordable health care coverage and better control of their own decisions about their health care coverage. The HealthCare.gov (N.d.) website explicitly acknowledged that “not all Americans have equal access to health care – or similar health care outcomes [and recognizes that] low-income Americans . . . have higher rates of disease, few treatment options, and reduced access to care. By improving access to quality health care for all Americans, the Affordable Care Act will help reduce these health disparities” (HealthCare.gov N.d.).

Primary Care

Although specialty care is considered to be the pride of the American health care system (Starfield 2005), primary care is the backbone of the U.S. health care system.

Primary care deals with most health problems for most people most of the time. Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care (AAFP 2009). Primary care is performed and managed by a personal physician and includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis, and treatment of acute and

chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Ideally, a primary care practice serves as the patient’s point of entry into the health care system and as the continuing focal point for all needed health care services. There is ample evidence that a good relationship with a freely chosen primary-care physician is associated with better and more appropriate care, better health, and much lower health costs (Starfield 2005).

Because this dissertation focuses on the relationship between family physicians and their patients, it is important to understand the differences among the primary care disciplines of general pediatrics, general internal medicine, and family medicine.

Understanding these differences will help the reader appreciate the perspective from which each approaches interactions with patients and patient care in the outpatient setting. Pediatricians focus on the physical, emotional, and social health of infants, children, adolescents, and young adults from birth to 21 years. Rather than focusing on a particular aspect of a child’s health, general pediatricians’ responsibilities include diagnosing and treating acute and chronic disorders, managing serious and life- threatening illnesses and referring complex conditions as needed, monitoring physical and psychosocial growth and development, and providing age-appropriate screening, health supervision, and anticipatory guidance for patients and parents (AAP 2006).

Internists diagnose and provide non-surgical treatment of a wide range of diseases and injuries of internal organs of adults (USDL BLS 2009). General internists do not limit their practice to one type of medical problem or organ system. They care for the broad, comprehensive spectrum of illnesses that affect adults and are recognized as

experts in diagnosis, treatment of chronic illness, health promotion, and disease prevention. General internists often care for patients over the duration of their adult lives; therefore, they have the opportunity to establish long-term relationships with their patients (ACP 2009).

Family medicine can be thought of as the cradle to grave specialty. It is the medical specialty that provides continuing, comprehensive care for individuals as well as the family, with a scope that encompasses all ages, both sexes, each organ system, and every disease entity. As a broad specialty, it integrates the biological, clinical, and behavioral sciences. Family medicine is a three-dimensional specialty, incorporating knowledge, skill, and processes. Knowledge and skill may be shared with other specialties, but the process of family medicine is unique. The center of this process is the patient-physician relationship with the patient viewed in the context of the family. It is the extent to which this relationship is valued, developed, nurtured, and maintained that distinguishes family medicine from all other specialties (AAFP 2009).

Worth noting, Bertakis et al. (1998) provided an overview of the differences in practice styles between family medicine and general internal medicine. Comparing family physicians to internists, family physicians tend to see patients who are younger and healthier. This difference in patient demographics, however, may be one of the reasons that internists tend to use more health care resources in their patient care.

Compared to family physicians, internists have a greater tendency to spend more time examining and instructing patients. However, internists tend to order more laboratory tests and to refer more patients to other specialists, leading to higher costs. Practice style

differences also impact hospitalizations, resulting in lower in-patient costs for patients under the care of family physicians due to a lower number of admissions, shorter hospitalizations, and significantly lower professional costs per hospitalization.

Patient-Centered Care

Communication is one of the foundations of health care (Wynia and Matiasek

2006). All health care interactions depend on effective communication – from making an appointment, to describing symptoms, discussing risks and benefits of treatment, and understanding care instructions. Good communication has been linked to improved patient satisfaction and adherence to medical recommendations, and better health outcomes (DiMatteo 1994; Gordon, Baker, and Levinson 1995; Stewart 1995; Williams,

Weinman, and Dale 1998; Wynia and Matiasek 2006). Health care communication is believed to be more effective when it is patient-centered (Wynia and Matiasek 2006).

Although the term “patient-centered care” is found frequently in the medical and social sciences literature, consensus has not been reached regarding its meaning (Mead and

Bower 2000). Laine and Davidoff (1996) used a definition of patient-centered care as care that is “closely congruent with, and responsive to patients’ wants, needs, and preferences” (p. 152). Stewart et al. (2003) provided a definition that included six interconnecting components: 1) exploring both the disease and the illness experience, 2) understanding the whole person, 3) finding common ground regarding management, 4) incorporating prevention and health promotion, 5) enhancing the patient-physician relationship, and 6) “being realistic” about personal limitations and issues such as the availability of time and resources, all components of which seem to be patient centered.

“Patient-centered medicine is concerned to encourage significantly greater patient involvement in care than is generally associated with the ‘biomedical model’” (Mead and

Bower 2000:1090).

Many factors have been identified that can and do influence patient-centered care.

These factors are best illustrated in Figure 1. Key measurable features important to this dissertation are: 1) time, which can facilitate the development of the relationship between a patient and a physician and enable the physician to increase his/her knowledge about the patient, 2) socioeconomic background of the patient, which often determines resources available for medical care including type of health insurance, 3) physician factors including knowledge of the patient, 4) patient factors including gender, age, and ethnicity, and 5) knowledge of the physician; and features of the consultation including time limitations.

Fig. 1. Factors Influencing Patient Centeredness (Mead and Bower 2000:1104)

Epstein et al. (2005) focused on one aspect of patient-centered care – patient- centered communication, the purpose of which is to help physicians provide care concordant with patients’ values needs and preferences, care that provides opportunities for patients to provide input and participate in decisions regarding their health care. They indicated that the term patient-centeredness should be reserved to describe a moral philosophy and that patient-centered communication between the patient and physician promotes patient-centeredness. Their operational definition of patient-centered communication has four components: 1) eliciting and understanding the patient’s perspective, 2) understanding the patient within his or her unique psychosocial context, 3) reaching a shared understanding of the problem and its treatment with the patient that is concordant with the patient’s values, and 4) helping patients share power and

responsibility by involving them in choices to the degree that they wish. Epstein et al.

(2005) stressed that four factors combine to influence patient-centered communication – patient factors, health system factors, relationship factors, and clinician factors. See

Figure 2.

Fig. 2. Factors Influencing Patient-Centered Communication (Epstein et al. 2005:1517)

Referring to Figure 2, expectations, the intersection of patient and relationship factors, can influence what patients anticipate will happen during their interaction with their physician and what they expect for their health as a result of their health care seeking behavior. These expectations can influence patients’ satisfaction with their physicians and the care delivered. Length of visit and visit frequency, the intersection of health system and clinician factors, also can impact the patient-physician interaction by

influencing how much information can be discussed or how many services can be delivered during a visit or throughout the year, and therefore, also can influence patient satisfaction.

Patient-Physician Relationship

In its earliest conceptualization, the patient-physician relationship was viewed as a bounded relationship between two parties, evolving into a relationship analogous to a parent-child relationship, with the doctor as the parental figure concerned for the best interest of his/her patient/child. In the 21st century, this relationship can be conceptualized more as an encounter rather than a relationship, a relationship that has become increasingly impersonal, reflecting the commercialization of medicine (Potter and

McKinlay 2005). However, research has shown that “when physicians listen fully, exhibit care and compassion, and engage in other prosocial behaviors, patients’ psychological status, physiological symptoms, and functional outcomes all improve” (Stewart 2003 in

Heritage and Maynard 2006:354). Further, Goffman stressed that the interaction between a physician and a patient is a significant element in the linkage between sociological variables such as race, gender, ethnicity, and socioeconomic status on the one hand, and medical decision making and outcomes on the other (Goffman 1983 in Heritage and

Maynard 2006:367).

In a small qualitative study, Bernheim et al. (2008) found that: 1) physicians’ views conflicted about the effect of patients’ socioeconomic status on clinical management decisions, typically indicating that their practice patterns should not be influenced by patients’ socioeconomic status, but nearly all recounting circumstances

when it did, 2) physicians believed that any changes they made in their typical clinical management due to patients’ socioeconomic status was in the best interest of the patient,

3) physicians varied in their beliefs regarding how these changes in clinical management impacted patient outcomes, and 4) physicians faced both personal and financial strains caring for patients of low socioeconomic status.

The Institute of Medicine (2001) recognized the need for “reestablishing clinician-patient relationships that are at the heart of good health care” (p. 48), with interpersonal interactions being shaped to meet the needs and preferences of individual patients, and care that is based on individuals’ particular needs and not on personal characteristics unrelated to the patient’s condition or the reason for seeking care. One difficulty surfaces when the term “relationship” is considered. Relationship is defined as

“the state of being related or interrelated,” with relate defined as “connected by some understood relationship” (The Merriam-Webster Dictionary 1997). Another term is important to consider – interaction. The U.S. health care system is changing. Patients often no longer have long-term “relationships” with their primary care physician due to limitations in physician choice dictated by their health care insurance plan. Further, those who are uninsured may have a “relationship” with a health care facility, e.g., a free clinic, but not with a specific physician as physicians who volunteer to provide care have limited time dedicated to the clinic. A different term to consider when discussing the patient- physician relationship, and possibility a better descriptive term, is “interaction,” defined as “mutual or reciprocal action or influence” (The Merriam-Webster Dictionary 1997).

Two additional terms often used in reference to the interaction that occurs between the

patient and physician are “encounter” and “visit.” These words will be used interchangeably throughout this dissertation.

Problem Statement

The Institute of Medicine (IOM) recognized that “health care is plagued by a serious quality gap” (IOM 2001:35), with quality being defined as “the degree to which health care services for individuals and populations increases the likelihood of desired outcomes and are consistent with current professional knowledge” (p. 44). The Institute of Medicine (2001) also called for change at all levels of the health care enterprise, including the patient-physician relationship. In order to close the gap, the Institute (2001) recognized the need for health care solutions that are patient-centered, and one that is

“more equitable and meets the needs of all Americans without regard to race, ethnicity, place of residence, or socioeconomic status” (p. 35). In order to improve the system, they put forth three recommendations, the second of which indicates that we should pursue six specific aims for improvement: health care should be safe, effective, patient-centered, timely, efficient, and equitable. They noted that “These aims are not new; they are familiar and have been valued, arguably for decades, among health care professionals, patients, policy makers, and communities. Yet American health care fails far too often with respect to these aims, despite its enormous cost and the dedication and good efforts of millions of American health care workers” (IOM 2001:43). Based on this information, an important question to be answered by this dissertation is – Does the interaction that takes place between the patient and the physician mediate the relationship between socioeconomic status and patient satisfaction?

CHAPTER II

THEORETICAL FOUNDATION

Men shape and organize the knowledge, perception and experience of illness, and much of the substance of illness behavior, its management and treatment. While man is a biological organism, he responds to himself and others in terms of the social meanings he assigns to his experience with the physical and biological world. . . . A critical difference exists between those considered to be competent to diagnose and treat the sick and those excluded from this special privilege – a separation as old and ubiquitous as the shaman or medicine-man. This difference becomes solidified when the expert healer becomes a member of an organized, full-time occupation, sustained in a monopoly over the work of diagnosis and treatment by the force of the state and invested with the authority to make official designation of the social meanings to be ascribed to physical states. When this stage of social organization occurs, only the expert healers are permitted to say what is and what is not legitimate illness, and who is and who is not legitimately ill. (Freidson and Lorber 1972:ix)

INTRODUCTION

The preceding quote from Freidson and Lorber (1972) provides an insightful summary of the elements that can impact the patient-physician relationship. Both the physician and the patient enter the relationship with unique experiences, understandings, and expectations that are shaped by their socialization and education. Further, each has a unique role in the encounter and responsibility for achieving and maintaining optimal health. Roles and status are critically important in understanding the interaction between patients and physicians. According to Susser, Watson, and Hopper (1985):

In each field of activity in which a person interacts with others, he or she acquires a status, and with this social position go certain expected forms

of behavior, particularly roles one is expected to play. Role is the dynamic aspect of status, and provides the link between individual behavior and social structure. . . . People anticipate predictable responses in specific situations according to the status of the parties involved; this role expectation is the habitual behavior that guides the forms of social intercourse. (P. 281)

Physicians, with their specialized training and legitimized power, have been granted the authority not only to advise actions but to “evaluate the nature of reality and experience, including the ‘needs’ of those who consult them” (Starr 1982:13). Patients also have expected behavior in the patient-physician encounter, behavior that is shaped by their social position and their expectations of the health care system. People, in particular those who are poor and of the working class, are more likely to experience difficulties in communication with professionals due to differences in linguistic and cultural backgrounds. Because they are less likely to share the same assumptions, those representing lower socioeconomic status groups “are more likely to be guarded in their communications and feel alien and hostile. . . . The cultural differences, difficulties in communication, and sense of powerlessness and dependency may be even greater with physicians than with other professionals because of the doctors’ wealth and high social status” (Starr 1982:12).

Mead and Bower (2000) indicated that “patient-centered medicine promotes the ideal of an egalitarian doctor-patient relationship, differing fundamentally from the conventional ‘paternalistic’ relationship envisioned by Parsons” (p. 1089). Stryker (1980) gave central importance to roles in interpersonal interactions and regarded them as shared behavioral expectations attached to social positions, positions such as the physician and the patient.

“Socialization” and, in particular, “reference groups,” are key concepts necessary to understand the specific roles ascribed to and performed by patients and physicians.

Socialization is the process whereby individuals acquire the knowledge, skills, and disposition to enable them to participate, more or less, as effective members of social groups and society. Reference groups, a particular group of people to whom an individual compares him/herself, help an individual define and understand his/her position and status in society, since one’s position is defined relative to that of others. Reference groups can serve as powerful influences on the attitudes of members who identify with that group, guiding their opinions, and influencing actions ranging from selecting a behavior from a set of alternatives to making a judgment about a problematic issue.

Reference groups also serve to link individuals with important social processes, especially that of socialization. It is through interactional processes with other members of a reference group that an individual’s behavior and attitudes are modified to be in conformance with those of the group to which he/she belongs or aspires to belong.

Reference groups play a significant part in the socialization process by providing an individual with a set of norms and values and a standard for the proper performance of a given role (Hardy and Conway 1978).

Given that the general purpose of the socialization process is to help prepare members of social groups to perform adult social roles attached to specific statuses within society and to help professionals move into their specific roles in the work force (Hardy and Conway 1978), patients as well as physicians are socialized through their social interactions and/or training to behave in prescribed ways in the health care setting and

during the patient-physician interaction. Walsh and Elling (1972) suggested that class structure is maintained through the efforts of work groups to establish themselves.

“Practitioners of a profession become self-conscious about their work, develop collective concerns about their destiny, and take collective steps to fit their work and themselves into the social order” (Walsh and Elling 1972:270). Thus, as physicians strive for increased power and prestige, their orientation to and behavior toward indigent and lower-class clients may be compromised. Physicians could potentially view dealing with the lower class or the poor as an obstacle to the quest for higher professional status, resulting in attitudinal and behavioral differences in dealing with these patients (Walsh and Elling 1972). However, the poor are defined so by society and evoke particular reactions from other societal members (Freidson and Lorber1972; Simmel 2009). The poor, who have not always been a part of society, emerged only when society elected to recognize poverty as a special status and assign individuals to that category, resulting in degradation and stigmatization of the individual who was poor (Freidson and Lorber

1972). Thus individuals who are poor could face an additional challenge as they attempt to achieve equality in the patient-physician relationship.

This chapter presents information to provide a sociological grounding for the dissertation. In regard to the patient, the physician, and the relationship between the patient and the physician, the philosophies of Georg Simmel, George Herbert Mead,

Erving Goffman, and Talcott Parsons are presented. The potential impact of a patient’s socioeconomic status on the patient-physician relationship is noted, as applicable, throughout the chapter. Finally, patient beliefs and the socialization of physicians within

the profession of medicine are discussed, grounded by the ideas of Eliot Freidson, which can help in understanding reasons behind patient and physician behavior and the expectations of each for the patient-physician encounter.

DYADS

In sociology a dyad is used to indicate the social grouping of two individuals. The grouping of two specific individuals, the patient and the physician, and their interactions and relationships is relevant to understanding health care communication and how communication might differ dependent on the social characteristics of the patient, specifically the patient’s socioeconomic status. Each member of this specialized dyad holds a special status within society with corresponding expected forms of learned behavior (Susser et al.1985). A critical difference exists between those considered to be competent to diagnose and treat the sick and those excluded from this special privilege

(Freidson and Lorber 1972).

The Ideas of Georg Simmel

Simmel, whose sociology emphasized process and function, viewed society as a

“constellation of forms of sociation, including emergent and permanent forms. . . .

Simmel declared that ‘I see society everywhere, where a number of human beings enter into interaction and form a temporary or permanent unity’” (Frisby 2002:xv). Simmel was primarily interested in small-scale issues in society, particularly individual action and interaction between and among individuals, a “geometry” of social relations. He was particularly interested in numbers as well as social distance, and the impact of the number

of people on the quality of the relationship. He began his study of social interaction with the dyad, the simplest sociological formation, the reciprocity of which occurs in the interaction between two people (Spykman 2004). The dyad does not achieve any meaning beyond the two individual interactants with each member of the dyad maintaining a high level of individuality (Ritzer 1996).

Physicians and their patients are a special dyad, which was of particular interest to

Simmel who was concerned with interaction and relationships between conscious actors.

Simmel believed that “every action among men is a sociation” (Simmel 1955:13). The most simple sociological formation is that which operates between two people, but this relation is possible only through complex and indirect connections (Simmel 1982a). The limitation to two interactants results in a specific condition under which alone the relationship exists and is dependent on several elements for its formation and continuation: 1) each of the two members feels himself confronted only by the other, 2) the dependence of the dyad rests on both individuals for the secession of either would destroy the whole, and 3) the life of the dyad depends on each of the two members alone, but for its death, only one. These elements make the dyad “into a group that feels itself both endangered and irreplaceable” (Simmel 1982a:46). Thus, the patient-physician relationship is equally dependent on both parties for its formation as well as its continuation.

Authority and prestige play an important role in social life, particularly considering dyads of superordination and subordination (Simmel 1982b). As authority figures, physicians attain their authority via both means specified by Simmel (1982b),

through their superior significance due to the weight of their opinions as well as authority granted from above, i.e., the state. Simmel indicated that people are defenseless in the face of authority, which would make it difficult, at best, for a patient to challenge his/her physician. Of significance is that “certain personal relations consist in the fact that the exclusive function of one of the two elements is service for the other” (Simmel

1982b:119). One element must surrender to the other even though they are on a different level in the relationship, requiring a personal feeling of reciprocity. The relationship between a patient and his/her physician is possible only because of this reciprocity and the unstated acknowledgment of the difference in authority and responsibility of each to maintain the relationship.

The Ideas of George Herbert Mead

George Herbert Mead was the first social psychologist to introduce the idea that the self is reflexive, i.e., the belief that individuals take the attitudes of others toward themselves as well as their general attitudes toward social institutions in constructing their actions and influencing their interactions. Mead gave primacy to the social self and perceived the self as essentially a dynamic social structure, arising only in social experience (Lemert 1999). An individual develops his/her self indirectly from the standpoint of other individual members of the same social group or from the “generalized standpoint of the social group as a whole to which he belongs. . . he becomes an object to himself only by taking the attitudes of other individuals toward himself within a social environment or context of experience and behavior in which both he and they are involved” (Lemert 1999:225). Communication, therefore, is not only directed at another

individual, but also at the individual, him/herself. Communication is essential to the development of “mind,” which develops only “by a conversation of gestures in a social process or context of experience – not communication through the mind” (Strauss

1977:162). The conversation of gestures enables individuals engaging in conversation to make adjustments in their attitudes and behaviors in light of the other’s, i.e., the reflexive behavior of social interaction (Strauss 1977). However, because the self is developed from the standpoint of other members of the same social group, there is likely to be a mismatch in communication between a physician and a patient, particularly between physicians and patients who are of low socioeconomic status and from social groups different from the physician. The physician, as a professional, is a member of a special class of men “who are engaged on a full-time basis in creating knowledge, formulating laws, morals, and procedures, and applying knowledge and moral principles to concrete cases. These men formulate and administer a special corpus of social meanings that is always different in kind from the social meanings of the ordinary citizenry” (Freidson

1988:303).

The Ideas of Erving Goffman

Goffman, “the most famous exponent of the study of normal deviance” (Lemert

1999:199), focused much of his sociology on what he termed “impression-management,” or the belief that individuals in social interactions were engaged in the artful management of what others thought of them. Goffman, primarily concerned with the structure of social encounters, wrote that:

Every person lives in a world of social encounters, involving either face- to-face or mediated contact with other participants . . . he tends to act out what is sometimes called a line . . . a pattern of verbal and nonverbal acts by which he expresses his view of the situation and through this his evaluation of the participants, especially himself . . . so that if he is to deal with their response to him, he must take into consideration the impression they have possibly formed of him. (Lemert 1999:330)

Goffman indicated that the acts presented by individuals in their day-to-day actions and interactions had much in common with theatrical performances, his dramaturgical theory.

Although a lengthy quote, Goffman’s introduction to The Presentation of Self in

Everyday Life (Goffman 1959), captures the essence of his perspective of interpersonal interaction.

When an individual enters the presence of others, they commonly seek to acquire information about him or to bring into play information about him already possessed. They will be interested in his general socio-economic status [emphasis added], his conception of self, his attitude toward them, his competence, his trustworthiness, etc. Although some of this information seems to be sought almost as an end in itself, there are usually quite practical reasons for acquiring it. Information about the individual helps to define the situation, enabling others to know in advance what he will expect of them and what they may expect of him. Informed in these ways, the others will know how best to act in order to call forth a desired response from him. For those present, many sources of information become accessible and many carriers (or ‘sign vehicles’) become available for carrying this information. If unacquainted with the individual, observers can glean clues from his conduct and appearance which allow them to apply their previous experience with individuals roughly similar to one before them or, more important, to apply untested stereotypes to him. (P. 1)

Goffman also indicated that no amount of evidence can take the place of acting on the basis of inferences, “we live by inference” (Goffman 1959:3). The purpose of an individual’s actions, i.e., performance, is, therefore, to influence how others’ perceive the individual – to influence the definition of the situation.

Goffman proposed that a performance is dictated by an individual’s status or social place, which prescribes the individual’s pattern of appropriate conduct, or the expression of self. Status is part of an individual’s social grouping, the members of which express themselves, or perform, in ways different from other groups based on attributes such as age, sex, and social status. Further, in each case, the attributes are “elaborated by means of a distinctive complex cultural configuration of proper ways of conducting oneself. To be a given kind of person, then, is not merely to possess the required attributes, but also to sustain the standards of conduct and appearance that one’s social grouping attaches thereto” (Goffman 1959:75). Through these performances, such as the interactions that occur between patients and physicians, the superiority of the physicians, due to special aptitudes and training, likely will be demonstrated and the weaker role of the patients likely will be maintained.

The “work-tasks” that comprise the performance tend to be “converted into activity oriented toward communication” (Goffman 1959:65). If perception, then, is considered to be a form of communication, then individuals can use communication to maintain social distance. Physicians must be practiced at what Goffman termed

“dramaturgical discipline,” or the management of one’s face and voice. During their interactions and communication with patients, physicians may need to conceal their actual affective response in exchange for one that is more appropriate – the giving of a proper amount of attention, the willingness to hold in check one’s performance, and the inhibition of all acts or statements that might create a faux pas. This, too, may be true for patients alike. The length and/or closeness of the relationship between a physician and

patient also can influence the performance and communication that takes place. Goffman

(1959) indicated that performers also take into consideration how much information others have about them. “The more information the audience has about a performer, the less likely it is that anything they learn during the interaction will radically influence them. On the other hand, where no prior information is possessed, it may be expected that the information gleaned during the interaction will be relatively crucial” (Goffman

1959:222). Therefore, patients and their physicians who have known each other for a long time may be more relaxed during their interaction, and those new to each other may be likely to present more careful performances. Further, “care will be great in situations where important consequences for the performer will occur as a result of the conduct”

(Goffman 1959:225).

Goffman (1959) further divided the region in which performances are given into the front and the back stage. In the front stage, individuals present themselves in rather fixed ways, prescribed in most part by their status or social place, designed to maintain certain impressions, impressions that the individual most wants others to perceive.

Goffman (1959) also spoke of the personal front, which he divided into appearance and manner. Appearance, i.e., physical appearance and manner, or the way in which the individual behaves, provides others with clues to the performer/individual’s social status.

For example, a person dressed in a knee-length white lab coat, carrying a stethoscope, with a concerned expression walking purposefully down the corridor of a hospital will probably be perceived by others as a physician (Hardy and Conway 1978). The

assumption of this identity is crucial for physicians to maintain their social role and their position of authority with patients.

Hardy and Conway (1978) drew on the work of Goffman in their discussion of roles of health professionals. They indicated that in selecting how individuals present their selves, whether it be physicians or patients, they are conveying to others the image or identity they wish to assume in any given situation. This image also is indicative of the resources they possess. Through the act of selective presentation to others, individuals make a claim to a certain identity and to the resources associated with that identity. An individual’s presentation exerts a social pressure on others to support his identity claim. If the performance is skillful, others will not question the presented identity nor its associated resources. Actors’ performances both present and sustain their claim; if they succeed, others interact with them accordingly. For Goffman, the ritualistic performance of roles is essential for basic social relationships as well as for maintaining legitimacy of position in the social structure. Thus, Goffman would see that both the patient and physician act in prescribed, ritualistic ways.

In summary, social theory highlighted thus far can serve as a basis for understanding the interaction that occurs between a patient and a physician. The reflexive nature of the social world lies at the heart of the theory of George Herbert Mead.

Interaction occurs between people, as individual selves, as a conversation of gestures.

However, there is likely to be a mismatch in the interaction between a patient and a physician, particularly a patient from a lower socioeconomic group, since the self is developed from the standpoint of others in the same social group.

Erving Goffman, who was concerned with the structure of social encounters, proposed that individuals act in ways that are intended to influence how others perceive them. That performance is dictated by an individual’s status or place in the social system.

Further, the superior social position of the physician, due to special aptitudes and training, will be apparent in an interaction with a patient, and the patient’s weaker role likely will be maintained.

Georg Simmel’s interest in social geometry, affiliations, and the relationships between conscious actors helps in understanding the patient-physician relationship as a special dyad. This two-person affiliation is equally dependent on both parties for its formation as well as its continuation. With the physician in an authority role, the patient must surrender to the physician, resulting in a personal feeling of reciprocity. I now turn to Talcott Parsons whose theory provides a more in-depth understanding of the roles that both the patient and physician play in the encounter.

THE PATIENT AND PHYSICIAN AS A DYAD

The Ideas of Talcott Parsons

Parsons (1951) accorded specific behaviors and responsibilities to the roles of both the patient and the physician. The patient is relegated to the role of being sick, giving the patient special protection and privileges, which are socially defined and applied, and dependent on the society’s agreement about the cause, meaning, and consequence of illness. The sick role has four major aspects, providing the patient with exemptions as well as obligating the patient to responsibilities. Parsons (1951) indicated that “like all institutionalized patterns the legitimation of being sick enough to avoid

obligations can not only be a right of the sick person but an obligation upon him” (p. 436-

37). Regarding exemptions, first, Parsons did not regard the sick person as being responsible for his condition; no fault is attributed to the person, himself, nor can the sick person simply will the sickness away. Second, being sick excuses the person from his routine roles and obligations to his work and family. Regarding obligations, first, the sick person is expected to define his/her position of being sick as undesirable with an obligation to want to get well. Second, the sick person has an inherent obligation to seek technically competent help, i.e., seek the advice of a physician and cooperate with the physician in the process of trying to get well. Therefore, a sick person is not competent to help himself – only a technically trained physician has that qualification. However,

Parsons (1951) noted that a lay person does not have the qualifications to judge the technical qualifications of a physician. Finally, Parsons (1951) indicated that the combination of helplessness, lack of technical competence, and being emotionally disturbed makes a sick person particularly vulnerable to exploitation.

In contrast to Parsons’ definition of the role of the patient as being dependent and obedient, Parsons regarded physicians as benevolent, knowledgeable authority figures.

His primary definition of the physician’s responsibility was to “‘do everything possible’ to forward the complete, early and painless recovery of his patients” (Parsons 1951:450).

He specified that the physician is responsible for the welfare of the patient and for facilitating recovery to the best of the physician’s ability. Physicians are required to achieve and use a high level of technical competence in medical science, recognizing that their knowledge, skills, and resources might not be adequate for all situations, situations

which might be out of their control. The physician is responsible for defining the illness situation for patients and their families, recognizing that patients and families have a deep emotional involvement in what the physician can and cannot do.

THE PROFESSION OF MEDICINE

Although the physician and the patient occupy different positions in the social system, physicians are not just authority figures. As members of a powerful monopoly, they not only can recognize illness, they are similar to judges and priests, who by their power can define and actually create illness (Bullough 1978; Freidson 1988). Physicians have a mission to seek out illness and to intervene, seeking to “create social meanings of illness where that meaning or interpretation was lacking before” (Freidson 1988:252).

However, the physician “is supposed to treat illness without judging. . . . While (ideally) the person may not be judged, his ‘disease’ certainly is judged and his ‘disease’ is part of him. . . [The physician’s] mission is to impute social and therefore moral meaning to physical and other signs” (Freidson 1988:252-53). Although physicians are expected to treat without judging, Freidson (1988) acknowledged that no human can avoid bias and asked:

how the social characteristics of the physician himself – his religious background, ethnicity, sex, social class – enter into the prejudices he is likely to have in favor of certain diagnoses and modes of management . . . [and] how the characteristics of the setting in which he works – the type of patients he most often sees, the patient load, his contact with colleagues, and the like – influence the content and direction of the choices and responses he makes. (P. 268)

Freidson (1988) stressed the point that the notion of illness is a “social creation”

(p. 278), rather than a biological fact, one that is created by the medical professionals

who are both “active in seeking out illness” (p. 252), assigning meaning to illness, and are best positioned to treat it. To Freidson (1988) the physician is a “moral entrepreneur” who “seeks to create social meanings of illness where that meaning or interpretation was lacking before,” thereby creating “new rules defining deviance” and “seeking to enforce those rules by attracting and treating the newly defined deviant sick” (p. 252). “The everyday practitioner’s task is to assign a medical label to symptoms that laymen have already singled out as undesirable” (Freidson 1988:253).

The lay recognition of illness also is a function of social experience, which is culturally and historically variable with normality established by everyday experiences.

However, there is a tendency for laymen to report fewer symptoms and illness than physicians, which “is as much a function of attention as it is of differential knowledge and perception: the layman may be aware of the signs and symptoms that a physician would label a symptom of an illness, but he may not ascribe the same importance to them” (Freidson 1988:285-86). Culture also impacts medical care-seeking behavior. For example, Western societies are more likely to hold ideas of illness and treatment consistent with those of modern medicine. As stated by Freidson (1988):

Furthermore, within modern Western societies, those members of the population who are most like the members of the medical profession in attitude and knowledge manifest a culture or subculture that is more likely to lead them to demonstrate medically approved conceptions of illness than are those least like the profession. Within modern societies, the empirical variables of socioeconomic status [emphasis added] – most particularly formal education – seem to be the most useful indicators of such compatibility. (P. 287)

Physician Socialization

Hardy and Conway (1978) indicated that “the process of becoming a health professional is a process of both adult and occupational socialization. . . .Unlike providing training for an occupation in general, the goal of professional training institutions is to inculcate into their aspirants the norms, values, and behaviors deemed imperative for survival of the occupation” (p. 145). The training and socialization of physicians to be different includes the learning of a perspective, or what Becker et al.

([1961] 2008) refered to as a coordinated set of ideas and actions that a physician would use to think about, deal with, and act in a particular situation – those shared understandings that serve as a guide in the profession. The medical perspective, including the ideas and expected actions, is defined by the medical school faculty. In a very authoritarian manner, the ideas and actions of the faculty affect the development of medical students’ perspectives. The faculty has a:

. . . tremendous amount of power over the students and, in principle, can control student activities very tightly and cause students to act in whatever fashion they (the faculty) want. To the degree that the faculty actually exercises such power, students will have no opportunity to build their own perspectives and will simply take over ideas forced on them by the faculty. (Becker et al. [1961] 2008:48)

The process of medical education and socialization is apparent and results in differences in language, appearance, and actions, taught overtly as well as through the hidden curriculum. Becoming a physician involves learning a very specialized, technical language that is used primarily to communicate with other physicians, and to identify those who belong to the group and those who do not (Hardy and Conway 1978). This specialized language not only serves as an identifier but also as a means of excluding

others who are not familiar with the language, particularly those with lower levels of education who are the least likely to be exposed to or understand medical jargon and technical words and concepts.

Appearance also serves as a special identifier for physicians and an indication of their status as a practitioner. Early practitioners perceived themselves as a status profession and defined themselves as a privileged rank, emulating the style of the upper class including distinctive manners and fashionable dress (Starr 1982). Now, the white coat is an essential element in physicians’ appearance and plays a particular role in the socialization process. Medical students wear hip-length coats. As they progress in their training, and prestige, they can wear a mid-thigh-length coat as a resident. When they become full attending physicians, they have the privilege of wearing a full-length white coat.

Clothing creates an image before the voice reaches another. Clothing’s possibilities for communication are innumerable and provide an efficient clue for the classification of others. Friedman (1979) suggested that the clothing worn by practitioners as well as patients will likely have a significant effect on the health care process. Kriss (1975) offered keen insight into the symbolism of the white coat indicating that:

The relation between a physician and his patient is serious and purposeful, not social, casual or random . . . . For a very long time it has been customary for individuals in society to dress rather formally when conducting serious business, and less formally when they are at leisure. The physician’s dress should convey to even his most anxious patient a sense of seriousness of purpose that helps to provide reassurance and confidence that his or her complaints will be dealt with completely. (P. 1024)

Young (1997) summarized the relevance of the white coat quite succinctly when she stated “this simple garment is a symbol of your commitment to maintaining the highest standards of professional behavior and conduct. People and patients will look at you differently when you wear one of these” (p. 10).

In order to be successful in the field of medicine, students not only have to perform satisfactorily, they also must act in ways that the system, as well as others, expect. Medicine, like other professions, “claims to enjoy dignity not shared by ordinary occupations and a right to set its own rules and standards” (Starr 1982:37). Starr (1982) referred to medicine as “a world of power,” and physicians, as medical professionals, have an “especially persuasive claim to authority” (p. 4). That authority is granted by people who want physicians’ interpretation of experiences and regard “science as a superior and legitimate complex way of explaining and controlling reality” (Starr

1982:19). While Parsons’ expected that physicians be technically competent, physicians also are expected to be universalistic, functionally specific, affectively neutral, and collectivity-oriented rather than self-oriented (Parsons 1951). However, the objective neutrality of the physician is not always the case in practice. Actions of physicians and patients’ medical treatment can be affected by a patient’s race, gender, and social status, regardless of the patient’s clinical presentation. Studies, such as these, will be described in Chapter 3.

Jordan J. Cohen, M.D. (1999), former president of the Association of American

Medical Colleges, posed the question, “Can it be that physicians, schooled in the ethic of medical professionalism, committed to focusing only on their patients’ best interest,

could succumb to attitudes disruptive of objective decision making” (p. 2)? Schulman, et al. (1999) offered the explanation that bias in physicians’ actions could represent overt prejudice on the part of physicians; however, biases in thoughts or actions more likely could be the result of subconscious perceptions rather than deliberate. It is important to keep in mind that positive beliefs and attitudes toward a stereotyped group, whether it be based on race, ethnicity, gender, or socioeconomic status, may not be reflected in actions toward that group (Devine 1989). It is the thought similar to that of Devine (1989) that prompts the question, Does physicians’ communication style differ with patients of various socioeconomic status groups, and if so, how are patients’ outcomes affected?

CHAPTER III

LITERATURE REVIEW

What most physicians have taken as given about disease, social science makes problematic. (Susser et al. 1985:3)

INTRODUCTION

Many factors influence the patient-physician interaction leading to satisfaction as well as dissatisfaction on both the part of the patient and physician potentially impacting patient health outcomes. This chapter will present a review of the literature in selected areas of patient-physician interaction and patient satisfaction. First, a brief review of the literature on socioeconomic status as a fundamental cause of disease will be presented as a key theory for understanding how socioeconomic status can affect health and health care outcomes. Second, the literature regarding factors that influence the patient- physician interaction will be summarized with attention given to the impact of factors related to socioeconomic status. Third, the relationship between patient satisfaction and health will be discussed including how patient satisfaction is measured and the difficulties inherent in doing so, and the factors that affect patient satisfaction. Finally, the contributions of race and gender to differences in patient-physician interactions, as well as other considerations, will be discussed briefly. Although not the focus of this dissertation, it would be incomplete if the contributions of race and gender to health care inequalities were not acknowledged. Because the literature in these areas is vast, this

literature review will be limited to a few key studies in each area. Articles were selected considering the relevance to this dissertation and the stability of the characteristics under investigation.

SOCIOECONOMIC STATUS AS A FUNDAMENTAL CAUSE OF DISEASE

The Black Report 1980 (SHA 2009) offered four theoretical explanations for the persistent class-based health outcomes in the United Kingdom, theories that can be applied equally to the U.S. population. First, artifact explanations propose that any relationship that exists between health and socioeconomic status is artificial, that is, an

“artifact of little causal significance” (SHA 2009:Section 6.4). Second, theories of natural or social selection, also known as the drift hypothesis, treat social class as the dependent variable with physical weakness and poor health having little social worth. These theories assert that those in the lower socioeconomic status groups are in those positions due to their health, with the strongest and healthiest people rising to the highest socioeconomic status groups. Third, grounded in Marxist theory, materialist or structural explanations propose that inequalities in health are due to economic and social-structural differences between the classes. Lowered economic opportunities lead to the increase in health problems for those in lower socioeconomic status groups. Finally, cultural-behavioral explanations focus on the individual as the unit of analysis with responsibility for health attributed directly to the individual and the personal decision to engage, or not, in unhealthy behaviors.

Each of these theoretical explanations for health disparities has valid arguments as well as limitations for explaining socioeconomic differences in health. However, these

are not the only four theories of socioeconomic differences in health and health outcomes that should be considered. I believe that there are two additional distinct schools of thought that merit attention regarding the impact of socioeconomic status on health and health care in the United States: 1) those who believe that the elimination or lowering of financial barriers to health care itself would “greatly reduce differences in the quality of health care as well as health care outcomes across socioeconomic groups” (Andrulis

1998:412), and 2) those who propose that socioeconomic status is a “fundamental cause” of disparities related more to access, or lack thereof, to important resources rather than as a result of direct access, or not, to health care (Link and Phelan 1995).

When considering the impact of socioeconomic status on health care, Dennis

Andrulis (1998) asked the question, “But would leveling the differences created by financial inequity really eliminate major disparities, or is this a shibboleth that masks more complex, deep-seated concerns that would continue to perpetuate great inequality in health care access and health status?” (p. 412). Unlike a generalist Marxist approach that would address overall access to resources to improve socioeconomic status, Andrulis believes that financial resources for health care itself are the key to “breaking the link between poverty and lack of access to improve health outcomes” (p. 413). He acknowledged that there are a multitude of factors that can influence health but continued with his assertion that “the ability to substantially improve access for low-income populations through elimination of financial barriers is probably a sine qua non when it comes to eliminating disparities in health status” (p. 413). He cited literature in defense of his proposition including studies that demonstrated differences in health care due to

socioeconomic status and implied that removing or improving financial barriers to health care for the poor would result in improved access to inpatient care (Bindman et al. 1995), reduced hospitalizations (Pappas et al. 1997) and the likelihood of dying in the hospital

(Hadley, Steinberg, and Feder 1991), fewer visits to the emergency department for non- urgent care (National Center for Health Statistics 1994), seeking care sooner in the disease process (Donelan et al. 1996), and improved access to medical specialists and primary care (Donelan et al. 1996). One study cited by Andrulis (1998), Saver and

Peterfreund (1993), indicated that providing Medicaid to the uninsured improved their access to care, but these patients never reached access levels comparable to individuals with private insurance. Whether uninsured or insured by Medicaid, the fact remains that poor people, regardless of their insurance status, have limited access to health care in the

United States.

While Andrulis (1998) clearly supported the first half of his question – that socioeconomic inequities in health would be reduced by improving financial barriers –

Link and Phelan would defend the second half of Andrulis’ question – that financial inequities mask more deep-seated reasons for inequities in health, and that inequities would continue in spite of improved financial access to health care. Link and Phelan

(1995) presented a convincing argument that social conditions are the fundamental causes of disease, with social conditions defined as “factors that involve a person’s relationship to other people” (p. 81). Social conditions have been recognized for centuries as the connection between people and the diseases they experience. Link and Phelan (2002) cited Virchow from the 19th century as well as Susser et al. (1985) from the 20th century.

In 1848, Virchow, a German epidemiologist, declared that “medicine is a social science, and politics nothing but medicine on a grand scale” (Link and Phelan 2002:2). Susser et al. (1985) were of the opinion that:

Societies in part create the disease they experience and, further, they materially shape the ways in which diseases are to be experienced. Cross- cultural studies of disease consistently show that the varieties of human affliction owe as much to the inventiveness of culture as they do to the vagaries of nature. If disease is seen in its full dimensions as a phenomenon besetting persons in communities, its status as a culturally consistent reality becomes apparent. (P. 17)

The standard way of thinking, as reported by Link and Phelan (2002), is that

“social conditions expose people to risk factors and those risk factors cause disease, thereby producing patterns of disease in populations” (p. 2), and that “this standard way of thinking is evident in most attempts to understand the association between socioeconomic status and health” (p. 3). Further, Link and Phelan (2002) stressed that

“once the association is observed the critical issue turns to a search for the connecting mechanisms. What mediates the association? Is it smoking, diet, exercise, depressive symptoms, or orientation of mastery, or what? This way of thinking dominates the effort to understand the SES-disease association” (p. 3).

Following this logic, once the risk factors are identified and addressed, the social patterns of disease, too, will be addressed. In the standard way of thinking from an epidemiological and medical perspective, it is the risk factors that are of primary importance and serve as the explanatory mechanism for differences in diseases, disease rates, and mortality. Risk factors, such as behavioral health habits (ex., diet and smoking), and biological indicators (ex., hyperlipidemia and hypertension) – the

proximal causes of disease – receive far more attention from medical and epidemiological researchers than more distal causes of disease. Link and Phelan (1995) stressed that modern epidemiology, with its focus on personally controllable risk factors and cultural values “conspire[s] to focus attention on proximate, individually-based risk factors and away from social conditions as causes of disease” (p. 81). In spite of the best planned interventions and the best efforts of researchers, there continues to be a persistent association between socioeconomic status and disease even though there are changes in intervening mechanisms (Link and Phelan 1995).

Phelan et al. (2004) argued that access to and the effective use of resources is the

“key feature of fundamental social causes” (p. 269). People with higher socioeconomic status have greater access to and use resources such as money, knowledge, power, prestige, and beneficial social connections more effectively to optimize their health and their health outcomes – to avoid risks for morbidity and mortality and/or to minimize the consequences of disease once it occurs (Link and Phelan 2002; Phelan et al. 2004). Thus, social factors (i.e., conditions), as a fundamental cause of disease, cause individuals to be vulnerable to a wide array of disease, not any one specific disease (Link and Phelan

1995). Social conditions, more distal risk factors in the causal chain of disease, exert an indirect effect on diseases and disease outcomes by shaping people’s life circumstances and exposing them to risks that they are unable to avoid (Link and Phelan 1995). Link and Phelan (1995) posed, and answered, the question:

Why is it so important that we strive to contextualize risk factors? One reason is that efforts to reduce risk by changing behavior may be hopelessly ineffective if there is no clear understanding of the process that leads to exposure. . . . Without an understanding of the context that leads

to risk, the responsibility for reducing the risk is left with the individual, and nothing is done to alter the more fundamental factors that put people at risk. (P. 85)

Phelan et al. (2004) examined the 1995 National Longitudinal Mortality Study

Public Use File to test their fundamental cause theory. They hypothesized that socioeconomic status is more strongly inversely related to mortality from causes that are preventable as compared to causes that are less preventable. Comparing the magnitude of the mortality risk associated with socioeconomic status for both deaths from high as well as low preventability causes, they found that for each socioeconomic status measure for each age group, gaps between survival curves for different levels of socioeconomic status were much larger for causes of death that are highly preventable, a finding that held across gender and racial/ethnic groups. An interesting finding was that the advantage of higher SES diminished with age and disappeared at about age 85 considering income as well as education. This presumably is because old age is an instance when socioeconomic status-related resources are of limited use in prolonging life when the medical system does not know how to prevent life-threatening illnesses, or people have reached the

“ragged edge,” or the age at which the decline of the human body is irreparable (Callahan

1998). Thus, for preventable causes of disease, the study by Phelan et al. (2004) showed support for the importance of access to resources for achieving and maintaining health.

The recognition of the importance of the relationship between social conditions and health is not limited to the social sciences literature. Those contributing to the medical literature are now appreciating that improving health for those in lower SES groups will require more than improving access. In 1998, the Annals of Internal Medicine

published a powerful article that turned the standard medical approach to improving health upside down. Pincus et al. (1998) indicated agreement with the advocacy efforts of major medical professional organizations for universal access to medical care as important to improving the health of the U.S. population. However, they were quick to express concern that improving access may have a limited impact on improving health, particularly in the outpatient setting “where the actions and life situations of patients may determine outcomes as much as the actions of health professionals and the health care system do” (Pincus et al. 1998:411). They based their concerns not on opinion but on a substantial literature documenting what they referred to as “persistent and widening disparities in health according to socioeconomic status” (Pincus et al. 1998:411) identified in most developed nations. They acknowledged that the better health enjoyed by those in higher socioeconomic status positions is due to more than just more frequent interactions with the health care system. They cited literature that suggested that the poorer health of those in socioeconomically disadvantaged populations is due more to unfavorable social conditions and ineffective self-management than access to care.

From a social science perspective, it is refreshing to read that Pincus, Esther,

DeWalt, and Callahan (1998), three of whom are physicians, said that “medicine and health exist in a social context” (p. 410). They concluded their article by indicating that, based on the available evidence, in order to improve health in the population, physicians must serve as advocates for improved social conditions, and general and health education.

Most importantly, they advocated that individual physicians can have the most influence on their one-on-one encounters with their patients.

THE PATIENT-PHYSICIAN INTERACATION

Medical interviews have been referred to as “the most commonly performed

‘procedure’ in clinical medicine” (Epstein et al. 1993:377). In fact, it has been estimated that over a 40-year career, the average primary care physician performs about 200,000 medical interviews (Lipkin, Putnam, and Lazare 1995)! Lipkin et al. (1995) referred to medical interviewing as “a core clinical skill” (p. ix) and the medium of patient-physician communication. The patient-physician relationship is the most important single source of diagnostic data. Further, it is the means through which the physician elicits the patient’s partnership and participation in the process of care. It is primarily through the medical interview that patients and their physicians interact and relationships are formed and established.

Good communication between patients and their physicians has been linked to many positive patient-oriented outcomes including improved patient satisfaction, adherence to medical recommendations, and better health outcomes (Wynia and Matiasek

2006). However, communication between patients and physicians occurs in many different ways (Stiles and Putnam 1995), and interviewing patients is an art as much as it is a science. The success and outcomes of this interaction are not solely dependent on the physician, but on the patient as well. Clinical communication is the “final common pathway of medical care, the medium by which all care is effected [sic]” (Inui and Carter

1995:482). Inui and Carter (1995) also indicated that “reading in this investigative domain, however, is not a simple task” (Inui and Carter 1995:482), with the majority of the contributions occurring only in the last 30 years. In this section, I will present a brief

review of the literature regarding the medical interview and patient-physician communication, with a focus on primary care.

The physician’s task in the medical interview is to elicit the patient’s story, “a story that demonstrates the interaction among the biologic, psychologic, and social components of his or her life” (Smith and Hoppe 1991:470). Two general approaches to the medical interview are the patient-centered approach and the physician-centered approach. In physician-centered interviewing, the biomedical aspects are privileged. The physician’s agenda dictates the communication that occurs with a focus on gathering data from the physician’s perspective. Following a purely physician-centered interview, the physician typically would not gain a complete understanding of the patient’s story because this interviewing approach often “eschew(s) the human dimension in favor of a purely biologic story” (Smith and Hoppe 1991:470). Sullivan (2003) pointed out that medicine is turning away from this scientific ideal, or what he called “’perspective-less’ assessments of disease and health” (p. 1595).

In contrast to a physician-centered interview, a patient-centered interview, a more humanistic interaction, yields rich information about the patient’s concerns because patients are heard and understood in a different way (Smith and Hoppe 1991). The goal of patient-centered communication is to help physicians provide care that is concordant with patients’ values, needs, and preferences, and allows patients to participate actively in the interaction and in decisions about their health and health care (Epstein et al. 2005).

The patient-centered approach is important for developing a sense of connectedness between patients and their physicians (Smith and Hoppe 1991).

Aita et al. (2005) examined features of a primary care practice to identify ways in which patient-centeredness was behaviorally defined and observed in patient-physician encounters. They asked the question, “What occurred during the encounter that differentiated a patient-centered physician from one who was not?” (Aita et al.

2005:296). Having the opportunity to examine narrative descriptions of 1,500 patient- physician encounters, they identified four explanatory themes: 1) physician characteristics including style, values, and philosophy of medicine, 2) patient characteristics including priorities, values, and philosophy of health, 3) practice organization, priorities, and culture and their relationship to physician philosophy, and 4) community culture, priorities, and their relationship to medical care expectations. This summary of their results will be limited to the themes related to the physician and the patient.

Aita et al. (2005) indicated that one of their most important findings is that while patient-centered practice recognizes infinite differences in patients, it does not recognize the impact of the vast differences in personality types, values, beliefs, clinical interest, and practice contexts of physicians, which play an important role in patient-physician interactions. They found that regardless of the physician’s personality type, each could be patient-centered when they “adapted their personalities and ways of working to the temperaments of their patients” (Aita et al. 2005:298). This finding was echoed by

Zandbelt et al. (2006) who found that specialist physicians could evoke patient-centered communication during particular patient interactions, identifying it as a trait as well as a practice style.

From the patients’ perspective, Aita et al. (2005) found a number of characteristics that influenced both patients’ expectations of health care as well as the extent to which patients were willing or able to comply with their physicians’ recommendations. These characteristics of the patients included age, background and experience, and social, educational, and financial circumstances including health insurance status. Using complexity theory to aid in their understanding of the vast amount of qualitative data, Aita et al. (2005) found that individual physicians function not only within their personal and professional value systems, but also within practice systems in which an environment can be established or manipulated to facilitate patient-centered communication. Patients, who also exist in their own individual systems, respond to the attributes of the patient-centered system and foster or inhibit the occurrence of future patient-centered actions. Each of the systems, the patient system and the physician system, is dynamic and influences the other, with any event in either system having the ability to foster or inhibit physicians’ ability to act out patient-centered values.

While Aita et al. (2005) focused more on a patient-centered practice, Epstein et al.

(2005) focused specifically on patient-centered communication. They endorsed patient- centered communication as an essential component of high-quality health care and placed the responsibility for achieving patient-centered communication on the physician –

“patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient’s values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care”

(Epstein et al. 2005:1516). They noted that it is particularly challenging to measure

patent-centered communication due to the need to gather information about communication behaviors from multiple points of view including an objective description of the patient visit, as well as the subjective experiences of patients and physicians. They noted specifically that there often is a discrepancy between subjective reports of the encounters by the patients and physicians, and objective ratings.

Mead et al. (2002) studied the relationship between physician’s behavior and patient outcomes. The study focused on three dimensions of patient-centeredness measured in terms of five variables: biopsychosocial perspective (asking patient psychosocial questions), sharing power and responsibility (time for the patient), sharing power and responsibility (involving the patient), therapeutic caring (verbalizing caring), and therapeutic alliance (non-verbal demonstrations of caring). Two measures of patient outcomes were used: satisfaction, measured using the 18-item Consultation Satisfaction

Questionnaire, and enablement, measured using the Patient Enablement Instrument.

Mead et al. (2002) found that none of the patient-centered variables predicted patient satisfaction, with the best predictors being visit length, patient age, and the physician’s level of acquaintance with the patient.

Street, Gordon, and Haidet (2007) recognized the potential for a reciprocal relationship between patients’ and physicians’ communication. They examined almost

300 primary care encounters and assessed physicians’ perceptions of those encounters to determine the relationship between physicians’ patient-centered communication

(specifically if the physician was informative, supportive, and engaged in partnership building), affect (if the physician displayed a positive affect or was contentious) and

physicians’ perceptions of their patients, and the extent to which physicians’ communication and perceptions were influenced by physicians’ characteristics, patients’ demographic characteristics, patient-physician race and ethnicity concordance, and patients’ communication. Whether or not a physician’s communication was patient- centered was predicted most strongly by the patient’s communication style. Physicians were more patient centered, actively involved with the patient, and showed a more positive affect when the patient had a positive affect. Conversely, physicians were more contentious with patients who were contentious. Race and ethnicity, too, played a role with physicians being more contentious with black patients as compared to patients who were white or Hispanic. When physicians reported that they had a more patient-centered approach, objective observation substantiated this claim, with physicians who were black and white showing more positive affect than physicians who were Asian. Patients who showed a more positive affect and appeared to be less contentious were more likely to be rated by their physicians as effective communicators and more likely to be satisfied with the visit. None of the patient communication variables was related to physician perceptions of the likelihood that the patient would be adherent. Physician race, again, played a role with physicians perceiving that patients who were black were less effective communicators and less satisfied than patients who were white or Hispanic. More specifically, Asian physicians perceived patients who were black as less effective communicators than did physicians who were black or white. Conversely, physicians who were black felt that their patients who were black were more satisfied with their care than did physicians who were Asian, although, neither differed significantly from the

satisfaction predictions of physicians who were white. Thus, patients’ communication style can exert a powerful influence on physicians’ communication style, physicians’ perceptions of patient satisfaction with the visit, and the likelihood that patients will adhere to physician recommendations.

Willems et al. (2005) also demonstrated that patients’ communication style influenced physicians’ communication style. They analyzed 12 research articles published from 1965-2002 with the intent of focusing on patients’ socioeconomic status and patient-physician communication. The communication variables they tested fell into four categories: verbal behavior – instrumental, verbal behavior – affective, non-verbal behavior, and patient-centered behavior. They found several examples of the influence of patients’ socioeconomic status on patient-physician communication. Regarding verbal behavior – instrumental, physicians provided varying amounts of information to patients strictly based on the patients’ personal and social attributes. For example, the higher the patient’s socioeconomic status, the more likely they were to receive more overall communication as well as more information from the physician, regardless of the patient’s communication behavior. More educated patients received more diagnostic and health information. Physicians perceived that they listened more to patients from higher socioeconomic status groups as well as provided these patients with more information and gave them more help. Conversely, physicians gave less advice to patients from lower socioeconomic status groups, but examined them more. With patients from lower socioeconomic status groups, physicians spent less time questioning the patient, assessing

their health knowledge, negotiating, and counseling. Willems et al. (2005) also found that patients who were less educated also were less likely to have their expectations met.

Regarding verbal behavior – affective behavior, Willems et al. (2005) identified that patients who were more affectively expressive, specifically negatively, received more physician comments indicating support, reassurance, and empathy. They concluded that because patients of higher SES were more likely to be affectively expressive, they received more affective attention from their physicians. Physicians’ patient-centered behavior, too, was affected by the patients’ SES. Patients with a high school education or less were less involved in treatment decisions, less likely to be asked by their physician to take responsibility for self-care, and less likely to receive partnership-building utterances from their physician. Poor patients were less likely to be engaged by their physician in discussions about psychosocial issues, less likely to be in control of the interaction, and more likely to be the recipient of biomedical talk and a high percentage of questions from the physician. Because patients’ communication behavior is directly influenced by personal and social attributes, Willems et al. (2005) indicated that “patients from lower social class and doctors often find themselves in a vicious circle” (p. 143) with patients of lower educational levels being “doubly disadvantaged: first of all because of their more passive communicative style and secondly because the physicians’ misperception of their desire and need for information” (p. 144).

Bertakis et al. (1999) studied the impact of resident physician familiarity with patients on physician practice style in primary care visits. Acknowledging the multitude of factors that can affect the process of providing care, including patient selection of their

physician, the practice setting, patient sociodemographics, and patient-physician familiarity, they randomly assigned new patients either to a family medicine or internal medical resident and monitored the delivery of care for the subsequent year. Patient visits tended to be more technical (history taking, physician examination, treatment) throughout the follow-up period when the patient had poorer health as well as when the first visit with the patient was more technical. Health behavior was more likely to be discussed with healthier patients as well as in return visits when discussions were initiated in the first visit. Preventive services were more likely to be offered to women on their return visits than men. Physicians gave more attention to the provision of counseling in return visits when patients had better health at the baseline measure and when patients returned more often for care. Finally, physicians were more likely to encourage established patients’ active involvement in their care when a similar approach was used in the first visit, when the patient was older, and when the patient had higher income. Bertakis et al.

(1999) hypothesized that higher patient activation with patients of higher income could be due to physicians being able to communicate more easily with patients who have a socioeconomic status more similar to that of the physicians. Also worthy of note is that physicians’ behavior in subsequent visits can likely be predicted by behavior during the first visit. Bertakis et al. (1999) referred to this as “repeated practice patterns that reflect their personal interactional style” (p. 193), with the practice style in follow-up visits strong reflecting the practice style in the initial visit.

Although a somewhat older study, Hall, Roter, and Rand (1981) also found a relationship between physicians’ communication style and the likelihood of patients

returning for subsequent visits. The stimulus for their research was a critical component of the patient-physician interaction (the term they chose to use) – how something is said is as important as what was said. Patient visits to female physicians at a family and community health center were evaluated. The 50 participating patients were largely black, poor, and female with low levels of education (mean of about 10 years), and known to the physicians. Audio tapes of the visits were rated by relatively untrained raters in order to obtain naive impressions. Both patients and physicians were rated on four scales: angry/irritated, sympathetic/kind, anxious/nervous, and likelihood that the patient will return for the next appointment. The patients only were rated on two additional scales: assertive/self-confident and satisfied/pleased. And, the physicians only were rated on two additional scales: dominant/controlling and businesslike/matter-of-fact.

Patients also provided ratings of their attitude-toward-physician, and patient-contentment and satisfaction. Hall et al. (1981) found strong correlations between patients’ and physicians’ communication. Physician positive communication (physician expression of sympathy) was correlated with patient satisfaction and the likelihood that the patient would return. Negative communication, such as patient anger, was positively correlated with a reciprocal physician response of anger. Greater physician dominance was associated with greater patient negativity including a negative impact on satisfaction.

In a large observational study of almost 3,000 visits to family physicians, Flocke et al. (2002) examined the relationship between the attributes of primary care and patient satisfaction. Patient perceptions were measured using the Components of Primary Care

Instrument that separated physician interaction style into five areas: interpersonal

communication (ease of exchange of information), physician’s accumulated knowledge of the patient (understanding of patient’s medical history, health care needs, and values), coordination of care (receipt and incorporation of information from previous visits and specialists), preference to see usual physician, and continuity of care (proportion of visits to the regular doctor out of all physician visits in the past year). Satisfaction was measured using the MOS 9-item Visit Rating Scale. They found that physicians clustered into four groups: person focused (more focused on the person rather than the disease), biopsychosocial (more focused on the disease but elicited some psychosocial information from the patient), biomedical (focused almost exclusively on the patient’s disease), and high control (physician domination of the encounter and disregard of patient’s agenda).

Of interest is that physicians in the person-focused group were predominately female, four times more than in the biopsychosocial and the high control groups. This finding is also supported by Zandbelt et al. (2006) who found that female physicians were more likely to be facilitative in their patient encounters. Further, Flocke et al. (2002) found that patient visits were the longest when the physician was patient focused. Finally, patients reported being most satisfied when their physician was person focused, and least satisfied when their physician was high control.

Epstein et al. (2005) noted that including patient satisfaction as an outcome measure could be problematic for several reasons: 1) patients are likely to be attracted to physicians who have a particular practice style that is preferred by certain patients, 2) patients may be most satisfied with a practice style that is more familiar to them, i.e., a physician-centered approach, 3) patients who are more accustomed to participating in

their care might be more attuned to deficiencies they perceive in their physicians, and 4) improved satisfaction with patient-physician communication could overshadow deficiencies in other areas of the practice.

PATIENT SATISFACTION

Ethical arguments have been advanced for the importance of patient-centered care, although there has been no convincing empirical indication that it leads to better patient outcomes (Mead et al. 2002). The most frequently measured outcome was patient satisfaction (Mead et al. 2002). Although objective measures of clinical outcomes, such as achieving goal blood pressure or hemoglobin A1c, are considered gold standards for evaluating effectiveness of clinical care, measuring such outcomes in primary care is difficult. Measuring effectiveness is compounded by the wide range of problems presented to primary care physicians, the need to treat patients as individuals, as well as the fact that health outcomes are influenced by a wide variety of factors, many of which are out of the control of both the physician and the patient and are not amenable to change via communication between the physician and the patient. Therefore, many studies have relied on patient satisfaction as the main outcome of patient-centered care

(Mead et al. 2002).

Patient satisfaction is a key outcome for measuring the delivery of health services because of the “ethico-political desire to ensure that patients find their care acceptable and that evaluations of service quality incorporate a user-perspective, and because of the current lack of any appreciable alternative” (Mead et al. 2002:285). Further, Mead et al.

(2002) indicated that “in studies of patient-centeredness, satisfaction would appear to be a

theoretically appropriate outcome” (p. 285). Patients value physicians’ humanness, informativeness, technical competence, attention to psychological problems, provision of sufficient time, and selected aspects of the patient-physician relationship such as continuity, mutual trust, and respect, all of which are attributes commonly included in patient satisfaction measures and reflect conceptualizations of patient-centeredness. Mead et al. (2002) concluded that the best independent positive predictors of patient satisfaction are length of the visit, patient age, and the level of acquaintance between the physician and the patient.

Measuring Patient Satisfaction

First and foremost, satisfaction simply describes health care services from the patient’s point of view (Sitzia and Wood 1997). However, one of the most frustrating aspects of measuring patient satisfaction for researchers is the consistently high level of satisfaction that is reported by patients (Edwards, Staniszweska, and Crichton 2004).

Edwards et al. (2004) indicated that the most significant, longstanding problem is the consistently positive ratings of satisfaction when patients are surveyed using questionnaires versus more wide-ranging options found when patients’ opinions are sought using a qualitative approach. Nonetheless, surveys are the most common form of measuring patient satisfaction with the delivery of health care and can help identify ways in which to improve practice.

According to Sitzia and Wood (1997), evaluating health care should involve defining the objectives of the care that is delivered, monitoring health care inputs, measuring the extent to which outcomes have been achieved, and assessing the extent of

any unintended consequences. Coulter (1991) suggested that four fields need to be evaluated in the health care arena: 1) evaluation of specific treatments, 2) evaluation of patterns of care for particular groups, 3) evaluation of organizations, and 4) evaluation of health systems. Of these fields, the evaluation of patterns of care for particular groups is of particular importance for the measuring the effectives of primary care, which is of particular relevance to this dissertation. However, defining the construct, “patient satisfaction,” is critical. Ware et al. (1983) were some of the first to help specify the distinction between process and content of care. They argued that satisfaction ratings should reflect three variables: 1) the personal preferences of the patient, 2) the patient’s expectations, and 3) the realities of the care received. Therefore, the satisfaction rating is as much a measure of care as it is a reflection of the patient who is responding to the survey (Sitzia and Wood 1997).

Linder-Pelz (1982) suggested that patient satisfaction be defined as “the individual’s positive evaluations of distinct dimensions of health care” (p. 580). She proposed that the definition of patient satisfaction is determined by five social psychological variables, three of which match with those suggested by Ware et al.

(1983): occurrences – the individual’s perception of what occurred; value – evaluation the goodness or badness of an attribute or aspect of a visit; expectations – beliefs about what should occur; interpersonal comparisons – comparing what occurred to the individual’s previous knowledge or experiences; and entitlement – the individual’s belief that there are grounds for expecting a particular outcome.

Based on a literature review, Sitzia and Wood (1997) suggested that there are three determinants of patient satisfaction. First, expectations of the patient emerge as a fundamental feature including the patient’s perception of the benefits of care and the extent to which the care delivered met the patient’s expectations. Expectations, however, is a complex concept and difficult to use as an evaluation tool. They indicated that there are relationships among patient expectations, socioeconomic status, and associated values and attitudes among various patient groups, and degree of familiarity with the physician.

Therefore, context must be considered when interpreting responses. Second, patient characteristics, including social class, education, gender, and age, can predict satisfaction.

Third, psychosocial determinants are often considered to be “social-psychological artefacts [sic]” (p. 1836) because patients may report being more satisfied than they actually are due to the perceived social desirability of giving more positive feedback.

Sitzia and Wood (1997) also suggested components of satisfaction, and relied heavily on the work of Ware et al. (1992). They identified the need for a taxonomy with eight dimensions: interpersonal manner, technical quality of care, accessibility/convenience, finances (or the patient’s ability to pay for services); efficacy/outcomes of care, continuity of care (including consistency of provider as well as location of care), physical environment, and availability (including facilities as well as providers).

White (1999) offered suggestions for measuring patient satisfaction including both survey structure and content. She recommended that surveys be brief, clear, and consistent. Surveys should measure three key issues reflecting physicians’ goals when

they interact with patients: to provide quality health care, to treat patients with courtesy and respect, and to make that care accessible, citing the National Committee for Quality

Assurance that indicated that patients place access issues at the top of the list of what makes them satisfied with health care. Finally, White (1999) recommended that surveys ask what she referred to as the key question: “Overall, how satisfied are you with your physician?” (p. 42).

Factors Affecting Patient Satisfaction

Factors that affect a patient’s satisfaction with the care provided by a physician are quite varied and include patient characteristics, physician characteristics, and characteristics of the care delivery site.

Patient characteristics. Linn et al. (1984) proposed that peoples’ general sense of physical or emotional well-being, their values and expectations, their basic approach to evaluating services, and demographic characteristics can influence their assessment of physicians’ delivery of care. Their observational study, involving respondents viewing and rating patient-physician encounters, sought to answer three questions: 1) How much consensus is there among viewers in their evaluations of satisfaction with the physician’s behavior? 2) To what extent do respondents share values associated with various physician behaviors? and 3) To what extent do respondents’ specific values relate to their subsequent evaluations of and satisfaction with physician behavior? Recall that these key questions are patterned after the earlier work of Ware et al. (1983) who argued that satisfaction ratings should reflect three variables: 1) the personal preferences of the patient, 2) the patient’s expectations, and 3) the realities of the care received.

Respondents in the study by Linn et al. (1984) included second-year medical students, registered nurses in a master’s program, and undergraduates in a health psychology course, who were young (mean age 24), female (56 percent), white (73 percent), and single (68 percent). They rated, from the patient’s point of view, a 14-minute patient- physician interaction (middle-aged female physician and elderly female patient) using the

Medical Preference Survey that asked them to rate their preference, or value, for four physician behaviors: 1) technical quality, 2) psychosocial concern, 3) courtesy, and 4) mutual participation. Regarding what the respondents’ valued, mutual participation was rated the highest, followed in order by technical quality of care, psychosocial concern, and courtesy. In general, satisfaction was rated high with the highest scores of physicians given for psychosocial concerns and courtesy, and the lower for mutual participation, which would be a crude measure of a patient-centered interaction. Respondents’ reported that their personal values influenced their ratings of the interaction. For example, those who valued psychosocial concern more highly rated the physician significantly lower for courtesy, psychosocial concern, and mutual participation. The values reported were unrelated to the respondents’ educational background, but younger respondents tended to value psychosocial concern and mutual participation more highly. Age and gender were unrelated to satisfaction ratings with the exception that women were more satisfied with the physician’s technical quality than men. Finally, respondents with less education were more likely to rate physicians higher on all four attributes.

Hall et al. (1998) attempted to uncover which of two competing reasons might underlie two explanations of why less healthy patients reported to be less satisfied with

their health care. The two explanations they proposed were that: 1) poor health can affect satisfaction directly, such that a patient’s negative affect can be attached to the physician as well as other parts of the patient’s life, and 2) the dissatisfaction associated with poor health is produced through a mediating effect of physicians’ behavior in which physicians may react negatively to sicker patients. For example, sicker patients may be less rewarding to care for, or physicians may “blame” patients for their poor health. In one study reviewed by Hall et al. (1998), patient visits to rheumatologists were evaluated with satisfaction being measured using the Medical Interview Satisfaction Scale, a 28-item survey to assess physicians’ information-giving behavior and humanness-respect. The direct hypothesis was supported. In all analyses, better health had a positive, direct association with satisfaction. Conversely, they found no evidence in support of any mediator. In the second study that assessed care provided by primary care physicians, satisfaction was measured using an unnamed scale that included 20 items assessing the physician’s technical competence, humanness-respect, and provision of information.

Again, they found support for the direct hypothesis as well as for the mediation hypothesis with social conversation being the potential mediator. They reported that patients in better health received more social conversations leading to higher satisfaction ratings; conversely, patients who were sicker rated satisfaction lower presumably due to the lack of social conversation received from the physician. Chatting appeared to matter leading patients to believe that they were cared about as a person. Hall et al. (1998) concluded that patients’ health does influence satisfaction regardless of the

communication that takes place between the patient and the physician, with only limited evidence that informal conversation mattered to patient satisfaction.

Linn, Cope, and Leake (1984) measured the satisfaction of patients at a postgraduate residency training program in internal medicine. The 68-resident program had two training track options, one a traditional program and one a general internal medicine track. Post-visit patient satisfaction was measured using a self-designed, 14- item questionnaire that had two components – nine items reflecting art-of-care

(physician’s manner and interpersonal style, and patient’s feelings about the physician) and five items reflecting the technical quality of care. The majority of the respondents were female (68 percent), had an average age of 53, and almost half (46 percent) were insured by Medicaid or self-paying. Overall, patients reported being very satisfied with their care. Patient characteristics, including gender, age, and type of insurance coverage, had no relationship with satisfaction with care. Patients of residents in the general internal medicine program were more satisfied on the art-of-care scale than patients of resident physicians in the traditional track. Without an in-depth knowledge of the differences in the curriculum between the two tracks, an explanation of this finding is not readily apparent. A hypothesis might be that the general track may include more training in outpatient medicine with attention to the patient-physician interaction in the primary care setting versus the traditional track with more emphasis on in-patient care.

In summary, there is considerable variability in patients’ perceptions of the quality of the medical care they receive and those ratings vary, often predictably, based on patients’ sociodemographic and personal characteristics including health status, their

insurance status, and personal preference. I turn now to a more specific aspect of medical care that can influence patients’ perceptions – the characteristics of the physicians, themselves, who provide the care.

Physician characteristics. In addition to patient characteristics and physician behavior, patients’ satisfaction with their physicians also can be attributed to characteristics of physicians. It is important to begin this section with a brief discussion of how patient characteristics, including socioeconomic status, can impact physicians’ clinical behavior. More than 40 years ago, Davis (1968) found that the vast majority of physicians (85 percent) felt that “they give the same amount of attention to all patients”

(p. 339), i.e., they believed that they were affectively neutral and exhibited detached concern in their patient-physician encounters. Later research indicated that physicians’ clinical behavior is influenced by patients’ characteristics and behaviors.

Meyers et al. (2006) asked primary care physicians in Washington, D.C., to complete a brief card following patients’ visits and indicate if they altered their management strategy as a result of the patient’s insurance status in a way they believed might negatively affect the patient, and the degree to which insurance entered their clinical decision-making process, regardless of whether the consideration resulted in a change. Patients were primarily female (58 percent), with a equal number of white (44 percent) and black (44 percent) patients, and almost half (43 percent) were under- or uninsured. Almost half the time, physicians considered their patients’ insurance status during the visit. The vast majority of physicians (88 percent) made a change in their management plans at least once, with 24 percent of the changes attributed to the patient’s

insurance status. Changes in management plans were more likely when patients were uninsured and least likely when patients had private insurance. Finally, physicians reported that insurance played the strongest role in their decision making when the patient was uninsured.

These findings were echoed in a qualitative study of primary care physicians

(Bernheim et al. 2008). In-depth interviews were conducted in order to determine perceptions, beliefs, and experiences in caring for patients of low socioeconomic status.

Of the 18 physicians interviewed, six were women, half were from minority racial backgrounds, and three were Hispanic. Four themes emerged. First, physicians had conflicting views about the impact of patients’ socioeconomic status on their clinical management decisions. Second, physicians felt that any deviations in their typical clinical management decisions due to socioeconomic status were in the patient’s best interest, and those changes were central to providing high quality care and making care more affordable for the patient. They reported taking more time to communicate information but limited the information given due to concerns about patient literacy. Third, they varied in their thoughts about whether or not the change influenced the patient’s outcome.

In fact, one physician believed that the care he/she delivered to more affluent patients was excessive. Finally, the physicians indicated that they faced both personal and financial strains in their care of patients of lower socioeconomic status. It is important to note that all physicians who participated in the study described situations in which they changed their care because of a patient’s socioeconomic status. I turn now to the impact of physician characteristics on patient satisfaction.

Many early studies of the impact of physician characteristics on patient satisfaction occurred prior to and in the midst of the gender shift in medicine during which more women became physicians. Considering what is often referred to as the feminization of medicine, in 1970 only 8 percent of practicing physicians and 13 percent of medical students were women (Paik 2000). Paik (2000) projected that by 2010, nearly one third of practicing physicians would be women. With nearly half of the entering medical school classes now composed of women, the physician workforce will soon approach gender parity (AAMC 2009). Further, the gender distribution by medical specialty choice is also undergoing a transformation. From 1998 to 2008, female residents overall increased from 36 percent to 45 percent. In the primary care field, the number of female residents in family medicine increased from 46 percent to 55 percent, and from 39 percent to 45 percent in internal medicine (less the subspecialties). Although general pediatrics is considered a primary care discipline, the numbers for pediatrics are not reported here because general pediatrics and subspecialties were not separately reported by the Association of American Medical Colleges (AAMC 2009).

In the midst of the gender shift, Linn et al. (1984) reported that the most dramatic and consistent finding of their study of patient satisfaction with internal medicine residents was that patients of female residents, regardless of the gender of the patient or the residents’ training track (traditional or primary care), reported being significantly more satisfied on the art-of-care scale and total satisfaction.

Almost 20 years after the study by Linn et al. (1984), Bertakis, Franks, and Azari

(2003) noted the growing number of women practicing medicine and the documented

gender difference in clinical behaviors and communication style. For example, female physicians spent more time with their patients, provided more preventive health screening and patient education, were more nondirective, and allowed for and encouraged patient participation in the interaction. Male physicians focused more on the biomedical aspects of care (Bertakis et al. 2003). Given these physician gender differences in practice style and the potential impact on patient satisfaction, Bertakis et al. (2003) studied new patients randomly assigned to primary care physicians (family medicine and internal medicine residents). They measured the impact of gender on patient satisfaction, while controlling for confounding patient variables, to examine the extent to which differences in patient satisfaction with male and female physicians can be explained by observable aspects of the patient-physician interaction. Physician practice styles were measured using the Davis Observation Code (Callahan and Bertakis 1991). Patient satisfaction was measured (using an unspecified questionnaire) before and after the visit – a general satisfaction survey before, and a visit-specific satisfaction survey after the visit. They found that patients were most satisfied with female physicians, with noted differences in practice style from male physicians. In spite of no differences in visit length between male and female physicians, female physicians spent more time discussing preventive services and counseling about psychosocial issues, but less time in technical practice, even after controlling for patient characteristics (age, gender, income, education, and health status) and encounter-related factors (physician specialty, visit length, and physician practice style).

Thus, characteristics of patients and characteristics of physicians have both been found to influence patients’ perceptions of their medical care experiences. The final major factor that can influence patients’ perceptions of their care, that will be discussed here, is the care delivery site.

Characteristics of the care delivery site. The impact of the type of practice was recognized at least 30 years ago as having a potential impact on patient experiences with medical care. Ross, Wheaton, and Duff (1981) studied patient satisfaction across pediatricians in medical partnerships, small groups, solo practices, and large prepaid multispecialty groups. They examined visit length, physicians’ technical ability, and physicians’ “caring” regarding psychosocial issues. Of no surprise, the mothers reported high satisfaction with the medical care provided to their children, with satisfaction being the highest among patients going to solo practices and large prepaid multispecialty groups, and lowest in partnerships. Physicians practicing in large prepaid groups were rated highest for psychosocial care and for giving the best illness care. These physicians also spent the most time with their patients; physicians in solo practice spent the least amount of time. The psychosocial component of care had the most positive effect on satisfaction. Both time spent with the patient and the technical component were insignificant. These differences disappeared, however, when the longevity of the patient- physician relationship was considered.

A 1982 study by Ross, Mirowski, and Duff examined the relationship between physicians’ status characteristics (age, gender, religion, and socioeconomic background) and patient satisfaction. They hypothesized that patient satisfaction would be lower in

large prepaid multispecialty group practices in which patients are assigned to physicians.

Further, they proposed that patients would be most satisfied with physicians who had normative physician characteristics, i.e., white, middle-aged Protestant or Jewish males from higher status backgrounds. Race was not examined due to lack of variability in the sample of pediatricians. Quality of care issues were measured by combining responses into a measure of overall satisfaction. The survey included questions about willingness to refer others to the pediatrician, interest in changing pediatricians, if the pediatrician was available when needed, general opinion of the pediatrician, if advice given was confusing or harmful, if advice was followed, and how the pediatrician compared to the patient’s conception of the ideal pediatrician.

Results from large group practices supported the hypothesis. Patients were least satisfied with female pediatricians, those who were Catholic followed by Protestant, those who were older, and those from low-status backgrounds. Conversely, in small fee- for-service practices, patients were less satisfied with physicians from high status backgrounds, the only anomaly in the results. When patient characteristics were considered, only one interaction changed the results. Although patients in large prepaid groups were less satisfied with pediatricians who were Catholic, the effect was offset if the family had been a patient of that physician for a long period of time. In both types of practices, patients reported higher satisfaction with physicians who provided quality psychosocial care, considering communication elements such as listening, respect, explaining, awareness of concerns, and knowledge about the patient. Finally, patient social class played an important role in satisfaction with the physician. Patients in higher

social classes getting their care at large prepaid practices tended to be less satisfied, but social class of the patient was unrelated to satisfaction in the small, fee-for-services practices.

Rubin et al. (1993) used data from the large Medical Outcomes Study (MOS) to examine the relationship between practice characteristics and patient satisfaction. The

MOS sampled patients in Boston, Chicago, and Los Angeles who sought care at health maintenance organizations, multispecialty group practices, and solo or single-specialty small group practices. Patient satisfaction was measured using two forms. Half of the patients were asked to rate only the overall quality of the visit. The other half of the patients were asked the single item as well as eight additional items that included the technical skills of the person they saw, the personal manner of the person they saw, how long they waited to get an appointment, the convenience of the location of the office, getting through to the office by phone, length of time waiting at the office, time spent with the person they saw, and explanation of what was done for them. As consistent with other studies, the vast majority of the patients in this study rated their visit highly (55 percent excellent and 32 percent very good). Technical skills were the highest rated element, and office waits received the fewest high ratings. Patients at solo fee-for-service sites were more likely to give excellent overall and visit-specific ratings in each of the eight aspects of care. Taking the satisfaction rating one step further, the authors found that patients, regardless of the practice situation, were less likely to stay with a physician who received lower overall satisfaction ratings.

Does patient satisfaction matter? One major issue now remains to be discussed regarding patient satisfaction – why does patient satisfaction matter? Why do physicians care if their patients are satisfied with the care they are receiving? Why do those who manage health care systems care if patients are satisfied? Why does patient satisfaction matter to the patients, themselves? The preceding discussion of patient satisfaction now needs to be grounded.

Patient satisfaction matters because there is a demonstrated relationship between patient satisfaction and patient outcomes, a “substantial research” according to Safran et al. (1998:213). Patients who are satisfied are more likely to have improved health outcomes, such as better adherence to physicians’ advice, and increased likelihood of symptom improvement and resolution of health problems. However, measures of satisfaction and outcomes often are entangled with issues of patient-physician communication.

The link between patient-physician communication and patient satisfaction has been established. Beck, Daughtridge, and Sloan (2002) examined the relationship between patient-physician communication and outcomes, with the assumption that better communication leads to better outcomes. They reviewed the results of 14 studies that focused on physicians’ verbal behaviors, all of which were conducted in primary care settings. In one third of the studies, at least 60 percent of the patients were classified as racial/ethnic minorities, and studies tended to include more female patients. Amazingly, they found 22 physician behaviors positively associated with patient outcomes. Behaviors relevant to this dissertation include various expressions of empathy; allowing the

patient’s point of view to guide the conversation; information giving including increased time on health education, sharing medical data with the patient, and discussion of treatment effects; and more time on history taking. Behaviors that were negatively associated with patient outcomes were high rates of biomedical questioning and one-way flow of information to the provider (i.e., information collection without feedback).

Reported outcomes linked higher satisfaction with compliance with a prescribed therapeutic regimen, and patients’ comprehension of their health and health concerns.

In an earlier literature review, which demonstrates the long-standing positive relationship between patient satisfaction and outcomes, Pascoe (1983) examined the measurement of patient satisfaction in primary health care settings. Attention was given to the relationship between patient satisfaction and health-related patient behaviors in terms of utilization of health care services and compliance. In the majority of the studies reviewed, patients’ use of services increased as satisfaction increased. Further, dissatisfaction, or a low satisfaction score, was related to patients’ intention to switch services, terminate a relationship with a health care provider, and to seek care elsewhere without a referral, also referred to as “doctor shopping.” Dissatisfaction with the physician, i.e., both the process of care as well as structural aspects of care, has been related to changes in health care provider. Finally, regarding compliance issues, studies reported a positive relationship between patient satisfaction and appointment keeping, intent to comply with physicians’ recommendations and to follow instructions, and taking medications as prescribed.

Safran et al. (1998) recognized that understanding the contributions of a variety of characteristics of care giving and outcomes are important to strengthening the delivery of primary care. However, they indicated that previous studies of the elements of primary care are limited because few studies measured more than one or two characteristics at a time, hence, the relative importance of these characteristics had yet to be determined.

Therefore, Safran et al. (1998) studied the association between the defining elements of primary care, as specified by the Institute of Medicine, and three outcomes of care – patients’ adherence to their primary physicians’ advice, patient satisfaction, and improved health outcomes. Satisfaction and health outcomes were measured simply with two items:

All things considered, how satisfied are you with your regular doctor? and, Compare your current health status with that of four years ago. The strongest correlations for patient adherence were found to be with physicians’ knowledge of the patient and patients’ trust in their physician. Other variables associated with patient adherence were being female, white, more educated, and higher self-reported physical and mental health.

Consistent with the majority of previous studies of patient satisfaction, Safran et al. (1998) found that three fourths of the respondents were either completely satisfied (33 percent) or very satisfied (44 percent) with their physician. The correlate most strongly associated with satisfaction was trust in the physician. Other variables related to high satisfaction were better self-reported mental health, and higher levels of education.

Worthy of specific note is that patients with the highest trust scores (95th percentile) were five times more likely than those with medium levels of trust to report complete satisfaction with their physicians. Patient reports of improved health status, a proxy for

health outcomes, were positively related to issues of trust, communication, thoroughness of the physical examination, and physician’s knowledge of the patient. Safran et al.

(1998) noted that adherence was strongly related to the strength of the patient-physician relationship and suggested that physician’s trust in the patient and the physician’s knowledge of the patient superseded all other factors. Further, patients’ trust in their physicians exceeded all variables in the association with patient satisfaction. Primary care relationships that are patient-centered with patient-centered communication allow the physician to gain whole-person knowledge of the patient and for high levels of patient trust in the physician to emerge.

IMPACT OF GENDER AND RACE ON HEALTH AND HEALTH CARE, AND

OTHER CONSIDERATIONS

Although not the focus of this dissertation, it would be incomplete if the contributions of gender and race to health care inequalities were not acknowledged.

Beginning more generally, Hooper et al. (1982) studied the effect of patient age, ethnicity, gender, and neatness of appearance on physician behavior. They found all positive relationships between physician behavior and patient appearance. Physicians were rated higher on interviewing skills, attention given to the patient, courtesy, and delivering more empathy. Patients rated highest on appearance were interrupted less often by their physicians. Age of the patient had no influence on physician behavior with one exception. Patients over the age of 74 were treated with more courtesy. Interview ratings and empathy were higher for Anglo-American patients than Spanish-American patients, with a trend for the physician to spend more time with Anglo-Americans. Finally,

specific to gender, they found that physicians were more empathic and provided more information to female patients, and when telling their stories, female patients were interrupted by their physicians significantly less often.

Physician practice style also can be influenced by patient gender. Using the Davis

Observation Code, Bertakis and Azari (2007) examined office visits of patients randomly assigned to primary care residents. Female patients (62 percent) were more likely to have lower levels of education, lower income, and lower self-reported physical and mental health. There was no difference in the average length of the visit regardless of patient gender. After controlling for patient and physician characteristics, they found that female patients received more discussions about the results of therapeutic interventions and more preventive services, but fewer discussions about smoking or other substance use, and fewer physical examinations. When gender concordance was considered, the only significant finding was for a female/female pair. In spite of having smoking rates similar to men, women of female physicians received less tobacco counseling and fewer discussions regarding use of alcohol or other substances. Bertakis and Azari (2007) concluded that these differences are not the result of gender bias. Rather, physicians may be making some of their clinical decisions based on gender-related considerations as well as stereotypes.

In a study specific to the relationship between race and patient-centered communication, Cooper et al. (2003) found that regardless of race, either black or white, when there was concordance between the patient and the physician, the visits were longer and the rate of speech was slower, patients demonstrated a significantly more positive

affect, and physician affect was rated more positively, although not significant. Patients in race concordant visits rated their physicians as allowing more patient participation and were more likely to strongly agree with the statements, “Overall, I was satisfied with this visit,” and “I would recommend this physician to a friend.” The concordance/discordance outcomes were consistent regardless of whether the concordant pair was white or black.

Johnson et al. (2004) used the Commonwealth Fund 2001 Health Care Quality

Survey to examine racial and ethnic differences in patients’ perceptions of bias at two levels: 1) their primary care physician’s bias and competence in terms of respectfulness, level of cultural understanding, and acceptance of the patient and his/her way of life, and

2) bias and competence experienced in the health care system. The study sample was primarily female, and patients of minority groups were more likely to be less educated, have lower income, and report poorer health. Hispanics and Asians were less likely to report that their physician listened to everything they had to say, that they as a patient understood everything the doctor had to say, that the doctor involved them in decision making to the extent they preferred, and spent as much time with them as they wanted.

Hispanics reported having the worst communication with their physician, but perceived the same level of respect and dignity as their white counterparts, which actually was greater perceived respect and dignity after adjusting for the worse communication. Those having higher levels of education also reported being treated respectfully by their physicians. Those who were more likely to agree with the statement that their physician looks down on them and the way they live their lives were black, Hispanic, and Asian, and those with lower levels of education and poorer health. Regarding perceptions of the

health care system overall, racial and ethnic minorities were more likely to perceive bias and lack of cultural competence. In summary, patients’ perceived biases regarding both their physicians and the health care system were found to be related to race/ethnicity and socioeconomic status, with minorities and those of low socioeconomic status perceiving the most bias.

The influence of social distance on the patient-physician interaction also must be given consideration. Schnittker (2004) referred to the patient-physician interaction as one in which there is a “high degree of mutual uncertainty and asymmetric power” (p. 217).

Due to patients’ uncertainties and abilities to assess quality of care and the asymmetry in power, patients’ trust in their physicians is crucial. Patient trust is crucial for physicians in order to fulfill their role obligations successfully, and crucial for patients trusting that their physician will act in their best interest (Schnittker 2004). Schittker (2004) reported that members of minority groups and those of lower socioeconomic status are more likely have low levels of trust in physicians and be more skeptical of medicine in general.

Although patient characteristics can influence physician behavior, an explanation for varying levels of trust in physicians is the ways in which people of different socioeconomic status groups interpret physicians’ behavior. Schnittker (2004) indicated that “not all patients rely on physicians’ behavior to the same extent as a signal of trustworthiness” (p. 219) with physicians’ behavior having the most impact on the opinions of minority patients. The most favorable patient-physician interaction must be an optimal balance of social distance and proximal familiarity with too much distance impeding the development of an effective relationship.

Schnittker (2004) used data from the Community Tracking Survey, a large nationally representative dataset, to study the relationship between patients’ demographic variables (education, income, and race/ethnicity) and physician trust and behavior. Not surprisingly, overall, the majority of respondents reported being satisfied with their physicians’ thoroughness, listening skills, and ability to provide information in understandable ways. However, physicians were felt to be significantly less responsive to patients who were racial and ethnic minorities. White patients, women, those with a high school education or college degree, those of higher socioeconomic status and higher income, and those with private insurance (versus the uninsured) reported the highest level of trust in their physicians. Type of visit also made a difference with those presenting for well care and those who had positive previous experiences being more trusting.

Schnittker (2004) also found that physicians’ behavior mattered. Physicians who explained, listened, and were thorough were trusted more strongly. However, these evaluations were associated with trust less strongly for patients who were black or

Hispanic. Thus, evaluation of physicians’ behavior mattered less for patients who were more socially distant from their physician. Schnitter (2004) concluded that social distance decreases the salience of physicians’ behavior for assessing physicians’ trustworthiness.

Socially distant patients may be both more skeptical about doctors in general and less confident in their interpretations of their own physician’s behavior. Finally, socially distant patients may make their judgments by placing less weight on physicians’ current behavior and rely instead on prior beliefs and experiences.

Malat (2001), too, assessed the role of social distance and patients’ ratings of their physicians, with particular attention given to race. Considering the Hall and Dornan

(1990) meta-analysis of sociodemographic predictors of patient satisfaction that described conflicting results, Malat (2001) evaluated the role of social distance and race in accounting for the differential ratings. There is often a socioeconomic mismatch between patients and their physicians given that physicians have high educational attainment and typically higher income, and patients represent the complete range of sociodemographic characteristics. Given that both race and socioeconomic status are important markers of social distance, at least in the United States, Malat (2001) indicated that people tend to apply more extreme judgments to people in an out group, which is more likely to affect lower socioeconomic status and black people who seek medical care, given their likely mismatch with their physicians. However, those in lower socioeconomic status groups may have been treated poorly by past health care providers, and, therefore, have lower expectations and rate health care delivery as more favorable.

Using data from the 1995 Detroit Area Study, Malat (2001) found that those with the least education gave their physicians high ratings for respect and having spent enough time with them. However, when racial concordance between the patient and the physician was considered, only the ratings for respect were significant. She concluded that patients’ expectations based on previous experiences and prejudices from daily life coupled with class- and race-related social distance can affect the evaluation of patients’ experiences in the health care setting. Malat (2001) closed by stating that researchers need to consider

other factors that can influence the interpersonal relationship between patients and their health care providers – health insurance coverage, in particular.

From the opposing point of view, that of the physician, van Ryn and Burke (2000) examined the impact of patient race and socioeconomic status on physicians’ perceptions of patients. Although the study was related to post-angiogram encounters and not primary care, their findings are noteworthy given the possible interaction between physicians’ perceptions of patients and the potential for altered behavior toward patients. In spite of the general expectation that physicians remain unaffected by patients’ social or demographic characteristics and view each patient objectively and impartially, physicians too, like many other people, may rely on stereotypes in forming impressions of their patients. van Ryn and Burke (2000) attribute this to potential time pressures, limited time with patients, and the need to manage complex cognitive tasks, which is characteristic of physicians’ work. They surveyed more than 600 physicians, the majority of whom were white males, and asked them to rate their perceptions of their patients’ abilities and personality characteristics, their feelings of affiliation toward the patients, and their perception of patients’ behavioral likelihoods and role demands. van Ryn and Burke

(2000) found that physicians were less likely to have positive perceptions of their black patients, with black patients less likely to get reports of physician affiliation with them, and less likely to be the kind of person with whom the physician could be friends.

Physicians rated black patients as less intelligent and educated, even after controlling for patient socioeconomic status.

Further, the interaction between socioeconomic status and race played a role. Of patients in the lowest third of the socioeconomic status distribution, black patients were perceived by their physicians as being less pleasant and less rational than their white counterparts. Patients of lower socioeconomic status were perceived by their physicians as less likely to have responsibility for care of a family member and less likely to have significant career demands. Finally, patients of racial/ethnic minority groups and lower socioeconomic status were seen by physicians as less likely to be compliant, less likely to desire an active lifestyle, and to be at risk for inadequate social support. van Ryn and

Burke (2000) stressed that although patient race was associated with negative perceptions by their physicians, socioeconomic status appeared to have the more broad effect on physicians’ perceptions and affect a wider array of domains than did race. They concluded by citing findings from previous studies that suggested that physicians’ perceptions of patients matter – these perceptions affect the delivery and quality of care.

In an editorial introduction to an issue of Patient Education and Counseling,

Wissow (2005) provided an excellent summary of the impact of differences in socioeconomic status on patient-physician communication. He highlighted that physicians are more directive, less positive, and less encouraging of participation in the visit with patients from lower socioeconomic status backgrounds. Patients from low socioeconomic status backgrounds value a continuity relationship with their physicians, and Wissow (2005) sees this as an opportunity to promote better patient-physician communication by providing learning opportunities for both patients and physicians.

Return visits to the same physician would afford patients with opportunities to learn the

“rules” of communication in medical visits. Likewise, return visits to the same physician would provide the opportunity for patients to teach doctors about their world and ways of talking about it. Wissow (2005) pointed out that communication does not occur in a vacuum – physicians are influenced by what patients say just as patients are influenced by what their physicians say (and according to Hall, Roter, and Rand (1981), how they say it, too). Unfortunately, the communication that is received by patients of lower socioeconomic status is less satisfactory, and Wissow (2005) pointed out the need to examine social factors that shape physicians’ behaviors.

SUMMARY

As this chapter comes to a close, it is important to note the work of Potter and

McKinlay (2005) who wrote about the evolution of the patient-physician relationship. As the number of outside influences on the patient-physician relationship grows, such as pharmaceutical companies, insurance companies, and physicians’ employers, what used to be a private relationship between a physician and his/her patient is changing. The idealized vision of a the long-term relationship between a primary care physician and his/her patients that included a rich understanding of the patient, his/her family, and the patient’s community, is now becoming more fleeting. This changed prompted McKinlay to refer to what is more likely to happen now between a doctor and patient as an encounter rather than a relationship (Potter and McKinlay 2005). As the Parsonian conception of the patient-physician relationship as a bounded relationship is beginning to crumble, one begins to question whether this diminished relationship holds for patients of all socioeconomic status groups, or holds more for the disadvantaged who are more likely

to experience communication difficulties with their physician, whether it be a short- or long-term relationship. Given the importance of patient-physician communication, the relevance of patient satisfaction, and the impact of socioeconomic status on health and health outcomes, it is important to examine the relationships between and among these components of health.

The social science and medical literature tells us that socioeconomic status influences the patient-physician relationship that, in turn, impacts patient satisfaction.

Being of low socioeconomic status matters. Social conditions put people of low socioeconomic status at risk, at risk for disease, and at risk to be communicated with and treated differently by their physicians. For example, among these differences, patients of lower socioeconomic status receive less advice from their physicians and are less likely to have their expectations met (Willems et al. 2005), receive more technical visits and less health behavior discussion due to poorer health (Bertakis et al. 1999), and are more likely to have their physician alter their clinical management plan due to their insurance status (Bernheim et al. 2008).

In 1998, Andrulis indicated that the “literature is replete with studies linking problems with health care access, differences across socioeconomic groups, and health consequences” (p. 412). Unfortunately, that trend continues today. This dissertation will examine multiple characteristics of the patient-physician encounter in one model to examine and identify links between and among patient-physician communication, patient socioeconomic status, and patient satisfaction that will do more than reiterate previous,

limited studies. The following chapter will highlight the social theory and literature related to these relationships and propose hypotheses to be examined.

CHAPTER IV

RESEARCH QUESTIONS

Client [i.e., patient] satisfaction is of fundamental importance as a measure of the quality of care because it gives information on the provider’s success at meeting those client values and expectations which are matters on which the client is the ultimate authority. (Williams 1994:511)

INTRODUCTION

Recall from previous chapters, that primary care is the backbone of the U.S. health care system, helping the majority of the people with most of their health care concerns. The therapeutic efficacy of the patient-physician relationship is of central importance in medicine, particularly in primary care, which serves as patients’ point of entry into the health care system and as the focal point for their health care services.

Family medicine is the only primary care specialty that provides for patients’ care from the cradle to the grave, integrating the biological, clinical and behavioral sciences (AAFP

2009).

Patient-centered care is health care that is “closely congruent with, and responsive to patients’ wants, needs, and preferences” (Laine and Davidoff 1996:152) and seeks to understand and take care of the whole person through an enhanced patient-physician relationship (Stewart et al. 2003). One of the fundamental aspects of patient-centered care is patient-centered communication. Patient-centered communication not only focuses on

patients’ values, needs, and preferences, but also affords the opportunity for patients to provide input about and participate in decisions regarding their health care (Epstein et al.

2005).

Family physicians are likely to incorporate patient-centered communication in their patient-physician interactions for at least three reasons. Family physicians serve in the role of physician of first contact with the health care system and need to ask about and understand patients’ needs, values, and preferences as they provide medical therapy and/or refer patients to others in the health care system. The longitudinal nature of the patient-physician relationship in family medicine provides family physicians with more opportunities to ask patients about what they value, need, and prefer regarding their health care as well as more opportunities to involve patients in their health care decisions.

Finally, patient-centered communication is concomitant with family physicians’ mission to integrate biological, clinical, and behavioral sciences in the care of their patients.

Good communication between patients and physicians has been linked to positive outcomes including, but not limited to, better adherence to physicians’ recommendations, better health outcomes, and higher patient satisfaction (Wynia and Matiasek 2006).

Theoretically, physicians intend to be objective and unbiased in their interactions with their patients. In reality, biases may be introduced into the interaction by both the patient and physician, resulting in differential outcomes for selected groups of patients, particularly patients who are in lower socioeconomic status groups. The objective of this dissertation is to examine the relationship between patients’ socioeconomic status and their satisfaction with the care provided by their family physicians and if this relationship

is mediated by patient-physician communication, a fundamental aspect of patient- centered care. This chapter will highlight key aspects of social theory and the literature regarding patient-physician communication and patient satisfaction, and specify the research hypotheses that were investigated.

GENERAL ISSUE TO BE INVESTIGATED

The Gap

Parsons described the patient-physician relationship as one based on socially legitimized reciprocal roles, an interaction that was patterned and predictable but not spontaneous. Each party has certain rights and obligations, and each has expectations of him/herself as well as the other (Lazare 1995), presumably without deference to patients’ socioeconomic status. Figure 3 provides an illustration of how both the physician and patient have independent effects on the delivery of quality primary care, and how the effects can be mediated by the communication between the patient and the physician.

Research (both clinical/medical and social science) confirms that socioeconomic status influences health care quality and health outcomes (c.f., Marmot 2004; Meer and Rosen

2004; Mulatu and Schooler 2002; Patel and Rushevsky 1999; Sudano and Baker 2006).

Does socioeconomic status have an impact on patient-physician communication, in particular patient-centered communication, and ultimately on patient satisfaction?

According to Stange et al. (1998a), researchers and administrators need to know the most valid method for measuring the delivery of differences in services. Further, according to

Weiss (1988), “among the most difficult relationships to pin down have been those

between patient background characteristics and level of satisfaction” (p. 383). There is an opportunity to fill this knowledge gap by examining data from virtually unbiased direct observations of the delivery of primary care by family physicians.

Physician

Patient-Physician Delivery of Quality

Communication Primary Care

Patient

Fig. 3. General Factors Affecting the Delivery of Primary Care

Filling the Gap

Direct observation of the delivery of primary care is considered to be minimally biased and a gold standard for elucidating the component parts of the patient-physician encounter (Stange et al. 1998a). Data from the Direct Observation of Primary Care

(DOPC) study (Stange et al. 1998a) provides the opportunity to examine the relationships among patient socioeconomic status, patient-physician communication, and patient satisfaction in insured adults representing two very different groups – those who have

Medicaid health insurance and those who are privately insured. These two groups differ not only in their socioeconomic status, but in their understanding of their health and their

health needs, their expectations of physicians, and physicians’ expectations of them as patients. This examination of unbiased observations of patient-physician encounters and patient reports about their health care can help answer the question, “Does being poor matter to the delivery of patient-centered primary care?”

Specific Aim

The specific aim of this research is to examine the relationships among selected patient characteristics and patient satisfaction, and if these relationships are mediated by patient-physician communication. Figure 4 provides a conceptual model of limited aspects of factors that impact health outcomes. Of specific interest are: 1) patient characteristics, i.e., socioeconomic status, 2) the primary care visit, i.e., patient-physician communication, and 3) patient satisfaction.

Patient-Physician Communication

Patient Patient Socioeconomic Status Satisfaction

Fig. 4. Conceptual Model of the Present Research

HYPOTHESES

This research proposes three hypotheses, which follow. For each hypothesis, background information, including social theory and medical and social science literature, is summarized that led me to consider each hypothesis.

The Relationship between Patient Socioeconomic Status and Patient-Physician

Communication

Both physicians and patients have expected behavior in the patient-physician encounter. Patients’ behavior is shaped by their social position and expectations of the health care system. Physicians’ behavior, too, is shaped by the expectations of society, the health care system, and the specialized training they receive – the skills, knowledge, and shared understandings that serve as a guide to the profession (Becker et al. [1961]

2008). From a traditional point of view, Parsons (1951) prescribed specific roles for both the patient and the physician, with the patient relegated to the role of being sick, dependent, and obedient, and the physician being a benevolent, knowledgeable authority figure.

As patients and physicians come together in the clinical setting, they form a special dyad, with physicians holding positions of expert and authority. According to

Simmel (1982b), physicians attain their authority through their superior significance due to the weight of their opinion as well as authority granted from the state. People, in general, are defenseless in the face of authority, which makes it difficult for patients to challenge physicians (Simmel 1982b). This challenge likely would be most difficult for

patients from lower socioeconomic status groups due to the socioeconomic and power differentials between these patients and their physicians.

Through their training, physicians learn a specialized language that serves as an identifier as well as a means of excluding those unfamiliar with the language (Hardy and

Conway 1978), particularly those of lower levels of education. Further, the

“performance” that takes place when two people come together, i.e., the patient and physician, is dictated by an individual’s status or social place, which prescribes the individual’s appropriate conduct (Goffman 1959). This mismatch in behavior, including communication, will be particularly apparent between physicians and patients from lower socioeconomic status groups who are from social groups very different from physicians

(Strauss 1977).

Individuals develop their conceptions of their selves from their social group as well as the feedback they receive from others during their social interactions (Lemert

1999; Strauss 1977). Patients interact and communicate with their physicians in ways learned through and appropriate to their social group of reference, which may or may not be congruent with the communication style exhibited and expected by physicians.

Physicians, in turn, may or may not adjust their communication based on their interpretations of a patient’s way of interacting.

Willems et al. (2005) refered to the communication between physicians and patients of lower socioeconomic status as a “vicious circle” (p. 143) with these patients being “doubly disadvantaged” (p. 143) because of their passive communication style as well as physicians’ misperception of their needs. Willems et al. (2005) demonstrated that

patients’ style of communication influenced physicians’ communication style, primarily in the primary care setting, and that communication was influenced by a patient’s socioeconomic status. For example, they found that physicians listened more, communicated more general and health information, and provided more help to patients from higher socioeconomic status groups. Although it is recognized that patients are able to resist physicians’ authority and offer their own perspectives into the interaction, social factors can influence that ability (Ha, Anat, and Longnecker 2010).

This research and these theoretical perspectives lead me to consider Hypothesis 1:

The patient-physician encounter is more physician-centered for patients who have

Medicaid insurance, and the encounter is more patient-centered for patients who have private insurance.

The Relationship between Patient-Physician Communication and Patient Satisfaction

Goffman (1959) asserted that “we live by inference” (p. 3). Our actions, or performance according to Goffman, influence how others perceive us and influence the definition of the situation. This performance is dictated by an individual’s status or social place, which prescribes appropriate conduct as well as expectations of the other person in the interaction (Goffman 1959). Mead, too, asserted that behavior is based on expectations of the other, or what he referred to as the reflexive behavior of social interaction (Lemert 1999). Further, Starr (1982) offered that physicians and patients are unlikely to share the same assumptions due to differences in their linguistic and cultural backgrounds. Patients from lower socioeconomic status groups are more likely to be

“guarded in their communications” (Starr 1982:12) possibly disrupting physicians’

attempts to be more patient centered in their communication. The likely mismatch in expectations of behavior between the patient and physician, different communication styles, and difficulties in communication can lead to satisfying, or unsatisfying, experiences for both the patient and the physician.

Street et al. (2007) found that physicians’ behavior and communication was influenced by patients’ behavior and communication style. If the physician’s task in the medical interview is to elicit the patient’s story (Smith and Hoppe 1991), the patient should be the focal point of the interaction. In a physician-centered interview, the biomedical aspects of patients and their presenting concerns are privileged with a focus on physicians gathering information from their clinical/medical perspective (Smith and

Hoppe 1991). In contrast, the patient-centered interview allows patients to be heard and understood. It provides physicians with the information they need to consider patients’ values, needs, and preferences in decision making. It also provides the opportunity for patients to participate actively in the interaction and in decisions about their health and health care (Epstein et al. 2005). Patient centeredness is important for developing a sense of connectedness between patients and physicians (Smith and Hoppe 1991). This sense of connectedness could lead to patients feeling more satisfied with their physicians. Mead et al. (2002) proposed that patient satisfaction is an appropriate outcome for studies of patient centeredness given that patients value physicians’ informativeness, attention to psychosocial problems, and respect, elements of which are common to both patient centeredness and patient satisfaction measures.

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This theory and research leads me to consider Hypothesis 2: Patients whose primary care visit is characterized by more patient-centered communication are more satisfied than patients whose primary care visit is characterized by more physician- centered communication.

The Relationship between Patient Socioeconomic Status and Patient Satisfaction

Roles and statuses are critically important in helping to understand the interaction between patients and their physicians. According to Susser et al. (1985), “people anticipate predictable responses in specific situations according to the status of the parties involved” (p. 281). These predictable responses serve as a guide for social interaction. As physicians strive for power and prestige, their orientation to and behavior toward their patients of lower socioeconomic status could be compromised (Walsh and Elling 1972).

The poor, degraded and stigmatized by society (Freidson and Lorber 1972), could face an additional challenge to achieving equality in the patient-physician relationship, leading to a less satisfying patient-physician relationship for patients from lower socioeconomic status groups.

Patient satisfaction is a key outcome for measuring the delivery of health care services because of the “ethico-political desire to ensure that patients find their care acceptable” (Mead et al. 2002:285) and the positive relationship between patient satisfaction and patient outcomes (Safran et al. 1998). Research suggests that patient satisfaction of physicians is highest when patients feel that they can participate mutually in the interaction with their physician, and the physician demonstrates psychosocial concern and courtesy (DiMatteo 1994). Theory suggests that a mutually shared

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interaction is less likely to occur between patients and physicians when patients are from lower socioeconomic status groups (Freidson 1988; Freidson and Lorber 1972; Goffman

1959; Simmel 1982b; Starr 1982). Further, patients who are from lower socioeconomic status groups are less likely to be in good health (Marmot 2004). Hall et al. (1998) found that patients who were less healthy were less satisfied with their health care, presumably due to the type of conversation with their physicians.

This leads me to consider the following two related hypotheses. Hypothesis 3.1:

Patients who are insured by Medicaid are less satisfied with their primary care visit than patients who have private insurance. Hypothesis 3.2: The centeredness of the communication mediates the relationship between insurance status and patient satisfaction.

The following chapter, Chapter V, will detail my approach to testing these hypotheses by examining data from the Direct Observation of Primary Care study

(Stange et al. 1998a), which provides an objective account of the content of the interactions between patients and their family physicians.

CHAPTER V

RESEARCH METHODS

Unfortunately, health disparities, differences in the care or outcomes of patients that have nothing to do with the patients’ underlying medical conditions, are all too common nationally. Disparities can result from many factors including differential access to health care or high quality care, overt or subtle racism, and a lack of cultural competency and effective communication by health care providers. National health care disparities have been extensively documented. Mechanisms for the disparities are also well known. The crying need is for solutions. (Chin and Cook 2010:1)

INTRODUCTION

To examine the hypotheses proposed in the previous chapter, this chapter will describe the dataset that was available for analysis and the methods that were employed.

Hypotheses of the present study were tested through secondary analyses of the data from the Direct Observation of Primary Care (DOPC) study, used with permission from Kurt

C. Stange, M.D., Ph.D., principal investigator. The DOPC study was a landmark multi- method study representing the most comprehensive glimpse into the content and context of family medicine outpatient visits to date (Stange et al. 1998a). Although the DOPC study was designed to determine the optimal non-observational method of measuring the delivery of outpatient medical services, the study provided unmatched comprehensive data to help understand the complexity of the patient-physician encounter and to provide insight into what has been termed by physicians, and medical sociologists alike, as the

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“black box” of family medicine – the delivery of primary care unseen by policymakers and understood only in isolation through monocular views (Stange et al. 1998b).

METHODS

Because this dissertation is based on a secondary analysis of an existing dataset, the Methods section includes two sub-sections, the design and methods for the DOPC study followed by the design and methods for this dissertation.

The following description of the DOPC study, unless otherwise noted, was based on Stange et al. (1998a), the seminal article describing the study and the methods employed, and Stange, et al. (1998b), which provided additional characterizations of the practices, physicians, patients, and the patient visits. Only the data collection methods and measures of the DOPC study that apply to this dissertation are provided here. In addition, methods applying to patients under the age of 18 have been omitted from this description, since only the data from adults ≥18 years of age were used for these analyses. A more complete description of the DOPC study can be found in Appendices A and B.

Design/Methodology Strategies – The Direct Observation of Primary Care Study

Specific aim of the DOPC study. The DOPC study was undertaken to examine the inter-rater reliability and validity of the commonly used and relatively inexpensive medical record review and patient questionnaire methods compared to a gold standard of direct observation of outpatient visits to family physicians, a very time intensive and high-cost method.

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Sites and subjects of the DOPC study. Physicians and practices: Family physicians who were members of the Ohio Academy of Family Physicians and practiced within a 50-mile radius of Cleveland and Youngstown, Ohio, were invited to participate in the study. Family physicians who were not practicing in family practice settings and full-time academic family physicians were excluded, with the exception of 30 members of the faculty of the Department of Family Medicine at Northeastern Ohio Universities

College of Medicine (now known as Northeast Ohio Medical University) who practiced in six affiliated hospital-based family medicine residency training programs located in

Akron, Barberton, Canton, and Youngstown.

Patients: Patients eligible for participation in the study were those of all ages who presented for care from a participating family physician during one of the data collection days.

Data collection procedures of the DOPC study. Data collection overview: Each participating physician was visited by two research nurses two days of the data collection period at which time the nurses engaged in observation activities of the physician while he/she was providing outpatient care, and an additional two days during which the research nurses abstracted data from the medical records.

Patient informed consent: Consecutive adult patients presenting to the office for care on the observation days were informed about the study in the waiting room before meeting with their physician and were enrolled if they gave verbal consent (please note that written consent was not required by the IRB at that time).

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Eight data collection procedures were used in the multi-method DOPC study.

Procedures included: 1) patient-physician observation, 2) direct observation confirmation,

3) patient self-reported data, 4) medical record review, 5) physician self-reported data, 6) billing data, 7) practice environment, and 8) ethnographic field notes. Following are brief descriptions of the procedures with the exception of the direct observation confirmation and ethnographic field notes, which are not applicable to this dissertation. Detailed information regarding all procedures is provided in Appendix A.

Data collection – patient-physician observation: One of the two research nurses, the observing research nurse, accompanied consenting patients to the examination room and seated herself to observe the visit from the least obtrusive corner of the examination room, from a position that avoided eye contact with the physician as well as the patient.

Her task was to record the content of each 15-second interval of the entire patient- physician interaction.

Data collection – patient self-reported data: Immediately following their visit, consenting patients were approached by the second research nurse who provided them with a questionnaire to complete and place in an envelope to help maintain their confidentiality. Patients could complete the questionnaire at that time or take it with them to complete and mail back to the investigators.

Data collection – medical record review: Data were abstracted from consenting patients’ medical records on a day subsequent to the patient observation day. The research nurses: a) indicated whether or not a particular service was noted in the patient’s medical record for the observed visit, or for selected services, during a preselected time

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interval, b) assigned Current Procedure Technology (CPT) codes (American Medical

Association 1995) to each visit, and c) rated the components of the visit that led to the assignment of the CPT code according to the American Medical Association (1995) guidelines.

Data collection – physician self-reported data: Each physician was asked to complete a questionnaire that was distributed to the physician only after the second day of observation was completed to avoid biasing physician behavior during the study.

Data collection – billing data: After the observation days during the medical record review days, the research nurses obtained and recorded patient-related billing data specific to each observed patient-physician encounter.

Data collection – practice environment: The Practice Environment Checklist provided objective and subjective data about a variety of aspects of each of the participating practices. Data were collected from interviews of key office informants and the research nurses’ direct observations during both the patient care observation and medical record review days.

Measures used in the DOPC study. Eight measures were used in the DOPC study: 1) direct observation of the patient visit, 2) a direct observation checklist of services delivered during the patient visit, 3) a patient exit questionnaire, 4) medical record review, 5) a practice environment checklist, 6) billing data, 7) a physician questionnaire, and 8) ethnographic field notes. Following are brief descriptions of the measures used in the DOPC study with the exception of the direct observation checklist

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and ethnographic field notes, which are not applicable to this dissertation. Detailed information regarding all measures is provided in Appendix B.

Measure – direct observation of the patient visit: Using direct observation, elements of consenting patients’ visits were categorized using the Davis Observation

Code (DOC). The DOC has been shown to be a reliable and valid method for categorizing patient and physician behavior during either direct observation or review of videotapes of medical encounters (Callahan and Bertakis 1991). The DOC uses an interval coding system that categorizes time use during every 15-second interval of each patient visit into 20 different behavioral categories selected to capture specific aspects of primary care.

The original 20 code areas proposed by Callahan and Bertakis (1991) include: chatting, structuring interaction, counseling, history taking, family information, treatment effects, health knowledge, evaluation feedback, physician examination, patient question, compliance, preventive services, health education, health promotion, planning treatment, exercise, smoking behavior, nutrition, substance use, and procedure. Stange et al. (1998a) modified the DOC, using 19 of the original 20 categories, and replacing “treatment effects,” defined as “physician inquires about or patient describes results of ongoing therapeutic intervention for current episode or problem” with “negotiation,” which focused on eliciting input from patients into management decisions.

Measure – patient exit questionnaire: The Patient Exit Questionnaire was an attempt to collect a wide variety of information from the patient’s perspective. The self- administered survey included questions about demographics, reason for the visit, health

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status, referrals, about the doctor, the services provided, general questions, and satisfaction. Patient satisfaction was measured using a slightly modified version of the

VSQ-9, a visit-specific measure of patient satisfaction (Cronbach’s alpha = .89) (RAND

2009; Rubin et al. 1993). The survey, as presented by RAND (2009), requests that respondents rate nine items on a five-point Likert scale (left to right) (poor, fair, good, very good, excellent [note that no numerical values are associated with the scale]), given the instructions: “Thinking about your visit with the physician/health care Professional

[sic] you aw [sic], how would you rate the following: 1) How long you waited to get an appointment, 2) Convenience of the location of the office, 3) Getting through to the office by phone, 4) Length of time waiting at the office, 5) Time spent with the physician/health care professional you saw, 6) Explanation of what was done for you, 7) Technical skills

(thoroughness, carefulness, competence) of the physician/healthcare professional you saw, 8) The personal manner (courtesy, respect, sensitivity, friendliness) of the person you saw, and 9) The visit overall.

The adapted version of the VSQ-9 survey used in the DOPC study provided the instruction to patients: “Here are some questions about the visit you just made. In terms of your satisfaction, how would you rate each of the following on a scale from 1 to 5?”

The scale provided included (left to right) excellent (1), very good (2), good (3), fair (4), and poor (5). Items were presented as: 1) How long you waited to get an appointment, 2)

Convenience of the location of the office, 3) Getting through to the office by phone, 4)

Length of time waiting at the office, 5) Time spent with the person you saw, 6)

Explanation of what was done for you, 7) The technical skills (thoroughness, carefulness,

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competence) of the person you saw, 8) The personal manner (courtesy, respect, sensitivity, friendliness) of the person you saw, and 9) This visit overall. (Note that bolded and underlined words reflect the presentation of the items in the actual questionnaire.) The patients also were asked to respond to the question, “To what extent were your expectations met today?” using the scale (left to right) A lot, Quite a bit,

Moderately, Slightly, and Not at all.

Measure – medical record review: Data from the patient’s medical record included information specific to the observed visit, the delivery of services during the past year and other specific time intervals for selected services, demographics, the number of chronic illnesses and medications, the number of years as a patient of the practice, the number of visits in the past year, and if the patient had specific illnesses.

Measure – practice environment checklist: The practice environment of each participating site was evaluated in four general categories: 1) office set-up, 2) office operations, 3) external environment, and 4) physician characteristics.

Measure – billing data: Billing data relied on E&M CPT codes (American

Medical Association 1995) and International Classification of Diseases, Clinical

Modification (ICD-9-CM) diagnoses (USDHHS CMS 2008b).

Measure – physician questionnaire: Each participating physician completed a survey that solicited information that included demographics, questions about the observation day, practice characteristics, delivery of specific services, opinions about preventive services, personal health and health habits, decision making about screening, competing demands, familiarity with and feeling about practice guidelines, how their

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practice addressed the domains of primary care, and the validity of the Resource-Based

Relative Value System (RBRVS) method for billing patients.

Data security. All measures were linked using unique confidential identifiers for physicians and patients. Original data forms and identifier lists were stored in secure locations with access restricted to limited members of the DOPC research team. Stange has provided assurance that all identifier lists have been destroyed.

Data analysis techniques for the DOPC study. The representativeness of the physician sample was determined by comparing the demographics of the physicians who agreed to participate in the study with those of the members of the American Academy of

Family Physicians (AAFP 1996). The representativeness of the patient sample was determined using several methods. First, consenting patient and visit characteristics were compared with similar data from the National Ambulatory Medical Care Survey

(USDHHS CDC 2009). Second, a comparison was made between the research nurses’ perceptions of the observable characteristics of consenting patients and those patients who declined to participate. Research nurses also recorded any reasons for patient refusal.

Third, a subsample of 12 participating physicians reviewed the medical records of patients who declined, and recorded patient demographics and the number of years as a patient of that practice, which were compared to consenting patients’ data. Further, this subsample of physicians also recorded their supposition regarding why the patient might have declined to participate based on their knowledge of the patient and the characteristics of the patient visit during the observation day. Finally, using observation and medical record data for consenting patients, the characteristics of patients who

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returned patient questionnaires were compared to those who did not. T-tests were used to compare continuous variables, X 2 tests were calculated for ordinal variables, and the

Wilcoxon rank-sum test was calculated for highly skewed ordinal variables.

Descriptive analyses were calculated using a variety of data sources. Physician self-report data from the Physician Questionnaire were used to describe the physician sample. Data to describe the patient sample were derived from the Patient Exit

Questionnaire, and billing data were used to ascertain the type of insurance.

Characteristics of the visit were derived from direct observation data consisting of the research nurses’ assessment of the reason for visit and data collected while using the

Davis Observation Code including the length of the visit, which was the amount of time the physician spent in direct contact with the patient.

Brief overview of results of the DOPC study. Following is a brief summary of pertinent results of the DOPC study including characteristics of the original sample of physicians, patients, practices, and observed outpatient visits. Additional details can be found in Stange et al. (1998a and 1998b), which served as the basis for this report.

With a goal sample size of 120 family physicians based on power calculations,

531 family physicians were invited to participate in the study; 138 (26 percent) volunteered to participate. The majority were men (72 percent) who had completed a family medicine residency (89 percent) and had been in practice for an average of 11 years. Slightly more than half (53 percent) practiced in a single-specialty group, 30 percent were in solo practice, and they cared for an average of 104 patients each week in their practices. The physicians who agreed to participate in the DOPC study were similar

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in age, practice situation, and patients seen each week to active practicing members of the

American Academy of Family Physicians (AAFP 1996). However, the sample reflected training and gender shift trends with participating physicians more likely to be female (28 percent DOPC versus 21 percent AAFP) and residency trained (89 percent DOPC versus

73 percent AAFP).

During the two days of observation, participating physicians saw a total of 4,995 patients, of which 4,454 (89 percent) agreed to have their visits observed. The average age of patients was about 41 years, and 61 percent were women. The majority of the patients were white (91 percent), with only 30 percent having less than a high school education. Patients averaged four visits to the observed physician each year, with 7 percent reporting that it was their first visit to that physician. Regarding insurance status,

8 percent were insured by Medicaid, and 36 percent had a private insurance plan. Patients rated their overall health as average (3.4 of a possible 5.0). On average, physicians spent

10 minutes with each patient. Patient exit questionnaires were returned by 3,283 patients

(74 percent) who were more likely to be older, female, white, and have a longer relationship with the practice than those who did not complete an exit questionnaire.

The research nurses estimated that the patients who refused to participate were slightly older (age 45 versus 41, p = .01) with no differences by gender. Reasons for refusal included privacy, feeling too sick, and being a new patient and not comfortable yet with the physician. The subsample of 12 participating physicians who reviewed the medical records of patients who declined confirmed that these patients were older than participating patients but similar in gender, race, and number of years as a patient. In

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addition to privacy issues, the physicians projected possible additional reasons for refusal to include patient anxiety, embarrassment, and shyness.

Design/Methodology Strategies – The Present Study

Specific aim. The aim of this dissertation is to examine the relationship between patients’ socioeconomic status and patient satisfaction and how this relationship is affected by patient-physician communication.

Data. All quantitative data from the DOPC study (Stange et al. 1998a) data were provided for the present study by Kurt Stange, M.D., Ph.D., DOPC principal investigator.

Sites and subjects. Physicians and practices: Data from all physicians and practices included in the DOPC study were included in the present study if patients who participated from those sites met the inclusion criteria for the present study. Patients:

Only those patients who were age 18-64 with Medicaid insurance or privately insured were included in the analysis. Those who were privately insured are defined for the present study as those with managed care insurance (defined for patients in the DOPC study as “referral from primary care physician required for other health care”) and those with regular health insurance (defined for patients in the DOPC study as “you can choose to go to any doctor without a referral”). Those excluded from the present study were those who reported having Medicare, other insurance, or no insurance. Those who were uninsured may have been of higher socioeconomic status and opted not to purchase health insurance; therefore, they were excluded from the present analysis. Those who were at least age 65 or greater were eligible for Medicare insurance, regardless of socioeconomic status; therefore, they were excluded from the analysis. Because having

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“other” insurance is vague, these patients, too, were excluded, as well as those for whom insurance status was not available. Those also excluded from the present study were patients ≤ age 17, > age 65, and those for whom age was not available.

Institutional review board review and approval. The research protocol for protection of human subjects for the original DOPC study was reviewed and approved by the Institutional Review Board (IRB) of Case Western Reserve University. The protocol for the present study was reviewed and approved by the IRB of Kent State University as

Level I research (protocol #08-756). Documentation is provided in Appendix C.

Conceptualization and operationalization of the variables. Zandbelt et al. (2005) acknowledged that one reason for the difficulty in measuring patient-centeredness

“unequivocally is its supposed multi-dimensionality” (p. 662). The purpose of their 2005 study was to develop an instrument to measure patient-centeredness based on one specific dimension – physicians’ explorative communication skills. They defined patient- centeredness as “physicians’ behavior which enables the patient to express his/her perspective on illness and treatment and health-related behavior: his/her symptoms, concerns, ideas and expectations” (Zandbelt et al. 2005:662), implying that physicians use facilitating behaviors and avoid behaviors that restrain patients from expressing their views. According to Mead and Bower (2000), in spite of the fact that there is some consensus regarding the types of behaviors that are considered to be patient-centered, there also is disagreement on the inclusion of certain behaviors, in particular physicians’ information giving, as well as the role of the patient. Common to most systems of measurement of patient centeredness are physician behaviors that encourage patient talk,

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including question asking, empathic and affective statements, and non-medical discussion.

These reflections on patient centeredness served as a guide for categorizing the 20 behaviors from the Davis Observation Coding scheme that served as one of the main variables of interest – patient-physician communication. The measure used for communication in this dissertation was the physician’s verbal behavior during the patient-physician encounter, which was available for analysis using the Davis

Observation Codes recorded during the direct observation of the patient-physician encounter. The second variable of interest was patient satisfaction, which was available for analysis as a direct report by the patients. The third variable of interest was patient socioeconomic status for which patients’ medical insurance status was used as the indicator. Table 1 provides an overview of the variables that were used in the analysis.

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Table 1. Variables for Analysis for the Present Study Theoretical Concept Research Construct Variable Dependent Variable Patient satisfaction Satisfaction with care Satisfaction with the practice delivered during structure (scale components): observed visit to a  wait to get an appointment family physician  convenience of the location of the office  getting through to the office by phone  length of time waiting at the office

Satisfaction with the provider (scale components):  time spent  explanation of what was done  technical skills  personal manner

Satisfaction with the visit overall

Expectations met

Primary Independent Variables Patient-centered Patient-physician Physician-centered communication communication communication (score components):  history taking  planning treatment  evaluation feedback  compliance  structuring interaction  health education

Patient-centered communication (score components):  health knowledge  patient question

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Theoretical Concept Research Construct Variable  negotiation  counseling  health promotion  family information

Chatting

Socioeconomic status Patient socioeconomic Type of medical insurance status Medicaid Private insurance

Other Independent Variables Socioeconomic status Patient socioeconomic Education status

Patient characteristics Health status Overall health Physical health Mental health

Other demographics Age Gender Race/ethnicity

Visit characteristics Complexity of the visit Complexity of medical decision making (E&M CPT code)

Familiarity New or established patient

Visit duration Minutes of direct patient- physician interaction

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Creation of scales. Before analyses could commence, scales needed to be created for patient satisfaction with the practice site and patient satisfaction with the physician.

Patient satisfaction with the practice site reflects each patient’s average ratings of the following four items of the patient satisfaction measure: a) how long you waited to get an appointment, b) convenience of the location of the office, c) getting through to the office by phone, and d) length of time waiting at the office. Patient satisfaction with the physician reflects each patient’s average ratings of the following four items of the patient satisfaction measure: a) time spent with the person you saw, b) explanation of what was done for you, c) the technical skills (thoroughness, carefulness, competence) of the person you saw, and d) the personal manner (courtesy, respect, sensitivity, friendliness) of the person you saw.

Before any a priori designations of scales could be used in analyses, the validity of the measures needed to be determined. Cronbach’s alpha was used to determine if the items proposed for the scales were appropriately inter-correlated for: 1) patient satisfaction with the practice site, and 2) patient satisfaction with the physician, with a target reliability coefficient of .70 for each scale (Nunnally and Bernstein 1994). For patient satisfaction with the practice site, Cronbach’s alpha = .723, and Cronbach’s alpha

= .908 for patient satisfaction with the physician.

Creation of scores. Summed scores were created for patient-centered communication and physician-centered communication. Patient-centered communication reflects the sum of the proportion of Davis Observation Codes for each patient’s visit devoted to the following six categories: a) health knowledge, b) patient question, c)

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negotiation, d) counseling, e) health promotion, and f) family information. This summed score is referred to as the patient-centered score. Physician-centered communication (i.e., the physician-centered score) reflects the sum of the proportion of Davis Observation

Codes for each patient’s visit devoted to the following six categories: a) history taking, b) planning treatment, c) evaluation feedback, d) compliance, e) structuring interaction, and f) health education. This summed score is referred to as the physician-centered score. In addition, a centeredness score was calculated for each patient by subtracting the physician-centered score from the patient-centered score. Therefore, a centeredness score of zero would indicate that the proportion of DOC categories devoted to physician- centered behavior is equal to the proportion of DOC categories devoted to patient- centered behavior. A positive score would indicate that a greater proportion was devoted to patient-centered communication, and a negative centeredness score would indicate that a greater proportion was devoted to physician-centered communication. With the exception of chatting, all other categories were excluded from the analyses.

Creation of other new variables. Patients who were insured by regular insurance and those who were insured by managed care were combined into a category called

“private insurance.”

A variable called “established patient” was created by including all choices for

“length of time as a patient of that physician” other than “first visit.”

A variable called “other race” was created by combining “black,” “Asian,”

“Indian,” and “other.” Although it is recognized that “Hispanic” is an ethnicity and not a

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race, it, too, was included as part of “other race,” rather than excluding those patients from the analyses due to the low number of respondents who self-identified as Hispanic.

A variable called “complexity of the visit” was created from the assigned E&M

CPT billing code. These codes are indicative of the level of care provided during the office visit. They reflect the degree to which physician effort, time, responsibility, and medical knowledge are expended during a medical encounter with a patient in three key areas – history, physical examination, and medical decision making (AMA 1995). Codes range from the lowest level of 1 through the highest level of 5. A new category was created by using the last digit in the CPT code for either a new or established patient with

1 = 99201 or 99211, 2 = 99202 or 99212, 3 = 99203 or 99213, 4 = 99204 or 99214, and 5

= 99205 or 99215.

Coding of variables. Patient satisfaction: The three measures of patient satisfaction were all considered continuous variables ranging from 1= poor through 5 = excellent: 1) satisfaction with the practice site, 2) satisfaction with the provider, and 3) satisfaction with the visit overall. Note that these measures were reverse coded from the original numerical values indicated on the questionnaire and assigned by the patients.

Patient centeredness: The patient’s centeredness score was considered a continuous variable and ranged from negative through positive integers when it was first calculated. Because of the difficulty in interpretation of the minute differences among the scores, centeredness was recoded. Scores were clustered into eight groups that closely approximate the original distribution of scores, with the highest value, 8, indicating the

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most patient-centered visits, and the lowest value, 1, indicating the most physician- centered visits.

Insurance status: Insurance status is a dichotomous, nominal-level variable.

Therefore, dummy coding was used with private insurance serving as the reference group, which was given a value of 0, and Medicaid was given a value of 1. All other insurance groups were excluded from the analyses.

Patient education: The patient’s level of education was measured at the nominal level, but was considered a continuous variable for the analyses and assigned the following values: less than high school = 1, some high school = 2, high school graduate =

3, some college = 4, associate degree = 5, college graduate = 6, and graduate school = 7.

Familiarity: Familiarity was determined from patient response to “length of time as a patient of that physician” and was considered a dichotomous variable, dummy coded with established patient serving as the reference group and given the value of 0, and first visit (i.e., new patient) given the value of 1.

Patient health status: The patient’s health status had three continuous measures:

1) overall health was determined by patients’ response to “In general, would you say your health is” with the response choices ranging from 1 (poor) through 5 (excellent), 2) physical health was determined by patients’ response to “In the past four weeks, to what extent did health problems limit your everyday physical activities (such as walking and climbing stairs) with response choices ranging from 1 (extremely) through 5 (not at all), and 3) mental health was determined by patients’ response to “During the past four weeks, how much have you been bothered by emotional problems (such as feeling

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anxious, depressed, or irritable) with response choices ranging from 1 (extremely) through 5 (not at all). Note that these measures were reverse coded from the original numerical values indicated on the questionnaire and assigned by the patients.

Patient age: The patient’s age in years is a continuous measure, and was used as such in the analyses.

Patient gender: The patient’s gender is a dichotomous nominal-level variable.

Therefore, dummy coding was used with female serving as the reference group, which was given a score of 0, and male given a score of 1.

Patient race: The patient’s race is a nominal-level variable. Therefore, dummy coding was used with white serving as the reference group.

Complexity of the visit: Complexity of the visit was considered a continuous measure ranging from 1 through 5 (low to high).

Duration of the visit: Duration of the visit is a continuous measure reflecting the actual minutes of face-to-face contact between the patient and the physician, and was used in the analyses as such.

Analysis techniques. I proposed three hypotheses. For each hypothesis, the variables and analysis techniques are specified below. Data were analyzed using PSAW®

Statistics 18 (SPSS, Inc. 2009). The first step in the analysis was to calculate descriptive statistics for all independent variables, including measures of central tendency and dispersion for continuous variables, and percentages for categorical variables. These statistics were then compared for the two groups, Medicaid versus private insurance, using t-tests for continuous variables, and chi-square for nominal-level variables.

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Then, additional inferential statistics were calculated to test each hypothesis. If the resulting p value was equal to or less than .05, the coefficient was considered significantly different from zero, and if the p value was equal to or less than .01, the coefficient was considered highly significant and strong evidence of a non-zero coefficient (Allison 1999). Although there is no reason to believe that there is any multicollinearity among the independent variables, all regression tests included tests for multicollinearity. Multicollinearity was determined by examining the tolerance statistic.

An acceptable tolerance was indicated by a value greater than .40, indicating independence of the measures (Allison 1999).

Including physician-level data in the analyses could be problematic due to lack of independence of the measures. Although the data are nested, i.e., multiple patients observed for each participating physician, the high number of physicians, without having information regarding any significant characterizing features that would distinguish the uniqueness of the physicians, lead to my decision to exclude physician data from the analyses at this time. Using physician data would be further complicated because, in some cases, physicians were nested within practices. The purpose of this dissertation is to examine differences in patient group effects not physicians or practices. Therefore, physician-level data were not included in any analyses.

The relationship between patient socioeconomic status and patient-physician communication. Hypothesis 1: The patient-physician encounter is more physician- centered for patients who have Medicaid insurance, and the encounter is more patient- centered for patients who have private insurance. Dependent variable: The dependent

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variable was the centeredness score. Independent variables: The independent variable of principal interest was patient insurance status. Additional independent variables included in the model were patient education, patient age, patient gender, patient race, patient health status, familiarity, complexity of the visit, and duration of the visit. Analysis techniques: Hypothesis 1was tested using ordinary least squares (OLS) multiple linear regression according to procedures outlined in McClendon (1994) and Allison (1999).

Multiple regression is appropriate for a single dependent variable and multiple independent variables, particularly when the independent variables could be inter- correlated (McClendon 1994). Significance was considered to be p ≤ .05 with two-tailed testing.

As an additional comparison of interest, insurance status was regressed on the proportion of codes devoted to chatting with significance considered to be p ≤ .05 using the additional independent variables in the model as specified in the previous analysis.

The relationship between patient-physician communication and patient satisfaction. Hypothesis 2: Patients whose primary care visit is characterized by more patient-centered communication are more satisfied than patients whose primary care visit is characterized by more physician-centered communication. Dependent Variables: The dependent variables were each of the three measures of patient satisfaction – satisfaction with the practice site, satisfaction with the physician, and satisfaction with the visit overall. Independent Variables: The independent variable of principal interest was the centeredness score for the visit. Additional independent variables that were included in the models were patient education, patient age, patient gender, patient race, patient health

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status, familiarity, complexity of the visit, and duration of the visit. Analysis Techniques:

OLS multiple regression analysis was used to test hypothesis 2. Three models were analyzed, one for each of the three measures of patient satisfaction, with satisfaction as the dependent variable and the centeredness score as the principal independent variable.

For each model, significance was considered to be p ≤ .05 with two-tailed testing.

As an additional comparison of interest, the patient’s indication of expectations met, measured on the ordinal scale of 1 = not at all, 2 = slightly, 3 = moderately, 4 = quite a bit, and 5 = a lot, in response to the question, “To what extent were your expectations met today?” was regressed on the centeredness score including the additional independent variables specified for the previous analyses. Significance was considered to be p ≤ .05 with two-tailed testing.

The relationship between patient socioeconomic status and patient satisfaction.

Hypothesis 3.1: Patients who are insured by Medicaid are less satisfied with their primary care visit than patients who have private insurance. Hypothesis 3.2: The centeredness of the communication mediates the relationship between insurance status and patient satisfaction. Dependent Variables: The dependent variables were each of the three measures of patient satisfaction – satisfaction with the practice site, satisfaction with the physician, and satisfaction with the visit overall. Independent Variables: The independent variable of principal interest was patient insurance status. Additional independent variables that were included in the models were patient education, patient age, patient gender, patient race, patient health status, familiarity, complexity of the visit, duration of the visit, and the centeredness score. Analysis Techniques: OLS multiple regression

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analysis was used to test hypotheses 3.1 and 3.2. Three models were analyzed, one for each of the three measures of patient satisfaction, with satisfaction as the dependent variable and insurance status as the principal independent variable. For each model, significance was considered to be p ≤ .05 with two-tailed testing.

As an additional comparison of interest, the patient’s indication of expectations met, measured on the ordinal scale of 1 = not at all, 2 = slightly, 3 = moderately, 4 = quite a bit, and 5 = a lot, in response to the question, “To what extent were your expectations met today?” was regressed on insurance status including the additional independent variables specified for the previous analyses. Significance was considered to be p ≤ .05 with two-tailed testing.

CHAPTER VI

RESULTS

Among the most difficult relationships to pin down have been those between patient background characteristics and level of satisfaction. While sociodemographic variables have been studied on numerous occasions, a consistent picture of their effect on patient satisfaction has not emerged. (Weiss 1988:383)

INTRODUCTION

The intent of this dissertation is to help address a knowledge gap that has persisted for almost 25 years since it was articulated by Weiss in 1988 – to “pin down”

(p. 383) the relationships between patient background characteristics and level of satisfaction. The specific aim of this research attempts to narrow the gap articulated by

Weiss (1988) by examining the relationships among patient characteristics and patient satisfaction and if these relationships are mediated by patient-physician communication.

This chapter will present the results of the analyses used to examine the hypotheses proposed for this dissertation. First descriptive statistics are presented that characterize the patients and their physicians. Then the analyses examining each of the hypotheses are presented that include the relationships between patient socioeconomic status and patient- physician communication, between patient-physician communication and patient satisfaction, and between patient socioeconomic status and patient satisfaction considering communication as a mediating variable.

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THE STUDY SAMPLE

The complete dataset resulting from the Direct Observation of Primary Care study

(Stange et al. 1998a) consisted of 4,454 cases. Several fields contained indications of the patient’s insurance status. Based on the patients’ medical record, those who were insured by Medicare (n = 999), and those for whom insurance status was indicated as other or none (n = 322), or not available (n = 213) were excluded, leaving 2,920 cases eligible for analysis considering insurance status. The field containing the patient’s age as determined from the patient’s birth year as recorded in the patient’s chart contained the highest number of valid cases. Using that field as the most complete and likely the most accurate determination of the patient’s age, all patients whose age was indicated as zero (n = 65), whose age was indicated as being 1 through 17 (n = 737), and for whom no age was available (n = 29), were excluded leaving 2,089 cases available for analysis for this dissertation. Note that those patients whose age was more than 65 were eliminated from the database when those who had Medicare insurance were eliminated.

The demographic profile of the 2,089 patients is provided in Table 2, which also includes separate profiles of those patients insured by Medicaid and those who had private insurance as well as a comparison of the two groups of patients. Patients who had a private insurance plan were significantly older than patients who had Medicaid insurance. Privately insured patients were significantly more likely to be male, and patients insured by Medicaid were significantly more likely to be female. Considering patient race, patients with private insurance were significantly more likely to be white, and patients who had Medicaid insurance were significantly more likely to be black.

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Patients who had private insurance had significantly higher levels of education than those who had Medicaid insurance. Specifically, those insured by Medicaid were significantly more likely to have less than a high school education and less likely to have graduated from high school than patients who had private insurance. As an additional comparison of patients’ level of education, I calculated the mean level of education using seven rank numbers assigned to levels of education from less than high school (1) through graduate school (7). This rank-order measure of patients’ education was used in the regression equations to test the proposed hypotheses. The average educational rank for those who had private insurance was 4.31, or most having at least some college education (ranked as 4). The average rank for those insured by Medicaid was significantly lower at 2.88, or most not having graduated from high school (high school graduate ranked as 3) (t = -13.28, p = .000).

Patients who had private insurance reported having significantly better overall health than patients who had Medicaid insurance. Further, patients with private insurance reported that health problems were significantly less apt to limit their everyday physical activities and were bothered significantly less by emotional problems than patients who had Medicaid insurance.

Table 3 provides information describing and comparing the visits of patients who had Medicaid insurance to those who had private insurance. Significantly longer encounters (or visits) were documented for patients who had private insurance versus those patients insured by Medicaid. However, based on the evaluation and management

Current Procedural Terminology (CPT) code of services furnished during the visit,

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patients who had private insurance were significantly more likely to have had their visits coded at a lower level of complexity than patients with Medicaid insurance. Specifically, privately insured patients were significantly more likely to have their visits coded a level

2 (99201 or 99212) than patients with Medicaid insurance. As an additional comparison of complexity of decision making overall, I calculated the mean level. This rank-order measure of complexity of decision making for the visit was used in the regression equations to test the proposed hypotheses. The mean level of the total sample was 2.91

(s.d. = .67). The mean level of the patients who had private insurance was 2.90 (s.d. =

.67). The mean level for those insured by Medicaid was 3.02 (s.d. = .64), indicating that the visits were coded at a significantly higher level of complexity for those who had

Medicaid insurance (t = -2.32; p = .02). To assist in understanding these results, a visit coded at level 1 would indicate that the patient’s presenting problem(s) are self limited or minor, and the face-to-face time with the physician is about 10 minutes. Three key components help to define a level 1 visit: problem-focused history, problem-focused examination, and straightforward decision making. At the highest level of complexity, a visit coded at level 5 would reflect a visit with a patient who presented with a problem of moderate to high severity and face-to-face time with the physician typically being 60 minutes. Level 5 visits require comprehensive history taking, a comprehensive examination, and medical decision making of the highest complexity (USDHHS CMS

2008b).

Table 4 provides the demographic profile of the 137 family physicians, the vast majority of whom were male, who provided care for these 2,089 patients.

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Table 2. Demographic Profile of Medicaid versus Privately Insured Patients

Private Medicaid Total Insurance Insurance Difference (n = 2,085) (n = 1,911) (n = 174) 91.7% 8.3%

Frequency Frequency Frequency or Mean or Mean or Mean t-test (continuous) X2 (categorical) Standard Standard Standard Deviation Deviation Deviation

(Range) Age (years) 41.89 42.20 38.48 3.94*** 11.95 11.89 12.05 (18-64) Gender (%) 9.23** Female 65.4 64.4 75.9 Male 34.6 35.6 24.1 Race (%) 98.61*** White 86.8 88.9 62.8 Black 11.3 9.2 33.7 Other races/ethnicity 2.0 1.8 3.5 Education (%) 151.77*** Less than high school 1.3 0.9 6.3 Some high school 7.7 5.9 32.1 High school graduate 30.9 30.4 37.5 Some college 26.3 26.8 19.6 Associate degree 7.3 7.8 1.8 College graduate 15.5 16.5 1.8 Graduate school 11.0 11.7 0.9 Health Status Overall health 3.42 3.48 2.64 8.31*** (1 = poor, 5 = excellent) 0.91 0.88 1.03 (1.00 – 5.00)

Physical health 4.07 4.11 3.53 4.42*** (1 = extremely, 5 = not at all) 1.16 1.14 1.36 (1.00 – 5.00)

Mental health 3.79 3.83 3.15 5.31*** (1 = extremely, 5 = not at all) 1.14 1.11 1.32 (1.00 – 5.00) *p < .05, **p < .01, ***p < .001 (two-tailed tests)

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Table 3. Visit Profile of Medicaid versus Privately Insured Patients

Private Medicaid Total Insurance Insurance Difference (n = 2,085) (n = 1,911) (n = 174) 91.7% 8.3%

Frequency Frequency Frequency or Mean or Mean or Mean t-test (continuous) X2 (categorical) Standard Standard Standard Deviation Deviation Deviation

(Range) Familiarity (%) 2.32 Established patient 90.4 90.1 93.7 New patient 9.6 9.9 6.3 Visit Duration (minutes) 13.20 13.30 11.87 5.36*** 2.71 2.71 2.32 (0.72 – 18.57) Complexity of Decision Making (%) 10.24* 99201 or 99211 0.7 0.7 1.2 99202 or 99212 22.9 23.7 14.5 99203 or 99213 62.3 61.9 66.5 99204 or 99214 12.3 11.9 16.8 99205 or 99215 1.7 1.8 1.2 *p < .05, **p < .01, ***p < .001 (two-tailed tests)

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Table 4. Profile of Physicians

Physicians (n = 137)

Frequency or Mean Characteristic

Standard Deviation

(Range) Age (years) 43.13 7.63 (31 – 64) Gender (%) Male 71.9 Female 28.1 Practice Style Degree of control 2.12 (1 = low, 3 = high) .64 (1.00 – 3.00)

Degree of affiliation 2.35 (1 = low, 3 = high) .61 (1.00 – 3.00)

Please note that race was not available for physicians.

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THE RELATIONSHIP BETWEEN PATIENT SOCIOECONOMIC STATUS AND

PATIENT-PHYSICIAN COMMUNICATION

Hypothesis 1 proposes that the patient-physician encounter is more physician- centered for patients who have Medicaid insurance, and the encounter is more patient- centered for patients who have private insurance. Three equations were examined. The first was the bivariate relationship between socioeconomic status, as measured by insurance status, and the centeredness of the visit. In order to examine the contribution of two types of characteristics (those of the patient and those of the visit) to patient- physician communication, the control variables were entered in two stages. First, I entered the demographic and health characteristics of the patient, and second, the characteristics of the nature of the relationship between the patient and the physician and the visit itself. Therefore, the second equation included patient demographic and health characteristics as control variables, including patients’ level of education, age, gender, race, and self-reported overall health (1 = poor, 5 = excellent), extent to which patients’ physical health problems limited their everyday physical activities (1 = extremely, 5 = not at all), and extent to which patients were bothered by mental health problems (1= extremely, 5 = not at all). The third equation added characteristics of the visit itself as additional control variables, including familiarity between the patient and physician (first encounter or not), the duration of the encounter or the total time spend in face-to-face contact for the visit, and the level of complexity of the visit as determined by the evaluation and management CPT code. Although characteristics of the physicians, including age, gender, and their perceived approach to patient care (degree of control and

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affiliation) were available for analysis, I omitted these potential independent variables from all analyses due to concern about lack of independence of the measures.

Table 5 provides information about the relationship between patients’ insurance status and centeredness and indicates support for hypothesis 1. For analysis purposes, recall that the centeredness scores were clustered into eight groups that closely approximate the original distribution of scores, with the highest value, 8, indicating the most patient-centered visits, and the lowest value, 1, indicating the most physician- centered visits. The centeredness scores ranged from 1 to 8 overall, with a mean score of

3.96 (s.d. = 1.28). For patients insured by Medicaid, centeredness ranged from 1 to 8 with a mean score of 3.76 (s.d. = 1.46). For those patients who had private insurance, centeredness again ranged from 1 to 8 with a mean score of 3.98 (s.d. = 1.26).

It is important to mention the distribution and average centeredness scores before they were grouped for analysis purposes. Recall that I determined the centeredness score by subtracting the physician-centered score from the patient-centered score. Therefore, a positive score would indicate a more patient-centered visit, and a negative score would indicate a more physician-centered visit. Before categorization, the overall mean centeredness score was -.56 (s.d. = .161) with a range of scores from -1.00 to .29. The vast majority of the visits were more physician-centered than patient-centered. The mean for those who had private insurance was -.56 (s.d. = .159), and the mean for those who had Medicaid insurance was -.59 (s.d. = .184).

Equation 1, the bivariate regression analysis, indicated a significant relationship between insurance status and centeredness. Patients with Medicaid insurance had

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significantly lower centeredness scores, indicating that their visits with their physicians were significantly more physician-centered than patients who had private insurance.

Equation 2, which explored the relationship between insurance status and centeredness considering additional patient characteristics, continued to indicate a significant relationship between insurance status and centeredness, as well as additional significant relationships. Those with Medicaid insurance had visits that were more physician-centered than patients with private insurance, controlling for other patient characteristics. Controlling for other patient characteristics, men had more patient- centered visits than women. Visits for those who reported that their physical health problems were less apt to limit their everyday activities tended to be more patient- centered. In contrast, patients who reported being bothered less by emotional problems tended to have more physician-centered visits.

Equation 3, the multivariate analysis that considered both patient and visit characteristics, continued to indicate a significant relationship between insurance status and centeredness with privately insured patients having visits that tended to be more patient-centered. The significant relationships between centeredness and patient gender, physical health and emotional health continued. In addition, the complexity of decision making showed a significant positive association with centeredness, i.e., more complexity of decision making was associated with visits that were significantly more patient- centered with the effect being almost twice that of insurance status, gender, and limitations of physical and mental health. Tolerance statistics were high for all three

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equations (ranging from .708 to .979), indicating low multicollinearity among the independent variables.

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Table 5. Effect of Insurance Status on Centeredness

Equation 1 Equation 2 Equation 3

Variable b Beta b Beta b Beta Patient Insurance (Medicaid = 1) -.577*** -.114 -.597*** -.118 -.593*** -.117 (.173) (.184) (.182)

Patient Education -.022 -.026 -.017 -.021 (.030) (.029)

Patient Age .000 .003 -.003 -.031 (.004) (.004)

Patient Gender (Male = 1) .269** .101 .274** .103 (.091) (.090) Patient Race (White = 0) Black .060 .013 -.012 -.003 (.161) (.158)

Other races/ethnicity .224 .024 .270 .029 (.322) (.316) Patient Health Status Overall health .060 .044 .084 .062 (1 = poor, 5 = excellent) (.054) (.053)

Physical health limitations .124** .117 .109** .103 (1 = extremely, 5 = not at all) (.040) (.040)

Mental health limitations -.165*** -.148 -.142*** -.127 (1 = extremely, 5 = not at all) (.040) (.040)

Familiarity (New patient = 1) -.133 -.027 (.167)

Complexity of the Visit .377*** .201 (.065)

Duration of the Visit .001 .003 (.015) Intercept 3.958 3.859 2.767

F change 11.105*** 4.046*** 11.838***

R2 .013 .050 .089 b = unstandardized regression coefficient with standard error in italics in parenthesis *p < .05 **p < .01 ***p < .001

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As an additional analysis following the line of reasoning that suggested hypothesis 1, the relationship between insurance status and the proportion of the observation codes devoted to “chatting” that occurred between the patient and physician was examined using the same strategy as the previous analysis. Referring to Table 6, equation 3 did not provide any significant explanatory power over equation 2; therefore, my comments will be limited to results based on equation 2. There was no relationship between insurance status and the amount of chatting between patients and physicians.

There was, however, a significant relationship between gender and chatting, with significantly more chatting occurring between physicians and their male patients than female patients, and race and chatting, with significantly more chatting occurring with patients who were Hispanic, Asian or Indian rather than patients who were white or black. Tolerance statistics were high for all three equations (ranging from .709 to .979), indicating low multicollinearity among the independent variables.

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Table 6. Effect of Insurance Status on Chatting

Equation 1 Equation 2 Equation 3

Variable b Beta b Beta b Beta Patient Insurance (Medicaid = 1) -.010 -.047 .000 .002 -.001 -.003 (.007) (.008) (.008)

Patient Education .001 .032 .001 .032 (.001) (.001)

Patient Age .000 .040 .000 .043 (.000) (.000)

Patient Gender (Male = 1) .010* .088 .010** .094 (.004) (.004) Patient Race (White = 0) Black -.008 -.044 -.008 -.041 (.007) (.007)

Other races/ethnicity .033* .087 .033* .086 (.013) (.013) Patient Health Status Overall health .004 .076 .004 .074 (1 = poor, 5 = excellent) (.002) (.002)

Physical health limitations .001 .018 .001 .024 (1 = extremely, 5 = not at all) (.002) (.002)

Mental health limitations .002 .044 .002 .035 (1 = extremely, 5 = not at all) (.002) (.002)

Familiarity (New patient = 1) -.006 -.031 (.007)

Complexity of the Visit -.004 -.055 (.003)

Duration of the Visit -.001 -.043 (.001) Intercept .036 -.004 .019

F change 1.908 3.527*** 1.385

R2 .002 .035 .040 b = unstandardized regression coefficient with standard error in italics in parenthesis *p < .05 **p < .01 ***p < .001

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THE RELATIONSHIP BETWEEN PATIENT-PHYSICIAN COMMUNICATION

AND PATIENT SATISFACTION

Hypothesis 2 proposes that patients whose primary care visit is characterized by more patient-centered communication are more satisfied than patients whose primary care visit is characterized by more physician-centered communication. Recall that the centeredness scores range from 1 through 8, with 1 being the most physician-centered, and 8 being the most patient-centered. Three models were examined: 1) the relationship between centeredness and patient satisfaction with the practice site, 2) the relationship between centeredness and patient satisfaction with the physician, and 3) the relationship between centeredness and overall patient satisfaction. For each model, three equations were examined. The first equations were the bivariate relationships between centeredness and the particular aspects of satisfaction. Once again, I entered control variables in two stages, first the demographic and health characteristics of the patient, and second, the characteristics of the nature of the relationship between the patient and the physician and the visit itself. Therefore, the second equations included patient characteristics as control variables including level of education, age, gender, race, overall health, and physical and mental health. The third equations added characteristics of the visit including familiarity with the patient, complexity of the visit, and duration of the visit. Characteristics of the physicians were not used as additional control variables given the concern of lack of independence of the measures.

Hypothesis 2 was supported by model 2 (satisfaction with the physician) and model 3 (overall satisfaction), but not by model 1 (satisfaction with the practice site).

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Table 7 provides information about the relationship between centeredness and patient satisfaction with the practice site. Since equation 3 provides a significantly better explanation of variables that are likely to impact patient satisfaction with the site, I will limit my comments to that equation. Satisfaction with the site was not affected by the centeredness of the patient-physician communication. Satisfaction with the site, however, was related to the age of the patient, the patient’s overall health, and the duration of the visit. As patient age increased, and patients reported better overall health, they reported significantly higher satisfaction ratings of the site. However, satisfaction with the site decreased significantly as the length of the visit increased. Tolerance statistics were high for three equations for model 1 (ranging from .717 to .981), indicating low multicollinearity among the independent variables.

Table 8 provides information about the relationship between centeredness and patient satisfaction with the physician, which supports the hypothesis that centeredness is related to satisfaction. Since equation 3 provided a significantly better explanation of variables that are likely to impact patient satisfaction with the physician, I will limit my comments to that equation. There was a significant relationship between satisfaction with the physician and the centeredness of the patient-physician communication, with satisfaction ratings increasing as the visit became more patient-centered, controlling for patient and visit characteristics. As was the case in model 1, satisfaction with the physician was also related to the age of the patient, the patient’s overall health, and the duration of the visit. As patient age increased, and patients reported better overall health, they reported significantly higher satisfaction ratings of the physician. However,

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satisfaction with the physician decreased significantly as the length of the visit increased.

Tolerance statistics were high for all three equations for model 2 (ranging from .729 to

.975), indicating low multicollinearity among the independent variables.

Table 9 provides information about the relationship between centeredness and overall patient satisfaction, which also supports the hypothesis that centeredness is related to satisfaction. Once again, equation 3 provided the best explanation of variables that are likely to impact overall patient satisfaction. Overall patient satisfaction was significantly affected by the centeredness of the patient-physician communication, with satisfaction ratings increasing as the visit became more patient-centered, controlling for patient characteristics. As was the case in models 1 and 2, overall satisfaction was also related to the age of the patient and the patients’ overall health, as well as the length of the visit. As patient age increased, and patients reported better overall health, they reported significantly higher overall satisfaction ratings. Equation 3 also indicated that overall satisfaction decreased significantly as the length of the visit increased, with the effect size being almost twice that of centeredness. Tolerance statistics were high for all three equations for model 3 (ranging from .715 to .977), indicating low multicollinearity among the independent variables.

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Table 7. Effect of Centeredness on Patient Satisfaction with the Practice Site

Equation 1 Equation 2 Equation 3

Variable b Beta b Beta b Beta Centeredness .011 .018 .012 .019 .009 .014 (.023) (.023) (.023)

Patient Education -.024 -.046 -.021 -.040 (.019) (.019)

Patient Age .010*** .141 .009*** .132 (.002) (.003)

Patient Gender (Male = 1) .009 .006 .015 .009 (.061) (.061)

Patient Race (White = 0) Black .048 .016 .031 .011 (.105) (.015)

Other races/ethnicity -.049 -.008 -.035 -.006 (.213) (.212) Patient Health Status Overall health .084* .097 .079* .091 (1 = poor, 5 = excellent) (.036) (.036)

Physical health limitations .000 .000 .002 .002 (1 = extremely, 5 = not at all) (.027) (.027)

Mental health limitations .026 .037 .029 .041 (1 = extremely, 5 = not at all) (.027) (.027)

Familiarity (New patient = 1) .054 .017 (.111)

Complexity of the Visit .017 .015 (.044)

Duration of the Visit -.032** -.112 (.010) Intercept 3.942 3.236 3.629

F change .249 2.819** 3.669*

R2 .000 .028 .042 b = unstandardized regression coefficient with standard error in italics in parenthesis *p < .05 **p < .01 ***p < .001

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Table 8. Effect of Centeredness on Patient Satisfaction with the Physician

Equation 1 Equation 2 Equation 3

Variable b Beta b Beta b Beta Centeredness .051* .086 .051* .086 .045* .077 (.021) (.021) (.022)

Patient Education -.002 -.003 -.001 .003 (.018) (.018)

Patient Age .008*** .132 .008*** .120 (.002) (.002)

Patient Gender (Male = 1) -.048 -.031 -.039 -.025 (.057) (.057)

Patient Race (White = 0) Black -.056 -.021 -.077 -.029 (.098) (.098)

Other races/ethnicity -.078 -.014 .085 .016 (.197) (.196) Patient Health Status Overall health .079* .098 .078* .096 (1 = poor, 5 = excellent) (.033) (.034)

Physical health limitations -.020 -.031 -.017 -.027 (1 = extremely, 5 = not at all) (.025) (.025)

Mental health limitations -.017 -.026 -.015 -.022 (1 = extremely, 5 = not at all) (.025) (.025)

Familiarity (New patient = 1) -.008 -.003 (.103)

Complexity of the Visit .032 .029 (.042)

Duration of the Visit -.028** -.107 (.010) Intercept 4.169 3.713 4.013

F change 5.743* 2.335* 3.523*

R2 .007 .031 .044 b = unstandardized regression coefficient with standard error in italics in parenthesis *p < .05 **p < .01 ***p < .001

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Table 9. Effect of Centeredness on Overall Patient Satisfaction

Equation 1 Equation 2 Equation 3

Variable b Beta b Beta b Beta Centeredness .064** .100 .063** .099 .054* .085 (.022) (.023) (.023)

Patient Education -.021 -.040 -.016 -.030 (.019) (.019)

Patient Age .008*** .116 .007** .096 (.002) (.002)

Patient Gender (Male = 1) -.028 -.017 -.014 -.008 (.060) (.060)

Patient Race (White = 0) Black -.101 -.035 -.138 -.047 (.103) (.103)

Other races/ethnicity -.224 -.038 -.207 -.035 (.207) (.205) Patient Health Status Overall health .082* .093 .085* .097 (1 = poor, 5 = excellent) (.036) (.035)

Physical health limitations -.027 -.040 -.026 -.038 (1 = extremely, 5 = not at all) (.027) (.026)

Mental health limitations -.021 -.029 -.017 -.024 (1 = extremely, 5 = not at all) (.027) (.027)

Familiarity (New patient = 1) -.056 -.018 (.111)

Complexity of the Visit .068 .057 (.044)

Duration of the Visit -.039*** -.135 (.010) Intercept 4.083 3.764 4.125

F change 8.175** 2.433* 6.734***

R2 .010 .033 .057 b = unstandardized regression coefficient with standard error in italics in parenthesis *p < .05 **p < .01 ***p < .001

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As an additional analysis following the line of reasoning that suggested hypothesis 2, the relationship between centeredness and patient perception of having expectations met was examined, using the same strategy as models 1, 2, and 3 examining patient satisfaction. Table 10 provides information about the relationship between centeredness and patient perceptions of having expectations met, which does not add support for the hypothesis that centeredness is related to satisfaction. Equation 3 provided the best explanation; therefore, I will limit my comments to that equation. Patient perception of having expectations met was not affected by the centeredness of the patient-physician communication, controlling for patient and visit characteristics.

Perception of having expectations met was, however, related to patient age, gender, and duration of the visit. As patient age increased, patients reported significantly higher ratings of having had their expectations met during the visit. Further, women reported significantly higher ratings of having had their expectations met. Again, as in all previous models of the relationship between centeredness and satisfaction, as the length of the visit increased, ratings of having had expectations met decreased significantly. Tolerance statistics were high (ranging from .721 to .982), indicating low multicollinearity among the independent variables.

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Table 10. Effect of Centeredness on Patient Perception of Having Expectations Met

Equation 1 Equation 2 Equation 3

Variable b Beta b Beta b Beta Centeredness .044 .068 .050* .077 .044 .068 (.023) (.024) (.024)

Patient Education .023 .042 .026 .049 (.020) (.020)

Patient Age .008** .111 .007** .095 (.003) (.003)

Patient Gender (Male = 1) -.150* -.087 -.139* -.081 (.062) (.062) Patient Race (White = 0) Black -.008 -.003 -.036 -.012 (.107) (.107)

Other races/ethnicity -.216 -.034 -.190 -.030 (.226) (.224) Patient Health Status Overall health .063 .071 .063 .071 (1 = poor, 5 = excellent) (.036) (.036)

Physical health limitations .000 .001 .001 .001 (1 = extremely, 5 = not at all) (.028) (.028)

Mental health limitations .043 .059 .045 .061 (1 = extremely, 5 = not at all) (.028) (.028)

Familiarity (New patient = 1) .005 .002 (.112)

Complexity of the Visit .046 .038 (.045)

Duration of the Visit -.037*** -.128 (.010) Intercept 4.167 3.391 3.793

F change 3.647 2.953** 5.261***

R2 .005 .034 .053 b = unstandardized regression coefficient with standard error in italics in parenthesis *p < .05 **p < .01 ***p < .001

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THE RELATIONSHIP BETWEEN PATIENT SOCIOECONOMIC STATUS AND

PATIENT SATISFACTION

This relationship suggested two hypotheses. Hypothesis 3.1 proposes that patients who are insured by Medicaid are less satisfied with their primary care visit than patients who have private insurance. Hypothesis 3.2 proposes that centeredness mediates the relationship between insurance status and satisfaction. Three models were examined for each hypothesis: 1) the relationship between patient insurance status and patient satisfaction with the practice site, 2) the relationship between patient insurance status and patient satisfaction with the physician, and 3) the relationship between patient insurance status and overall patient satisfaction. Four equations were examined for each model. The first equations were the bivariate relationships between insurance status and the particular aspects of patient satisfaction. The second equations included the demographic and health characteristics of the patient including level of education, age, gender, race, overall health, and physical and mental health limitations. The third equations added the characteristics of the nature of the relationship between the patient and the physician and the characteristics of the visit including familiarity between the patient and physician, complexity of the visit, and length of the visit. The fourth equations added the centeredness measure. As in all previous models and equations, characteristics of the physicians were omitted due to concern about lack of independence of the measures.

None of the three models provided support for hypothesis 3.1, the relationship between insurance status and patient satisfaction. However, the models did provide

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mixed support for hypothesis 3.2, that centeredness mediates the relationship between insurance status and satisfaction.

Regarding the relationship between insurance status and patient satisfaction with the site, Table 11, equation 2 indicated a significant relationship between insurance status and satisfaction with the site, with patients who had Medicaid insurance being significantly more satisfied, controlling for other patient characteristics. However, when characteristics of the visit were considered, the relationship was no longer significant.

Equation 3 provided the best explanation. Patient satisfaction with the site was related to patient age, overall health, and duration of the visit. As patient age increased, and patients reported better overall health, they reported significantly higher satisfaction ratings of the site. However, satisfaction with the site decreased significantly as the length of the visit increased. Tolerance statistics were high for all four equations (ranging from .709 to

.981), indicating low multicollinearity among the independent variables.

The relationship between insurance status and patient satisfaction with the physician is displayed in Table 12. Once again equation 2 indicated a significant relationship between insurance status and satisfaction with the physician, with patients who had Medicaid insurance being significantly more satisfied, controlling for other patient characteristics. However, when characteristics of the visit and centeredness were considered, the relationship was no longer significant. Equation 4 provided the best explanation. The relationship between insurance status and patient satisfaction with the physician was not significant, but approached significance (p = .052); patients who were insured by Medicaid reported being more satisfied with their physician than patients who

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had private insurance. Patient satisfaction with the physician was significantly related to patient age, overall health, duration of the visit, and centeredness. As patient age increased, and patients reported better overall health, they reported significantly higher satisfaction ratings of the physician. However, satisfaction with the physician decreased significantly as the length of the visit increased. Centeredness also played an important role in satisfaction with the physician. As the visit became more patient-centered, satisfaction ratings of the physician increased significantly. Tolerance statistics were high for all four equations (ranging from .720 to .975), indicating low multicollinearity among the independent variables.

The relationship between insurance status and overall patient satisfaction is displayed in Table 13. There was no apparent relationship between insurance status and overall satisfaction. Equation 4 provided the best explanation. Overall patient satisfaction was related to patient age, overall health, duration of the visit, and centeredness.

Although complexity of the visit appeared to contribute to overall satisfaction, as indicated in equation 3, that relationship was no longer significant when centeredness was considered. Once again, as patient age increased, and patients reported better overall health, they reported significantly higher overall satisfaction. Overall satisfaction decreased significantly as the length of the visit increased. And, centeredness again played an important role. As the visit became more patient-centered, overall satisfaction significantly increased. Tolerance statistics were high for all four equations (ranging from

.705 to .977), indicating low multicollinearity among the independent variables.

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Table 11. Effect of Patient Insurance Status on Patient Satisfaction with the Practice Site

Equation 1 Equation 2 Equation 3 Equation 4

Variable b Beta b Beta b Beta b Beta Patient Insurance (Medicaid = 1) .136 .041 .247* .075 .207 .063 .215 .065 (.118) (.125) (.126) (.126) Patient Education -.018 -.034 -.016 -.031 -.016 -.031 (.019) (.019) (.019) Patient Age .010*** .147 .009*** .137 .009*** .138 (.003) (.003) (.003) Patient Gender (Male = 1) .010 .006 .015 .009 .011 .007 (.060) (.061) (.061) Patient Race (White = 0) Black .004 .001 -.006 -.002 -.006 -.002 (.107) (.107) (.107) Other races/ethnicity -.041 -.007 -.028 -.005 -.032 -.005 (.213) (.212) (.212) Patient Health Status Overall health .092** .106 .086* .099 .085* .099 (1 = poor, 5 = excellent) (.036) (.036) (.036) Physical health limitations .005 .007 .005 .008 .004 .006 (1 = extremely, 5 = not at all) (.027) (.027) (.027) Mental health limitations .029 .042 .032 .046 .034 .049 (1 = extremely, 5 = not at all) (.027) (.027) (.027) Familiarity (New patient = 1) .057 .018 .058 .019 (.111) (.111) Complexity of the Visit .022 .019 .017 .015 (.043) (.044) Duration of the Visit -.030** -.105 -.030** -.105 (.010) (.010) Centeredness .013 .021 (.023) Intercept 3.978 3.168 3.527 3.487 F change 1.346 3.141** 3.329* .329 R2 .002 .033 .045 .045 b = unstandardized regression coefficient with standard error in italics in parenthesis; *p < .05, **p < .01, ***p < .001

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Table 12. Effect of Patient Insurance Status on Patient Satisfaction with the Physician

Equation 1 Equation 2 Equation 3 Equation 4

Variable b Beta b Beta b Beta b Beta Patient Insurance (Medicaid = 1) .130 .042 .237* .077 .201 .065 .231 .075 (.111) (.118) (.118) (.119) Patient Education .004 .009 .006 .014 .007 .014 (.018) (.018) (.018) Patient Age .009*** .139 .008*** .124 .008*** .126 (.002) (.002) (.002) Patient Gender (Male = 1) -.039 -.025 -.030 -.019 -.043 -.028 (.057) (.057) (.057) Patient Race (White = 0) Black -.096 -.036 -.114 -.042 -.116 -.043 (.100) (.100) (.100) Other races/ethnicity .078 .014 .085 .016 .074 .014 (.197) (.196) (.196) Patient Health Status Overall health .088** .109 .087** .108 .085* .105 (1 = poor, 5 = excellent) (.034) (.034) (.034) Physical health limitations -.011 -.017 -.010 -.016 -.016 -.025 (1 = extremely, 5 = not at all) (.025) (.025) (.025) Mental health limitations -.019 -.029 -.016 -.024 -.008 -.013 (1 = extremely, 5 = not at all) (.025) (.025) (.026) Familiarity (New patient = 1) -.008 -.003 -.003 -.001 (.104) (.103) Complexity of the Visit .051 .047 .031 .028 (.041) (.041) Duration of the Visit -.026** -.099 -.026** -.100 (.010) (.010) Centeredness .050* .085 (.022) Intercept 4.360 3.793 4.009 3.869 F change 1.372 2.685** 3.560* 5.259* R2 .002 .029 .043 .049 b = unstandardized regression coefficient with standard error in italics in parenthesis; *p < .05, **p < .01, ***p < .001

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Table 13. Effect of Patient Insurance Status on Overall Patient Satisfaction

Equation 1 Equation 2 Equation 3 Equation 4

Variable b Beta b Beta b Beta b Beta Patient Insurance (Medicaid = 1) .134 .040 .236 .071 .182 .055 .218 .066 (.116) (.124) (.124) (.124) Patient Education -.016 -.030 -.012 -.023 -.011 -.021 (.019) (.019) (.019) Patient Age .008*** .123 .007** .099 .007** .102 (.002) (.003) (.002) Patient Gender (Male = 1) -.014 -.008 -002 -.001 -.017 -.010 (.060) (.060) (.060) Patient Race (White = 0) Black -.148 -.051 -.178 -.061 -.175 -.060 (.106) (.105) (.105) Other races/ethnicty -.221 -.037 -.201 -.034 -.216 -.036 (.208) (.206) (.205) Patient Health Status Overall health .094** .107 .096** .110 .092** .105 (1 = poor, 5 = excellent) (.036) (.036) (.036) Physical health limitations -.016 -.024 -.018 -.027 -.024 -.035 (1 = extremely, 5 = not at all) (.027) (.026) (.026) Mental health limitations .026 -.036 -.020 -.029 -.012 -.016 (1 = extremely, 5 = not at all) (.027) (.027) (.027) Familiarity (New patient = 1) -.055 -.017 -.052 -.016 (.111) (.111) Complexity of the Visit .089* .075 .068 .057 (.043) (.044) Duration of the Visit -.037*** -.128 -.037*** -.128 (.010) (.010) Centeredness .059* .092 (.023) Intercept 4.326 3.889 4.154 3.981 F change 1.332 2.755** 6.988*** 6.572* R2 .002 .028 .053 .061 b = unstandardized regression coefficient with standard error in italics in parenthesis; *p < .05, **p < .01, ***p < .001

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As an additional analysis following the line of reasoning that suggested hypotheses 3.1 and 3.2, the relationship between patient insurance status and patient perception of having expectations met was examined, using the same strategy as models

1, 2, and 3 examining patient satisfaction. Results are displayed in Table 14. Equation 4 provided the best explanation. Patient perception of having expectations met was related to patient age, gender, duration of the visit, and centeredness, but not to insurance status.

Although overall health status appeared to contribute to perceptions of having expectations met, as indicated in equation 3, that relationship was no longer significant when centeredness was considered. Women and older patients reported significantly higher ratings of having expectations met. As the length of the visit increased, patients reported significantly lower ratings of having had their expectations met. And, centeredness again played an important role. As the visit became more patient-centered, patients provided significantly higher ratings of having their expectations met. Tolerance statistics were high for all four equations (ranging from .712 to .981), indicating low multicollinearity among the independent variables.

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Table 14. Effect of Patient Insurance Status on Patient Perception of Having Expectations Met

Equation 1 Equation 2 Equation 3 Equation 4

Variable b Beta b Beta b Beta b Beta Patient Insurance (Medicaid = 1) .063 .019 .246 .074 .191 .057 .219 .066 (.118) (.127) (.127) (.128) Patient Education .028 .053 .031 .058 .032 .060 (.020) (.020) (.020) Patient Age .008*** .118 .007** .099 .007** .102 (.003) (.003) (.003) Patient Gender (Male = 1) -.141* -.082 -.132* -.077 -.143* -.083 (.062) (.062) (.062) Patient Race (White = 0) Black -.060 -.020 -.079 -.026 -.076 -.025 (.110) (.109) (.109) Other races/ethnicty -.219 -.034 -.189 -.030 -.208 -.033 (.226) (.224) (.224) Patient Health Status Overall health .075* .085 .073* .083 .070 .079 (1 = poor, 5 = excellent) (.037) (.037) (.037) Physical health limitations .011 .016 .009 .012 .003 .004 (1 = extremely, 5 = not at all) (.028) (.027) (.028) Mental health limitations .041 .056 .044 .060 .051 .069 (1 = extremely, 5 = not at all) (.028) (.028) (.028) Familiarity (New patient = 1) .006 .002 .010 .003 (.113) (.112) Complexity of the Visit .064 .052 .045 .037 (.044) (.045) Duration of the Visit -.035*** -.120 -.035*** -.120 (.011) (.010) Centeredness .049* .074 (.024) Intercept 4.337 3.454 3.774 3.639 F change .284 3.271*** 5.136** 4.172* R2 .000 .033 .051 .057 b = unstandardized regression coefficient with standard error in italics in parenthesis; *p < .05, **p < .01, ***p < .001

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Summary

In summary, data from the Direct Observation of Primary Care study (Stange et al. 1998a) were examined to determine the relationship: 1) between insurance status and patient-physician communication, 2) between patient-physician communication and patient satisfaction, and 3) between insurance status and patient satisfaction, and if that relationship is mediated by patient-physician communication. The data supported hypothesis 1. The patient-physician encounter was more physician-centered for patients who had Medicaid insurance, and the encounter was more patient-centered for patients who had private insurance.

Hypothesis 2 proposed a relationship between patient-physician communication and patient satisfaction. In general, patients whose visits were more patient-centered were significantly more satisfied with their physicians and with the visit overall. There was no relationship between centeredness and patient satisfaction with the site.

Finally, hypothesis 3 proposed a relationship between insurance status and patient satisfaction, and that that relationship would be mediated by the centeredness of the communication. In general, no relationship was found between insurance status and satisfaction with the practice site, satisfaction with the physician, overall satisfaction, or perceptions of having expectations met during the visit.

The following chapter, Chapter VII, will provide a comparison of these results to those reported by other investigators. In addition, limitations of this research will be discussed, implications will be presented, and suggestions for future research will be proposed.

CHAPTER VII

IMPLICATIONS

Decisions that are made regarding what is avoidable and unjust are not simple, but are based upon what we currently know and are political decisions based upon resources and ideology. These discussions are dependent on who is deciding what is avoidable and unjust, and how it is decided. (Carter-Pokras and Baquet 2002:426)

SUMMARY

Sociological theory tells us that both patients and physicians enter their relationships with understandings, behaviors, and expectations that have been shaped by their socialization and education. Further, each plays a unique role based on expectations and granted authority. Differing fundamentally from the paternalistic patient-physician relationship envisioned by Parsons in which the physician is the knowledgeable authority figure (Parsons 1951), patient-centered care, including patient-centered communication, puts the patient at the center of an encounter focused on patients’ wants, needs, and preferences (Laine and Davidoff 1996). Patient-centered communication as well as patient satisfaction have been linked to many positive patient-oriented health outcomes

(Wynia and Matiasek 2006). This dissertation examined the relationship between patient socioeconomic status and patient satisfaction and if this relationship was mediated by patient-physician communication.

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DISCUSSION AND INTERPRETATION OF FINDINGS

The Relationship between Patient Socioeconomic Status and Patient-Physician

Communication

Hypothesis 1 proposed that the patient-physician encounter is more physician- centered for patients who had Medicaid insurance, and the encounter is more patient- centered for patients who had private insurance. Results supported this hypothesis – patients’ insurance status related significantly to centeredness with patients insured by

Medicaid having visits that were significantly more physician-centered. Additional significant relationships in the model included both patient and visit factors. Male patients had visits that were significantly more patient-centered than female patients. This could be due to the higher probably of gender concordance between the patients and physicians with male physicians comprising almost 72 percent of the study sample. This result furthers the work of Bertakis, Franks, and Epstein (2009) who found that gender- concordant visits were characterized by more patient-centered communication specific to understanding the whole person.

Patients’ perceptions of the extent to which physical and mental health limitations impact their daily lives also had significant relationships with centeredness, but in opposite directions. As patients reported that they were less limited by their physical health, their visits became more patient-centered. As physical health improves or patients adjust to their physical health limitations as the new status quo, there may be less to discuss during the visit relative to the physical illness, so the interaction could shift to more of a patient focus. Conversely, as patients reported that they were limited less by

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their mental health, their visits became more physician-centered. Potentially, physicians do a better job of being patient-centered when their patients have emotional or mental health problems. According to one family physician, if everything is relatively stable from the patient’s perspective, then the agenda becomes the physician’s (Costa, Anthony

J., personal communication 2011).

Finally, complexity of the visit related significantly to centeredness. Recall that the measure of complexity of the visit is multidimensional and includes face-to-face time as well as complexity of the decision making, with time and complexity increasing relative to the measure of complexity. In the present study, the more complex the visit, the more the visit became significantly more patient-centered. Family physicians appear to consider and/or include the patient’s perspective as health care problems and health- related issues become more complex.

As an additional relationship of interest related to socioeconomic status and centeredness, the second model examined the relationship between insurance status and the proportion of time devoted to chatting between the patient and the physician. Recall that Hall et al. (1998) found that chatting appeared to matter leading patients to believe that they are cared about as a person. Further, the less the social distance between the patient and physician, the more likely they are to have common interests. However, the results of the present study indicated that the two factors significantly, positively related to chatting were being male and of a race/ethnicity other than white or black. The relationship between males and the occurrence of significantly more chatting could, once again, be explained by gender concordance. The number of patients in the “other

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races/ethnicity” group (n = 42) is too small to draw any conclusions about this relationship.

The Relationship between Patient-Physician Communication and Patient Satisfaction

Hypothesis 2 proposed that patients whose primary care visit is characterized by more patient-centered communication are more satisfied than patients whose primary care visit is characterized by more physician-centered communication. The hypothesis was supported when satisfaction with the physician and overall satisfaction were considered, but not satisfaction with the site. Satisfaction with the site was related to two patient characteristics, age and overall health, with older and more healthy patients giving significantly higher satisfaction ratings. There was a significant negative relationship between duration of the visit, which was measured as face-to-face time between the patient and the physician, and satisfaction with the practice site. There are two possible explanations for this finding. First, more of a good thing is not always better, assuming that the patient is rating the duration of the visit based on face time with the physician.

However, wait time before seeing the physician, either in the waiting room or in the exam room, or wait time after the visit in order to complete the check-out process could have affected satisfaction with the site.

The results were similar for satisfaction with the physician and overall satisfaction. In support of the hypothesis, patient-centeredness was related significantly to higher patient satisfaction ratings. Other significant relationships common to both models included age, overall health, and duration of the visit. Older patients reported being more satisfied, a finding that adds support to prior studies such as that by Callahan et al. 2000,

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who found that visit specific satisfaction increased significantly with age. The findings of the present study also echo the findings of Hall et al. (1998) that sicker patients rated satisfaction lower, presumably, according to Hall et al. (1998), due to the lack of social conversation received from the physician. In addition, the negative relationship between duration of the visit and satisfaction with the physician and overall satisfaction persisted in the present study. In addition to the possible explanations indicated above, one additional explanation might be related to information giving on the part of the physician.

The longer patients are in the room with the physician, particularly if patients are sick, the more patients may be hearing information they do not want to hear from the physician.

As an additional relationship of interest, the relationship between centeredness and patients’ perceptions of having their expectations met was examined. Again, age was significantly positively related to feeling like expectations were met for the visit. In addition, there were inverse relationships for gender and duration, with men and those who had longer visits reporting that their expectations might not have been met. A family physician explained that his male patients are less likely to seek care on their own; they often do so grudgingly, and often only when told to do so by others. These men do not want a visit that is focused on them; they want their treatment and to end the visit. Longer visits may increase their frustration – their expectation is to end the visit quickly (Costa,

Anthony J., personal communication 2011).

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The Relationship between Patient Socioeconomic Status and Patient Satisfaction

The results did not support hypothesis 3.1: patients who are insured by Medicaid are less satisfied with their primary care visit than patients who have private insurance.

Thought should be given to two competing explanations: 1) patient satisfaction is typically high, especially when measured quantitatively (Edwards et al. 2004), and 2) the high satisfaction ratings by patients in lower socioeconomic status groups may reflect lower expectations and not equally good treatment by the site and care by the physician

(Sitzia and Wood 1997). Unlike a study by Safran et al. (1998), patient self-reported mental health and higher education were not related to high satisfaction ratings in the present study. Further, the results of the present study are consistent with findings of Ross et al. (1982), who found that social class of the patient was unrelated to satisfaction in small, fee-for-service practices, practices which are similar structurally to the majority of those in the DOPC study.

Hypothesis 3.2, that centeredness mediates the relationship between insurance status and satisfaction, became a moot point in light of the lack of difference in satisfaction ratings between the two insurance groups. In spite of patients’ socioeconomic status, centeredness had an effect on satisfaction with the physician and overall satisfaction as well as patients’ perceptions of having their expectations met. As the communication between the patient and physician became more patient-centered, satisfaction increased.

Patient characteristics that were consistently significantly correlated with all measures of satisfaction (site, physician, overall, and having expectations met) were age

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and overall health. As age increased, satisfaction increased. And, patients who reported better overall health also reported being more satisfied. Again, these findings are consistent with those of Hall et al. (1998).

A surprising finding was the inverse relationship between all four measures of satisfaction and the amount of face-to-face time between patients and physicians. As the duration of the visit increased, satisfaction significantly decreased. This relationship was evident in three of the four models, including satisfaction with the physician, overall satisfaction, and having expectations met when centeredness was held constant. The only exception was the first model, satisfaction with the site, in which centeredness had no effect, as would be expected.

LIMITATIONS

The findings of this research need to be considered in light of limitations in the existing dataset of the Direct Observation of Primary Care (DOPC) study as well as how the data were used in this dissertation research.

First – Hawthorne effect. Stange et al. (1998a) recognized that the presence of the research nurse observer could “alter the phenomenon being studied” (p. 853). Steps were taken to minimize any possible biases in the ways in which the patient and physician interacted with each other. According to Stange et al. (1998b), physicians were told to practice as they usually would, and “the observation of consecutive patients made it impossible for physicians to spend more time or provide more services than their usual routine, without severely compromising their ability to stay on schedule” (p. 379). This comment addresses the length of the interaction as well as service delivery; however, it

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does not address issues related to the ways in which the physicians’ behavior and/or the patients’ behavior and feelings about the interaction might have been affected by the presence of an observer. Simply telling physicians and patients alike to ignore the presence of the nurse observer, “like a fly on the wall” (Stange 1998a:853), does not necessarily make it so.

Second – Temporal order. The time at which patient satisfaction data were collected could have impacted the responses. Specifically, questions concerning patient satisfaction with the site all asked for patients’ opinion about aspects of the site that preceded the actual encounter between the patient and the physician. These four items include wait time to get an appointment, convenience of the office, getting through to the office by phone, and length of time waiting at the office. However, patients’ opinions were collected following the patient-physician interaction. Patients could have had less than satisfactory opinions about aspects of the site, and these opinions could have been tempered by a satisfactory encounter with the physician, or vice versa.

Third – Prevalence of patients insured by Medicaid. Stange et al. (1998b) acknowledged that at the time of the study, Medicaid was not prevalent. This resulted in fewer cases being available for analysis for this dissertation as well as physicians having minimal experience with patients who were insured by Medicaid. Because of these low numbers, physicians in the DOPC study might have been relatively unaffected by differences between these patients and patients of higher social status. An increase in the number of patients insured by Medicaid, as well as negative changes in the

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reimbursement system, could change physicians’ behavior toward this group of patients as the literature suggests (c.f., Bernheim et al. 2008).

Fourth – Length and readability of the patient survey. The survey completed by patients was lengthy and potentially confusing to complete. It was four pages long, and patients were asked to complete or respond to 137 items using a variety of scales. Patients completing this lengthy survey following their office visit could have hurried to get through the items and not given in-depth thought before responding. Further, the document fails to adhere to current readability standards by using a small font (smaller than 12 point), crowded text, long sentences (longer than 8-10 words), and multisyllabic words (more than two syllables) (Labuda Schrop et al. 2005), which could have introduced bias in the patients’ responses.

Fifth – Measuring patient satisfaction. Edwards et al. (2004) indicated that

“research in the field of patient feedback, however, does not have a long history of success . . . . The most significant longstanding problem with the questionnaire approach is its tendency to record consistently and remarkably positive responses, compared with the more wide-ranging opinion that can be detected using qualitative research methods”

(p. 160). Of course, the questionnaire method is the most commonly used likely due to ease of administration and low cost compared to individual patient interviews. In addition, there is no consensus regarding the number of questions or aspects to be surveyed. The DOPC study used an adapted version of the VSQ-9. Results could have been much different had the DOPC researchers chosen any number of other patient satisfaction measures available at that time, such as the Medical Preference Survey used

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by Ware et al. (1983), or the Medical Interview Satisfaction Scale used by Hall et al.

(1998). Carr-Hill (1992) reinforced the difficulty of measuring satisfaction including the complexity of the concept and the wide variability in the sources of satisfaction and dissatisfaction such that “satisfaction is likely to be defined very differently by different people and by the same person at different times” (p. 237).

Sixth – The centeredness measure. Although the centeredness measure used in this dissertation was based on the literature (c.f., Zandbelt et al. 2005), it may not be a robust measure. Rather than defining the components that would be examined in the patient-physician encounter, the development of the measure that was used was limited by the data that were available in an existing dataset.

Seventh – Age of the data. It can be argued that the data used in the present analyses, which were collected more than 15 years ago, may not reflect patient-physician interactions of the present day. Changes in the health care delivery system that have occurred since 1995, such as the introduction of the electronic medical record (EMR) and the rise of consumerism, have the potential to change the dynamic of the patient- physician interaction. However, there are elements that remain unchanged in spite of a barrier between the patient and the physician that might be imposed by the EMR and patients as consumers who have the interest in becoming more active participants in their health and health care, potentially becoming more active participants in the patient- physician interaction. Physicians still need to elicit the patient’s history effectively including the appropriate use of open and closed questions, and determine the context of the presenting concern including the patients’ psychosocial information, the family and

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the community in which the patient resides. Although the data might be considered old, the DOPC data are the most complete and comprehensive look behind the door of the examination room and into the private world of patients and their physicians that exists to date.

Eighth – Nested data. It is recognized that the data as originally collected are nested, i.e., patients nested in physicians, and some physicians nested within practices.

Nested data typically indicates the need for hierarchical analyses. As indicated in Chapter

5, although the data are nested, the lack of characterizing features that would distinguish the uniqueness of the physicians and the practices lead to my decision to exclude physician and practice data from the analyses at this time. Further, statistical power would be compromised by the low number of patients in practices and, in particular, the low number of physicians in practice groups.

Ninth – Insurance status as a proxy for socioeconomic status. Indicators of socioeconomic status are markers of social relationships and provide information about access to and command over social and economic resources (Duncan et al. 2002).

According to Shavers (2007), using socioeconomic status in relation to health status and health care “is an attempt to capture an individual’s or group’s access to the basic resources required to achieve and maintain good health” (p. 1013). Common measures of socioeconomic status include occupation, education, and income, but these measures are not interchangeable, and there is little agreement on which indicators should be gathered

(Duncan et al. 2002). Shavers (2007) lists methodological and analytic issues related to the measures including the lack of precision of the measures, the difficulties associated

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with collecting the information from individuals, the stability of the measures over time, and the relation of the measures to socioeconomic status, e.g., socioeconomic status does not rise consistently with increases in years of education.

In spite of the difficulties associated with capturing accurate data from which to assign social class, socioeconomic status is a critical measure for health disparities research. Shavers (2007) recommended choosing a measure of socioeconomic status that is of relevance as an indicator for the population and outcomes being investigated.

Insurance status, which is available for the vast majority of patients and generally accurately reported in patients’ medical records, can serve as a proxy for socioeconomic status (c.f., Baquet and Commiskey 2000; Foraker et al. 2010; MacKinnon et al. 2007;

Marcin et al. 2003). Foraker et al. (2010) specifically indicated that Medicaid status had an independent effect in their research and could possibly operate through a mechanism such as the patient-physician relationship. The data from the Direct Observation of

Primary Care study did not include patient income or occupation. Further, education, although available, was self-reported by patients and not available for all patients in the subset of the dataset being used for the present study. Insurance status was available from the medical record for patients in the subset being analyzed. Therefore, insurance status was used in the present study as a proxy for socioeconomic status, recognizing that patients who were poor could have had private insurance, and patients insured by

Medicaid could have had higher incomes than reported when eligibility was determined.

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CONTRIBUTIONS

In spite of these limitations, the results of this study provide additional insight into the relationships among socioeconomic status, patient-physician communication, and patient satisfaction. Given the complexity of primary care, it is often difficult to measure patient outcomes, and patient satisfaction has been used repeatedly in the literature as a proxy for outcomes. The present study adds support for the notion that patient-centered communication matters to patient outcomes – the patient needs to be considered as the focal point of the patient-physician encounter. I return to the comments by Mark

Petticrew (2007), who stated that “while waiting for the gaps to be filled, we need to make better use of some of the evidence we do have” (p.411). It is my belief that the

DOPC dataset added additional support for the importance of patient-centered communication in primary care and shed additional light on modifiable factors that promote patient satisfaction, in particular, the time the patient spends in the physician’s office.

FUTURE RESEARCH

Mark Petticrew (2007) stated that in spite of the fact that health policy makers and researchers recognize the need and call for better evidence on the effects of interventions on health inequalities, there remains a relative absence of rigorous research in this area.

The present research adds additional credibility to the comment by Willems et al. 2005:

Physicians behave differently with patients from different SES and patients communicate differently with their doctor depending on their SES. These differences add to the already existing boundaries to health care utilisation [sic] by patients from lower SES. We suggest a four-way solution: broader and deeper research on social differences in the doctor-

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patient communication, promoting physicians’ awareness about their communicative style, developing teaching methods on inequalities in communication, and encouraging research on the implications of patient empowerment methods. (P.144)

However essential the research proposed by Willems et al. (2005), the research will only be as valid as the measures are robust. The first step needs to be the creation and validation of easy-to-administer or use measures of patient satisfaction and patient- centeredness. The logical second step needs to be the determination of the optimal balance between patient-centered and physician-centered communication, recognizing that each has a valid place in the patient-physician encounter, but the balance for particular situations needs to be determined.

Results suggest additional areas to be explored. The contributions of gender to the centeredness of the interaction, chatting between the patient and physician, and the lack of feeling that expectations were met warrant further investigation particularly in light of the gender shift in medicine and the increased likelihood that men will be receiving their primary care from female physicians. In addition, although the present research did not identify the proposed relationship between patient socioeconomic status and patient satisfaction (see Figure 4), new research using a more robust quantitative patient satisfaction measure or qualitative inquiry may reveal a relationship.

Further, results suggested that the model proposed in Figure 4 is incorrect. I found no relationship between patient socioeconomic status and patient satisfaction. Given the need for better measures of patient satisfaction, I am not ready to abandon the model at this time. The model warrants further testing once new, robust measures are available for investigating these relationships.

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Finally, it is imperative that the results of the present research, which have identified a relationship between patient socioeconomic status and the centeredness of the visit, need to be considered in the delivery of the patient-physician interaction curriculum in medical schools. Medical students, as well as practicing physicians, need to be educated about and become aware of potential biases in their communication with their patients – a bias that could negatively affect health outcomes.

FINAL COMMENTS

This dissertation ends by reiterating opening comments – patients’ socioeconomic status has been linked for many years to disparities in health and health care. This income-associated burden of disease can be considered one of, if not the leading, cause of morbidity and mortality in the United States (Muenning et al. 2005). In our two-tiered health care system (Patel and Rushefsky 1999), poor people fare the worst and face many barriers to achieving optimal access to the health care system, and therefore, to achieving optimal health. How people get sick, die, and the type of health care they receive depends not only on their race and gender, but primarily on the social class to which they belong

(Navarro 1993). Mechanic (2000) indicated that “there is a social gradient in the relationship between SES and health that transcends any plausible concept of poverty, deprivation, ignorance, or powerlessness” (p. 270).

This dissertation helps to understand the social gradient in health through research that merged two disciplines, both with keen interest in health and health care – sociology and medicine. Merging the two disciplines results in additional explanatory power for the interpretation of the results of this research. The discipline of sociology benefits by the

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addition of research that provides a unique perspective on and glimpse into the sacred world of patients and their physicians. The discipline of medicine, which often has an atheoretical approach to research, benefits through research enhanced by the explanatory power of sociological theory.

The importance of patient-centered interviewing is not a newly recognized phenomenon. More than 20 years ago, Levinstein et al. (1989) commented about patient- centered clinical interviewing and its importance to primary care. They stated that “The task of the physician is twofold: to understand patients and to understand their diseases.

In the process of medical history taking, we have a well tried clinical method for understanding diseases; we have no equivalent for understanding patients” (p. 107). They continue to offer three reasons for this gap in skills. First, the key to understanding illness is to understand the patient. Second, the focus of the primary care physician, unlike physicians who specialize in other medical disciplines, is on disease prevention, not necessarily diagnosis, and helping patients function with their diseases or problems. In order to do so, primary care physicians must understand the life worlds of their patients.

Third, management of disease, in order to be the most effective, must be tailored to patients’ individual needs. Primary care physicians’ management plans must consider the patient as an individual. Primary care physicians take care of disease as well as illness, with disease being “the thing that is wrong with the body machine,” and illness being

“the unique experience of a person who feels ill” (Levenstein et al. 1989:108).

There likely will be little argument about the importance of including patients as integral contributors to and integral parts of their health care. What can be argued is how

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much of each patient-physician interaction should be devoted to patient-centered communication versus physician-centered communication. Both are essential to optimize clinical outcomes. Just as physician-centeredness is likely not good in all cases, patient- centeredness is not good in all cases. Rather than making judgments about the quality of the patient-physician interaction based on the centeredness of the interaction, maybe we should be making judgments about the quality of the patient-physician interaction and helping physicians, at all levels along the medical education continuum, improve the ways in which they interact with patients.

If perceptions of patients do affect quality of care as the existing literature suggests, these findings point to the need for interventions . . . it is unrealistic to expect physicians to be able to avoid using stereotypes at will. Rather, physicians need more supports in terms of training and structural factors for incorporating individualized patient information into their perceptions of patients. (van Ryn and Burke 2000:825)

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Appendix A

The Direct Observation of Primary Care Study – Methods

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The Direct Observation of Primary Care Study – Methods

The following description of the Direct Observation of Primary Care (DOPC) study, unless otherwise noted, is based on Stange et al. (1998a), which is the seminal article describing the study and the methods employed, and Stange et al. (1998b), which provides additional characterizations of the practices, physicians, patients and the patient visits. Methods applying to patients under the age of 18 have been omitted from this description, since only the data from those 18-64 years of age are used for the analyses in this dissertation.

Specific Aim The DOPC study was undertaken to examine the inter-rater reliability and validity of the commonly used and relatively inexpensive medical record review and patient questionnaire methods compared with a gold standard of direct observation of outpatient visits to family physicians. Physician recruitment into the study began in the summer of 1994, and data were collected between October 1994 and August

1995.

Sites and Subjects Physicians and practices: Family physicians who were members of the Ohio Academy of Family Physicians and practiced within a 50-mile radius of Cleveland and Youngstown were invited by Kurt C. Stange, M.D., Ph.D., study principal investigator, to participate in the study of the content of family practice. Family physicians who were not practicing in family practice settings and full-time academic family physicians were excluded from the study. The exception was 30 members of the

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faculty of the Department of Family Medicine at Northeastern Ohio Universities College of Medicine (NEOUCOM) who practiced in six affiliated hospital-based family medicine residency training programs, which were located in Akron, Barberton, Canton and

Youngstown. The specific sites included Akron City Hospital, Akron General Medical

Center, Barberton Citizens Hospital, St. Elizabeth Health Center, Youngstown Hospital

Association – Northside Medical Center, and Aultman Hospital.

Patients: Patients eligible for participation in the study were those of all ages who presented for care from a participating physician during one of the data collection days.

Although no exclusion criteria were specified in the reference articles, it can be assumed that eligibility criteria included being cognitively intact and the ability to speak English.

Data Collection Procedures Data Collection Overview: Each participating physician was visited by one of four teams of two research nurses while providing outpatient care during two days of the data collection period and an additional two days during which the research nurses abstracted data from the medical records. During any given data collection day, one research nurse accompanied and observed the physician during all visits by patients who provided consent. The second research nurse explained the study to patients in the waiting room, obtained consent from patients, and gave participating patients the patient questionnaire to complete at the end of their visit. In order to maximize variation in seasonal reasons for patient visits, each physician’s observation days were separated by an average of four months. All observations were scheduled by the study coordinator, who requested that: 1) the observation day be a

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typical, representative patient care day, and 2) patients be scheduled in the customary fashion typical of the practice.

Patient Informed Consent: Consecutive patients presenting to the office for care on the observation days were informed about the study in the waiting room before meeting with their physician by being read a standard statement describing the research project. They were enrolled if they gave verbal consent (please note that written consent was not required by the Institutional Review Board [IRB] at that time). The IRB of

University Hospitals of Cleveland (UHC) reviewed the study protocol and deemed it fully acceptable without reservation. A copy of the UHC IRB materials, including the oral statement read to each patient, is provided in Appendix C.

Data Collection – Patient-Physician Observation: The observing research nurse accompanied consenting patients to the examination room and seated herself to observe the visit from the least obtrusive corner of the examination room, from a position that avoided eye contact with either the physician or the patient. She instructed physicians and patients alike to ignore her during the observed visit, with the intent that the she could be

“like a fly on the wall.” Her task was to record the content of each 15-second interval of the entire patient-physician interaction. The research nurse wore headphones and listened to a quiet recorded voice that denoted the beginning and end of each 15-second observation interval, beginning with “observe” followed 15 seconds later by the statement “record,” during which she had five seconds to record her observations of the content of the visit using a laptop computer and the Davis Observation Code (Callahan and Bertakis 1991).

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Data Collection – Direct Observation Confirmation: Immediately following the conclusion of each observed visit, for each service observed to have been performed or ordered during each patient-physician encounter, the research nurse checked the corresponding box on a form, the Direct Observation Checklist. For selected services, the research nurse indicated whether or not the service was performed in response to a patient’s symptoms or chronic medical condition.

Data Collection – Patient Self-Reported Data: Following their visit, consenting patients were approached by the second research nurse who provided them with a questionnaire to complete and place in an envelope to help maintain their confidentiality.

Patients who needed to leave immediately after their appointment were asked to complete the questionnaire as soon as possible and mail it to the research office in a postage-paid envelope. Those who took the questionnaire home to complete were sent a postcard reminder within one week of their visit, and if no response was received, a second reminder was sent within one month of the visit, after which no further attempts were made.

Patients who completed the questionnaire in the physician’s office were provided with help in clarifying questions by the research nurse. Patients who completed the questionnaire off site could call the research office for answers to their questions.

Data Collection – Medical Record Review: Data were abstracted from consenting patients’ medical records on a day subsequent to the patient observation day. The research nurses indicated whether or not a particular service was noted in the patient’s medical record for the observed visit, or for selected services, during a preselected time

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interval. The research nurses also assigned Current Procedure Technology (CPT) codes

(American Medical Association 1995) to each visit based on direct observation and the medical record review. During the review of the medical record, they also rated the components of the visit that led to the assignment of the CPT code according to the

American Medical Association (1995) guidelines, which provide a rating based on the extent of the history, complexity of the medical decision-making, extent of examination, and nature of the presenting problem.

Data Collection – Physician Data: Each physician was asked to complete a questionnaire that was distributed to each physician only after the second day of observation was completed to avoid biasing physician behavior during the study.

Data Collection – Billing Data: After the observation day, the research nurses obtained and recorded patient-related billing data specific to each observed patient- physician encounter, i.e., evaluation and management codes, which were provided by the responsible office staff member. Research nurses did not have direct access to the office billing records.

Data Collection – Practice Environment: Research nurses who visited a practice on one or more occasions collaborated on the completion of the Practice Environment

Checklist, which provided objective and subjective data about a variety of aspects of each of the participating practices. Data were collected from interviews of key office informants (e.g., the office manager) and the research nurses’ direct observations during both the patient care observation days and the medical record review days.

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Data Collection – Ethnographic Field Notes: Throughout each day spent in a practice, research nurses made brief “field jottings,” which they dictated using a hand- held audio recorder immediately after each visit to the practice. After each physician was visited once, input from all team members was gathered and ethnographic field notes were used to revise or expand the data collection instruments.

Stange et al. (1998a), used multiple strategies to minimize the possibility of a

Hawthorne effect, considering the possibility that a nurse observer could alter the phenomenon under study, including aspects such as the patient-physician interaction or the recording of information in the patient’s medical record. First, office staff and physicians were asked to follow their usual scheduling and patient care procedures.

Further, the observation of consecutive patients made it impossible, or at least more difficult, for physicians to spend more time or to provide more services than their usual routine without severely compromising their ability to stay on schedule. Second, to avoid biasing physician behavior, physicians were informed only that the study would use multiple methods to examine the content of the ambulatory patient visit; no specific hypotheses or study goals were shared with the physicians, their office staff or their patients. Further, according to previous research, providers do not change their behavior significantly when they are being observed (Gerbert et al. 1988). Third, the research nurses observed the visits from the least obtrusive corner of the examination room, from a position that avoided eye contact with either the physician or the patient.

Measures Eight measures were used in the multi-method DOPC study: 1) direct observation of the patient visit, 2) a direct observation checklist of services delivered

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during the patient visit; 3) a patient exit questionnaire; 4) medical record review; 5) a practice environment checklist; 6) billing data; 7) a physician questionnaire, and 8) ethnographic field notes. Following is a brief description of each of the measures.

Detailed information is provided in Appendix B.

Measure 1 – Direct Observation of the Patient Visit: Using direct observation, elements of consenting patients’ visits were categorized using the Davis Observation

Code (DOC). Although no existing interactional analysis system is ideal for describing the patient-physician encounter in its entirety, the DOC has been shown to be a reliable and valid method for categorizing patient and physician behavior during either direct observation or videotapes of medical encounters (Callahan and Bertakis 1991). The DOC was developed to measure content areas of patient and physician behaviors that are relevant to diagnosing and treating a patient’s illness as well as to help the patient modify unhealthy lifestyles and behaviors. The Davis Observation Code uses an interval coding system that categorizes time use during every 15-second interval of each patient visit into

20 different behavioral categories, which were derived from diverse sources including medical education textbooks, observations of patient-physician encounters, theories of good medical education interaction, health-risk behaviors that might be targeted for intervention by physicians, and behavior modification techniques.

Each patient-physician encounter is broken down into 20-second intervals of which 15 seconds is devoted to observation of the encounter and 5 seconds devoted to recording the observations on the DOC form. Callahan and Bertakis (1991) allotted 15 seconds to observation believing that it would allow sufficient time for important

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behaviors to occur and short enough to ensure that observers could remember codes until their rating time. The five-second recording time was selected because it was both long enough to permit the observer to record all pertinent data and short enough to ensure that few behaviors would be missed because they began and ended during a record interval.

The 20 operational definitions were selected to capture specific aspects of care that were described in the titles of the codes without overlapping significantly with other codes. While not easily measured, Callahan and Bertakis (1991) considered content and face validity in the selection of code items and their definition. Concurrent validity was measured using chart audits by comparing whether or not four specific behaviors (disease prevention, health education, health promotion, compliance checking) were noted by the physician in the patient’s chart compared to the presence or absence of the behavior observed on a videotape of the patient-physician encounter. However, Callahan and

Bertakis (1991) found little concordance between the chart audits and observation of the encounter regarding the four target behaviors, with most of the discordance involving under-recording of target behaviors in the patient charts. In addition, some behaviors were recorded in the charts that were not observed and/or documented on the videotaped observation. This finding lends support to the claim that direct observation of patient- physician behaviors is a far superior method for capturing elements of a patient-physician interaction, detecting behaviors that are not reflected in chart notations by physicians. In addition to being a sound method for capturing quantities of patient and physician behavior, Callahan and Bertakis (1991) state that the:

DOC can be used also to gauge the power of a variety of other influences in physician-patient behavior, such as the length of time available for the

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visit or the method of payment for the visit . . . By providing data on effective physician behaviors, DOC has potential as a valuable tool in defining and developing optimal health care. (P. 23)

(1998a), modified the DOC, using 19 of the original 20 categories, and replacing

“treatment effects,” defined as “physician inquires about or patient describes results of ongoing therapeutic intervention for current episode or problem,” (Callahan and Bertakis

1991) with “negotiation.” For clarity, Stange et al. (1998a), also added some, however minimal, additional text to a few operational definitions. Please refer to Appendix B,

Table B.1 for the categories and operations definitions used by Stange et al. (1998a), for the DOPC study.

Measure 2 – Direct Observation Checklist: The intent of the Direct Observation

Checklist was to provide a measure of congruence between services observed by the research nurse to have been performed or ordered by a physician during the observed patient-physician encounter and whether or not the physician made a record of that service in the patient’s medical record. Items were denoted as either “PER” if they were performed or ordered specifically by the physician (not anyone else) at that visit, or

“SYM” if the procedure was performed or offered to evaluate symptoms, rather than as a

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preventive service. Please refer to Appendix B, Table B.2 for a summary of the content of the Direct Observation Checklist.

Measure 3 – Patient Exit Questionnaire: The Patient Exit Questionnaire was an attempt to collect a wide variety of information from the patient’s perspective. The questionnaire began with a brief statement to the patient thanking them “for participating in this groundbreaking network study,” an indication that their responses were voluntary but important, and that responses would be kept confidential. The self-administered survey included questions about demographics, reason for the visit, health status, referrals, about the doctor, the services provided, general questions, and satisfaction with the experience. Patient satisfaction with the experience was measured using a slightly modified version of the VSQ-9, a visit-specific measure of patient satisfaction (RAND

2009) (Cronbach’s alpha = .89) (Rubin et al. 1993). Please refer to Appendix B, Table

B.3 for a summary of categories, the content areas, and the response scales used.

Measure 4 –Medical Record Review: Data from the patient’s medical record included information specific to the observed visit as well as the delivery of services during the past year and other specific time intervals for selected services. Data gleaned from the medical record also included demographics, the number of chronic illnesses and medications, the number of years as a patient of the practice, the number of visits in the past year, and if the patient had specific illnesses. Research nurses used a standard checklist to indicate whether or not specific information was recorded in the patient’s medical record or a service was delivered during a predetermined time period. A list of data gleaned from the medical records is provided in Appendix B, Table B.4.

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Measure 5 – Practice Environment Checklist: The practice environment of each participating site was evaluated in four general categories: 1) office set-up, 2) office operations, 3) external environment, and 4) physician characteristics. Please see

Appendix B, Table B.5 for general and sub data categories and the elements evaluated in each category.

Measure 6 – Billing Data: Billing data relied on Current Procedural Terminology

(CPT) codes (American Medical Association 1995) and International Classification of

Diseases, Clinical Modification (ICD-9-CM) diagnoses (USDHHS CMS 2008a). CPT coding is the most widely accepted terminology used by physicians for reporting services rendered and medical procedures performed for billing purposes for both public and private insurance programs. First published by the World Health Organization, and now jointly maintained by the National Center for Health Statistics and the Centers for

Medicare and Medicaid Services, the ICD-9-CM is the official system for assigning codes to diagnoses and procedures associated with hospital utilization in the United

States. This system is often used to capture morbidity information, including the outpatient setting.

Measure 7– Physician Questionnaire: Each participating physician completed a survey that solicited information including demographics, questions about the observation day, practice characteristics, delivery of specific services, opinions about preventive services, personal health and health habits, decision making about screening, competing demands, familiarity with and feeling about practice guidelines, how their practices address the domains of primary care, the validity of the Resource-Based

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Relative Value System (RBRVS) method for billing patients, and questions about the developing practice-based research network (PBRN). Please refer to Appendix B, Table

B.6 for the categories and items of this questionnaire, excluding the questions about the

PBRN.

Measure 8 – Ethnographic Field Notes: Ethnographic field notes prepared by each research nurse were used to: 1) gain insight into the culture of the practices, 2) gather information not captured through quantitative instruments or other measures, 3) assist with interpretation of the data, and 4) critique the study methods.

Data Security Measures were linked using unique confident identifiers for physicians and patients. Original data forms and identifier lists were stored in secure locations with access restricted to limited members of the DOPC research team.

Data Analysis Techniques The representativeness of the physician sample was determined by comparing the demographics of the physicians who agreed to participate in the study with those of the members of the American Academy of Family Physicians

(AAFP 1996). The representativeness of the patient sample was determined using several methods. First, consenting patient and visit characteristics were compared with similar data from the National Ambulatory Medical Care Survey (Schappert 1993). Second, a comparison was made between the research nurses’ perceptions of the observable characteristics of consenting patients and those patients who declined to participate.

Research nurses also recorded any reasons for patient refusal. Third, a subsample of 12 participating physicians reviewed the medical records of patients who declined and recorded patient demographics and the number of years as a patient of that practice,

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which were compared to consenting patients’ data. Further, this subsample of physicians also recorded their supposition regarding why the patient might have declined to participate based on their knowledge of the patient and the characteristics of the patient visit during the observation day. Finally, using observation and medical record data for consenting patients, the characteristics of patients who returned patient questionnaires were compared who those who did not. T-tests were used to compare continuous variables, the Wilcoxon rank-sum test was calculated for highly skewed ordinal variables, and X 2 tests were calculated for ordinal variables.

Questionnaire, and billing data were used to ascertain the type of insurance.

Characteristics of the visit were derived from direct observation data consisting of the research nurses’ assessment of the reason for visit and data collected while using the

Davis Observation Code including timing of the length of the visit that was the time the physician spent in direct contact with the patient.

Appendix B

The Direct Observation of Primary Care Study – Data Fields

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The Direct Observation of Primary Care Study – Data Fields

Table B.1. Operational Definitions of the Modified Davis Observation Code Used for Direct Observation Coding

Code Brief Description Definition CHAT Chatting Physician or patient discussing topics not related to current visit, e.g., small talk or humor which might be used to build rapport.

INTERACT Structuring Physician or patient discussing what is to be Interaction accomplished in the current interaction; or physician asking patient any questions. Excludes: a) physician requesting patient to do anything which is part of the physical examination or is done to prepare for the physical examination, and b) planning treatment. Can include statements describing what will be done in the physical examination.

COUNSEL Counseling Physician discussing interpersonal relations or current emotional state of patient or patient’s family, providing reassurance or support, using self-disclosure to reassure patient, restating what patient has said (in regard to above), or reflecting on the patient’s nonverbal behavior. Excludes “advice” asking for health behavior change (see Health Promotion).

HISTORY History Taking Physician inquiring about or patient describing details related to the current chief complaint or to prior illnesses or treatment. Includes: a) physician reading medical record, b) patient responding about current treatment, and c) physician asking if physical examination maneuver produces pain or feeling described in the chief complaint or the history.

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Code Brief Description Definition FAMILY Family Information Physician inquiring about or discussing family medical or social history or about current functioning of family (family can include unrelated significant others from social or work groups).

NEGOTIAT Negotiation Physician commenting or asking questions which facilitate or invite patient participation in diagnosis, treatment planning, or problem solving. Examples: “What do you think?” “What would work for you?” “How would you feel about doing it his way?” “Are there any ways you think might work?”

KNOWLEDG Health Knowledge Physician asking or patient spontaneously offering what patient knows or believes about health or disease (as opposed to patient’s own treatment history, which is coded History Taking).

FEEDBACK Evaluation Feedback Physician telling patient about results of history, physical examination, laboratory work, etc. Includes telling that laboratory tests are incomplete, inconclusive, etc. Results can be preliminary or speculative.

PHYSICAL Physical Examination Physician conducting any aspect of the physical examination of the patient including taking samples for laboratory tests or diagnostic procedures. Also includes asking patient to prepare for physical examination, telling patient to do something in the physical examination, or asking if the maneuver hurts or is tender.

QUESTION Patient Question Patient asking question of physician about diagnosis, treatment, side effects, history or disease.

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Code Brief Description Definition COMPLY Compliance Physician inquiring about or discussing what patient is currently doing or has done recently regarding previously requested behavior around taking medication, changing nutrition, or doing exercise or other behavior change.

PREVENT Preventive Services Physician discussing, planning or performing any screening task associated with disease prevention or asking about history or disease prevention. For example, Pap smear, breast examination, vaccination, hip click examination, testicular examination, rectal examination, thyroid examination, or scoliosis examination.

EDUCAT Health Education Physician presenting information regarding health to the patient. Can include information regarding diagnosis, etiology, drug effects and treatment, or accident prevention. May also include statements about health attitudes and motivation.

PROMOTE Health Promotion Physician asking for a change in patient’s behavior to increase or promote patient’s health (including accident prevention). Excludes changing behavior around taking medication or asking a patient to take medication. Any explanation of the procedure itself, its side effects, drug interactions, or contraindications should be coded Health Education.

PLAN Planning Treatment Physician prescribing a medication, diagnostic, or treatment plan to be followed other than behavior change (see Health Promotion). Includes physician asking if prescription refill is needed.

XERCISE Exercise Any question about or discussion of exercise.

SMOKING Smoking Behavior Any question about or discussion of smoking or other use of tobacco.

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Code Brief Description Definition DIET Nutrition Any question about or discussion of nutrition. Includes discussion of diet and/or food intake. Excludes questions regarding only appetite, which is coded History.

DRUGS Substance Use Any question about or discussion of drinking alcohol or use of any other substance.

PROCEDUR Procedure Any treatment or diagnostic procedure done the office, i.e., removing skin tags, removing warts, drawing blood, casting, dressing, etc. Excludes preventive services such as a Pap smear.

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Table B.2. Content of the Direct Observation Checklist

Category Elements Vital Signs Height, weight, and blood pressure

Physical Examination Head/neck, heart, lungs, abdomen, back, extremities, (gender appropriate) neurological, skin, testicles, breasts, pelvis (bimanual), and rectum

Tests Pap, gonorrhea culture, Chlamydia culture, fecal occult blood (in-office and home), TB skin, cholesterol, blood glucose, hematocrit/hemoglobin, chemistry panel, thyroid, PSA, urinalysis, chest x-ray, and mammogram

Procedures Vision and hearing screening, electrocardiogram, sigmoidoscopy

Questioning/Discussion Diet (calories, cholesterol, sodium, calcium, other), dental health, exercise, self examinations (breast, testicular, skin), sun exposure, injury prevention (safety belts, accidents, safety helmets, violence, other), estrogen discussion and prescription, aspirin prophylaxis, condom use, other contraception, HIV( prevention, testing/counseling), other STD prevention, passive tobacco exposure, and tobacco use history

Counseling and/or History Tobacco, alcohol, substance abuse, back pain prevention, family history, and social history

Immunizations Tetanus booster, flu, Pneumovax, measles, and hepatitis B

Pregnant Patients (only) History (genetic, obstetrics, herpes), tests (serum AFP, oral GTT, prenatal panel blood, ultrasound), and breast feeding counseling

General Referral: non-physician in office, non-physician out of office, another physician Other family member present Problem of another family member discussed Medical student present Nurse practitioner or physician assistant present Patient requested help with behavior change Patient requested other prevention

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Category Elements Patient raised an emotional content Physician responded to emotional content

Major Reason for Acute problem This Visit Acute, follow-up Chronic, routine Chronic, flare-up Prenatal care Postnatal care Postoperative care Well adult examination Counseling/advice Immunization Referred by another physician Administrative purposes Other

Other Provision of patient education materials

Service Description Evaluation & Management CPT Code* Established patient (99211, 99212, 99213, 99214, 99215) New patient (99201, 99202, 99203, 99204, 99205)

* Maintained by the American Medical Association, Current Procedural Terminology (CPT) codes identify the service or supply provided to a particular patient. These codes, which are used to bill for the services provided, are selected by the healthcare provider to represent best the services furnished during the visit. Two categories, or service types, are specified – new patient and established patient. A new patient is defined by the Center for Medicare and Medicaid Services (CMS) as one who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years. An established patient is one who has received professional services from the physician or physician group practice (same physician specialty) within the previous three years (USDHHS CMS 2008).

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Five CPT codes can be used to bill for office or other outpatient visits by a new patient, with similar definitions used for established patients (USDHHS CMS 2008). 99201: for problem(s) that are self-limited or minor and the physician typically spends 10 minutes face-to-face with the patient; requires three key components: problem-focused history, problem-focused examination, and straightforward medical decision making 99202: for presenting problems that are of low to moderate severity and the physician typically spends 20 minutes face-to-face with the patient; requires three key components: expanded problem-focused history, expanded problem-focused examination, and straightforward medical decision making 99203: for presenting problems that are of moderate severity and the physician typically spends 30 minutes face-to-face with the patient; requires three key components: detailed history, detailed examination, and medical decision making of low complexity 99204: for presenting problems that are of moderate to high severity and the physician typically spends 45 minutes face-to-face with the patient; requires three key components: comprehensive history, comprehensive examination, and medical decision making of moderate complexity 99205: for presenting problems of moderate to high severity and the physician typically spends 60 minutes face-to-face with the patient; requires three key components: comprehensive history, comprehensive examination, and medical decision making of high complexity

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Table B.3. Content of the Patient Exit Questionnaire

Category Elements Demographics Age (in years) Sex (female, male) Race (black, white, Hispanic, Asian, Indian, other) Education Level (less than 8th grade, some high school, some college, associate degree, college graduate, graduate school) Marital Status (married, widowed, divorced, unmarried)

Reason for Visit* Why did you come to the doctor today? (can choose more than one) For a new illness or problem For continued care of an old illness or problem For worsening of an old illness For a well visit For counseling or advice For pregnancy care For immunizations (shots) For paperwork Other

* Based on the typology from the National Medical Ambulatory Care Survey (Schneider et al. 1979; Schappert 1993)

Health Status** In general, would you say your health is: (5 = excellent, 4 = very good, 3 = good, 2 = fair, 1 = poor)

In the past 4 weeks, to what extent did health problems limit you in your everyday physical activities (such as walking and climbing stairs)? (not at all, slightly, moderately, quite a bit, extremely)

During the past 4 weeks, how much have you been bothered by emotional problems (such as feeling anxious, depressed, or irritable)? (not at all, slightly, moderately, quite a bit, extremely)

How much bodily pain have you generally had during the past 4 weeks? (none, very mild, moderate, severe, very severe)

During the past 4 weeks, how much difficulty did you have doing your daily work, both inside and outside the house, because of your physical or emotional problems? (not at all, slightly, moderately, quite a bit, extremely)

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Category Elements ** Modified five-item version (alpha=0.81) (Stange et al. 1998a) of the MOS 6-Item Health Survey (Ware et al. 1992)

Referrals Did the doctor have you see a nurse or other person in the office for additional teaching about a health matter today? (yes, no) Did the doctor refer to you another physician today? (yes, no) Did the doctor refer you to a non-physician today? (yes, no)

About the Doctor Please mark the response that best describes your visit to the doctor you saw today: I go to this doctor for almost all my medical care. This doctor does not know my medical history very well. This doctor knows a lot about the rest of my family. This doctor clearly understands my health needs. I can easily talk about personal things with this doctor. I don’t always feel comfortable asking questions of this doctor. This doctor always explains things to my satisfaction. Sometimes, this doctor does not listen to me. This doctor and I have been through a lot together. This doctor does not always know about care I have received at other places. This doctor communicates with the other health care providers I see. This doctor knows the results of my visits to other doctors. This doctor always follows up on a problem I’ve had, either at the next visit or by phone. If I am sick, I would always contact a doctor in this office first. If I had an emotional problem, I’d talk to this doctor about it. My medical care improves when I see the same doctor that I have seen before. It is very important to me to see my regular doctor. I rarely see the same doctor when I go for medical care. I want one doctor to coordinate all of the health care I receive. During the visit, the doctor involved me in making decisions about my health. The doctor addressed my main concerns today. There were things that I wanted to bring up with the doctor today that I wasn’t able to.

(Scale anchors: 5 = strongly agree, 3 = neutral, 1 = strongly disagree)

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Category Elements How many health problems did the doctor address today? (1, 2, 3, 4, 5, 6, 7, 8, 9+)

Services Done here today or in last year, or done elsewhere in last year: Provided Height, weight, or blood pressure measurement Examination of the eye, head or neck, abdomen, back, arms or legs, skin, or rectum Listened to heart or lungs In-office test for blood in stool Vision test (eye chart) or hearing test EKG (electrocardiogram) Chest x-ray Blood tests: blood sugar (glucose), blood count (check for anemia), HIV (AIDS test), thyroid, cholesterol, or other Urine test (except for pregnancy) Home stool testing for blood TB (tuberculosis) skin test Shots: flu, tetanus, pneumonia, or hepatitis Sigmoidoscopy Discussed family history Received written educational materials

Patient Education – Advised patient about: Diet, dental health, exercise, examination of skin, sun exposure, seat belt use, accident prevention, safety helmets, taking aspirin to prevent heart attacks, birth control, preventing HIV disease and AIDS, sexually transmitted disease risks, tobacco use, discussion of tobacco smoke exposure, alcohol use, illicit drug use, violent injury prevention, or back pain prevention

Women only: Breast or pelvic exam Pap smear Mammogram (breast x-ray) Advised about breast self-exam Discussed taking estrogen (female hormones)

Men only: Testicle exam Discussed how to examine testicle Prostate (PSA) blood test

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Category Elements

For pregnant women only: Discussed inherited family problems Discussed previous pregnancies Discussed any genital herpes in past Prenatal blood tests Blood test for alpha-fetoprotein (AFP) Oral glucose tolerance test (GTT) Ultrasound of the uterus Advised about breast feeding

General Do you consider the doctor you visited today your regular doctor? (yes, no) If no, is your regular doctor a member of this office? (yes, no) Do other members of your family see this doctor? (yes, no, not applicable) How many years have you been a patient of this physician? (1st visit, <1, 1-3, 4-6, 7-10, 10+) How many years have you been a patient of this practice? (1st visit, <1, 1-3, 4-6, 7-10, 10+) In the last year, how many visits have you had to this doctor (including this visit)? (1, 2, 3, 4, 5, 6, 7, 8, 9, 9+) In the last year, how many visits have you had to any doctor in this office (including this visit)? (1, 2, 3, 4, 5, 6, 7, 8, 9, 9+) In the last year, how many visits have you had to doctors outside of this office? (1, 2, 3, 4, 5, 6, 7, 8, 9, 9+) Of those visits outside of this office, how many were to referrals by a doctor in this office? (1, 2, 3, 4, 5, 6, 7, 8, 9 [sic]) In the last year, how many different doctors have you seen (including the doctor you saw today)? (1, 2, 3, 4, 5, 6, 7, 8, 9 [sic]) What type of medical health insurance do you have? (choose 1) (Medicaid, Medicare, managed care [referral from primary care physician required for other health care], regular health insurance [you can choose to go to any doctor without a referral], other, none) In the past two years have you been forced to change doctors because of changes in your insurance plan? (yes, no)

What is your smoking status? (current smoker, former smoker, never smoked)

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Category Elements How many glasses of alcohol, beer or wine do you drink? (none, one or fewer per day, more than one per day)

Satisfaction Here are some questions about the visit you just made. In terms of your satisfaction, how would you rate each of the following on a scale from 1 to 5? (5 = excellent, 4 = very good, 3 = good, 2 = fair, 1 = poor) How long you waited to get an appointment Convenience of the location of the office Getting through to the office by phone Length of time waiting at the office Time spent with the person you saw Explanation of what was done for you The technical skills (thoroughness, carefulness, competence) of the person you saw The personal manner (courtesy, respect, sensitivity, friendliness) of the person you saw This visit overall

To what extent were your expectations met today?

How much would you say the presence of the nurse-observer changed what you said or did today?

Scale: 1 = a lot, 2 = quite a bit, 3 = moderately, 4 = slightly, 5 = not at all

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Table B.4. Data Recorded from the Medical Record

Occurred Occurred Recorded in During During Information Recorded by Patient’s Observed Observed General Research Nurses Medical Visit Visit Information

Record and/or and/or Per Past Year Algorithm

Gender X

Marital status (married, divorced, X widowed, un-married)

Height X X

Weight X X

Blood pressure X X

Number of chronic illnesses on the X problem list

Number of medications on the X medication list

Smoking status X (yes, former, no, not noted)

Number of problems addressed X

If a drug was prescribed X

If there was a referral to a non- X physician in the office or out of the office, or a referral to another physician in the office or out of the office

If the Put Prevention Into Practice or X any other prevention flowsheet was used

If a family medical history was X recorded and there was a family history of breast cancer, colon cancer or alcohol abuse

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Occurred Occurred Recorded in During During Information Recorded by Patient’s Observed Observed General Research Nurses Medical Visit Visit Information

Record and/or and/or Per Past Year Algorithm

If there was a formal advanced X directive

If the patient had a history of heart X attack, stroke, diabetes (if yes, if the patient used insulin and if the glycosylated hemoglobin value was noted), hypertension, depression, and anxiety

Number of years with the practice X

Number of visits in the past year and X the number of visits in the last year with the observed physician

Number of nurse visits in the last X year

Thickness of the chart X

Legibility of the record X

If there was an old record present or X the use of a central database

Major reason(s) for the observed X visit (acute problem, acute problem follow-up, chronic routine, chronic flare-up, prenatal or postnatal care, postoperative care, well adult examination, counseling/advice, immunization, referred by another physician, administrative purposes, other)

Category of service (new patient X with complaint(s), established patients seen within three years with complaint(s), new patient with no

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Occurred Occurred Recorded in During During Information Recorded by Patient’s Observed Observed General Research Nurses Medical Visit Visit Information

Record and/or and/or Per Past Year Algorithm complaints for preventive services but not counseling, established patient with no complaints for preventive services but not counseling)

Health promotion, counseling, and/or X coordination of care provided to a healthy individual if more than half of the visit (counseling and/or risk factor reduction intervention(s), coordination)

Extent of the history and X examination (none, problem focused, expanded problem focused, detailed, comprehensive)

Complexity of the medical decision X making (straightforward, low complexity, moderate complexity, high complexity)

Nature of the presenting problem X (minimal, self-limited or minor, or of low, moderate or high severity)

Evaluation and management CPT X codes for an established or a new patient

Examinations of the head and neck, X heart, lungs, abdomen, back, extremities, neurological system, skin, testicles including self-exam, rectum, pelvis (bimanual), and breasts including breast self-exam

Tests including pap, gonorrhea and X Chlamydia culture, home and in-

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Occurred Occurred Recorded in During During Information Recorded by Patient’s Observed Observed General Research Nurses Medical Visit Visit Information

Record and/or and/or Per Past Year Algorithm office fecal occult blood, urinalysis, hematocrit/hemoglobin, blood glucose, chemistry panel, prostate- specific antigen (PSA), thyroid, and tuberculosis skin test; vision and hearing screening; electrocardiogram; chest x-ray; mammogram

Flu shot X

Dietary issues including caloric X balance, and sodium, calcium, and cholesterol and fat intake

Dental health X

Exercise X

Skin self exam, sun exposure; use of X safety belts and safely helmets, and other injury and violent injury prevention

Accidents X

Prescription for estrogen and X estrogen discussion

Aspirin prophylaxis X

Condom and other contraceptive use X

HIV prevention, testing and X counseling

Other sexually transmitted disease X prevention

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Occurred Occurred Recorded in During During Information Recorded by Patient’s Observed Observed General Research Nurses Medical Visit Visit Information

Record and/or and/or Per Past Year Algorithm

Tobacco use history, passive tobacco X exposure, tobacco counseling and nicotine replacement

Alcohol consumption history and X counseling

Substance abuse history and X counseling

Back pain prevention X

Family and social history X

Provision of patient education X materials

Pap smears (every 3 years) X

Mammograms (every 2 years) X

Sigmoidoscopy (every 5 years) X

Cholesterol (every 5 years) X

Tetanus booster (every 10 years) X

Pneumovax (every 10 years) X

Measles (second shot ever) X

Hepatitis B vaccine (ever) X

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Table B.5. Content of the Practice Environment Checklist

Office Set-up Category Elements Reminder Systems Presence of: Computer provider reminders Patient reminder cards Computer recall systems Telephone recall by nurse/office staff Periodic chart audit Prevention/health maintenance on the problem list Checklists/flowcharts Risk factor chart stickers Other

Type of Practice Health maintenance organization (HMO) Solo Single specialty group Multi specialty group Residency training practice

Waiting Room Descriptive information including décor

Degree of Managed Rating: Care None Very little (1-10%) Some (11-40%) A lot (> 40%)

Educational Materials Location where observed or available: Exam rooms Hallways Front desk or waiting room Use posters Use videos Use pamphlets Other None present

Put Prevention into Location where observed or available: Practice (PPIP) Material Waiting room poster Observed Exam room poster Prevention passport

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Office Set-up Category Elements Chart stickers Flow charts Provider buttons Prevention prescription pads

Number of Personnel Number in office on observed day, and total number: Physicians in office Physicians in group Registered nurses (RNs) Licensed practical nurses (LPNs) Nurse practitioners (NPs) Medical assistants Physician’s assistants (PAs) Clerical Other

Service Options Availability in office: Dietician Nurse counseling Counseling – smoking Counseling – drug or alcohol use Other

Adequacy of Space Indicate: Low Medium High

Office Hierarchy Clear ladder or hierarchy Confused Lateral or shared

Emphasis on Employee Smoke-free environment Health Availability of educational materials Other

Personnel Rate (scale: low, medium high): Degree of friendliness among staff Degree of friendliness toward patients Research nurse level of comfort in office Degree of office efficiency

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Office Set-up Category Elements Ability to work-in unscheduled patients Degree of patient privacy observed

Focus of office staff (scale: 1 = very little through 5 = very much, or not observed) Focus on taking care of patients’ needs Focus on keeping on schedule Focus on handling urgencies/emergencies Focus on finances Sense of time pressure

Office Operations Category Elements Use of Non-physician Staff involvement in patient education and who: Personnel Nurse Medical assistant Other

Ancillary Services Availability in office of: X-ray Lab (more than urine, hematocrit, urine chorionic gonadotrophin) Phlebotomy Consultants

Return of Patient Phone Rank order of: Calls Doctor RN LPN NP Medical assistant Other

Record System Indicate presence of: Innovations Family chart Other

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Office Operations Category Elements Patients Scheduled/Seen Number of patients scheduled Number of unscheduled patients Total number of patients Average number of minutes behind schedule Number of patient care hours Number of patients observed Number of no-shows

Billing Collection Indicate all that apply: Payment expected at time of visit Internal billing External billing Other

Indicate innovative roles for office personnel

Office Organization Indicate: Evening office hours Weekend office hours

External Environment Category Elements Physical Environment Rural Urban Suburban

Socioeconomic Class of % Poor Patients Seen % Working class % Middle class % Wealthy

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Physician Characteristics Category Elements Physician Style Degree of control (scale: low, medium, high) Observed Degree of affiliation (scale: low, medium, high)

Physician Use of For teaching (scale: low, medium, high) Windows of For prevention (scale: low, medium, high) Opportunity For office efficiency (scale: low, medium, high)

Patient Education When engaging in health promotion (any discussions of lifestyle behavior that are related to health) or counseling behavior change, how much the physician used: (scale: 1 = never through 7 = always) Feedback Reinforcement Individualization Goal setting Relevance Multiple education channels

When engaging in other patient education (e.g., discussions of medications or other health problems), how much the physician used: Feedback Reinforcement Individualization Goal setting Relevance Multiple education channels

Interaction with the How much the physician interacted: (scale: 1 = a lot, 2 = quite Research Nurse a bit, 3 = moderately, 4 = slightly, 5 = not at all) During patient care When not seeing patient

Presence Changing How much to you think your presence changed the physician’s Physician Behavior behavior during patient visits? (scale: 1 = a lot, 2 = quite a bit, 3 = moderately, 4 = slightly, 5 = not at all)

Other Characteristics Rate the physician’s: (scale: 1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent) Technical skills Intuition (ability to key in on what the problem was)

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Physician Characteristics Category Elements Patient activation/empowerment Listening ability Availability to the patient’s agenda Prioritization Thoroughness Ability to stay on time Ability to attend to multiple problems Knowledge of patients as people Focus on prevention Focus on coordination of care Focus on providing comprehensive care Focus on family Focus on managing chronic illness Focus on community health

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Table B.6. Content of the Physician Questionnaire

Category Items Demographics Age Year of graduation from medical school Completion of a family medicine residency (yes, no) Sex (male, female) Marital status (married, not married, divorced, widowed) Years in current practice Type of practice (solo, single specialty group, multi specialty group, residency training practice, other) Ownership of practice (full or part owner, employed by other physician group, employed by HMO, employed by other organization)

About the How typical was the observed day compared to usual? Observation Day Practice How much did the presence of the nurse observer change what you Characteristics did when you were with patients? (scale: 1 = not at all typical, 5 = typical)

How far is your primary office from your primary admitting hospital? (less than 1 mile, 1-5 miles, 5-10 miles, greater than 10 miles) During an average week of practice, about how many hours do you spend seeing patients in total, and how many patients do you see in each of the following settings? (office, hospital inpatient, emergency room, nursing home, other settings) Do you employ registered nurses (excluding LPNs, nurse practitioners, medical assistants and physicians assistants) in your office? (yes, no) If yes, indicate why (cost effectiveness, professionalism, services are billable, ability to act independently, versatility, ability to perform specific duties: history taking, patient health education, prenatal teaching, diet counseling, triage, returning phone calls, giving shots, other) Indicate the percent of patients with different types of insurance. (fee for service, Medicare, Medicaid, capitated care, uninsured) Do you perform prenatal care? (yes, no) Do you deliver babies? (yes, no) Do you perform care of children under 13 years of age? (yes, no) Indicate the degree to which the following descriptions apply to your practice: (scale: 1 = very little, 5 = very much) Focus on taking care of patient’s needs

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Category Items Focus on keeping on schedule Focus on handling urgencies/emergencies Focus on business and financial aspects of practice Focus on doing prevention Focus on managing chronic illness Focus on the family as the unit of care Focus on community/public health Sense of time pressure

How satisfied are you with these various aspects of your job? (scale: 1 = very unsatisfied, 5 = very satisfied) Out-patient care In-patient care Managing my practice Malpractice risks and claims Leisure and family time Feeling of control over your practice environment

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Category Items Delivery of Estimated percent of asymptomatic patients for whom Specific Services you routinely deliver these services (circle: 0, 10, 20, 30, 40, 50, 60, 70, 80, 90, 100) Breast exam every year (women) Lung exam Abdominal exam Pap test every 1-3 years (women age 19-64) Pelvic exam every 1-3 years (women age 19-64) Rectal exam every year (age 50-65) EKG every 5 years (age 50-60) Mammogram every year (women 50-75) Home fecal occult blood test every year (age 50-60) Cholesterol every 5 years (age 19-75) PSA screening test every year (men age 50-65) Flu shot every year (age ≥ 65) Pheumovax (once at age ≥ 65) Lead screening (at least once before age 5) Hepatitis B immunization for infants

Periodic counseling or health education about: Diet Dental health Exercise every year Breast self exam every year (women ≥ 40) Estrogen prophylaxis (women ≥ 50) Aspirin for prophylaxis of MI (men > 49) Contraception every year (ages 14-50) Tobacco use in smokers every year Familial or genetic diseases Advance directives (age > 64) Car seats for children every year Passive tobacco exposure every year

Opinions about Rate your opinion about the importance of the following services Preventive for asymptomatic patients: (scale: 1 = not at all important, Services 5 = very important), and Rate your effectiveness in delivering the following services for asymptomatic patients: (scale: 1 = not at all, 5 = very effective) Pap smears for women between 21 and 65 years old PSA screening for men between 50 and 75 years old Counseling smokers to quit Counseling about proper diet Tetanus immunization every 10 years

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Category Items Hepatitis B vaccine for infants Estrogen replacement for asymptomatic 60 year old women Aspirin to prevent MI in asymptomatic men over 50 years old

Your Health and Do you consider your health to be: (scale: 1 = excellent, 5 = poor) Health Habits How often do you wear seat belts? (scale: 1 = never, 5 = always) How often do you eat the right foods? (scale: 1 = never, 5 = always) How often are you bothered by stress and hassles at home or work? (scale: 1 = never, 5 = always) Would you describe your weight as (scale: 1 = extremely over, 5 = just right) How often do you exercise for at least 20 minutes (scale: 1 = occasionally, 5 = >3 times/week) What is your average alcohol consumption? (scale: 1 = don’t drink, ≤1 drink/day, 5 = >3 drinks/day) What are your smoking habits? (scale: 1 = never smoked, 3 = quit, 5 = current smoker)

Decision Making Rate the following factors as to their importance in your decision to about Screening provide preventive screening tests to asymptomatic patients: (scale: 1 = unimportant, 5 = very important) The patient’s health status and medical conditions The patient’s risk for the disease to be screened The patient’s interest in screening The availability of effective methods of treatment for the disease Whether the disease has an asymptomatic period during which detection and treatment significantly reduces morbidity or mortality The availability of tests acceptable to patients The cost of the screening test The prevalence of the disease Concern about being sued for failure to diagnose My professional experience My personal or family experience with screening My personal or family experience with the disease The opinion of professional colleagues Recommendations of nationally-recognized experts Protocols at my practice

Competing How much do the following demands compete for your time and Demands energy? (scale: 1 = none, 3 = some, 5 = a lot)

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Category Items Direct patient care in the office Direct patient care in other sites Charting medical records Follow-up of abnormal lab tests and x-rays Patient phone calls Organizing referrals Insurance related forms and phone calls Office personnel issues After hour emergencies Seeking information needed for patient care Teaching Other

Practice Guidelines Indicate your level of familiarity with the following guidelines: (scale: 1 = unaware, 2 = heard of it, 3 = have read some, 4 = a little familiar, 5 = very familiar) U.S. Preventive Services Task Force report American Cancer Society recommendations National Cholesterol Education Program guidelines American Diabetes Association guidelines National Heart Lung and Blood Institute Consensus Conference on Asthma Agency for Health Care Policy and Research (presently named the Agency for Healthcare Research and Quality) guidelines for the management of: Depression Otitis media Congestive heart failure

Indicate your feelings about practice guidelines: (scale: 1 = not at all, 3 = some, 5 = a lot) They can help me keep up to date They are practical aids to patient care They decrease malpractice risk They are applicable to real world family practice

How useful do you find advance directives (e.g., living wills or power of attorney) in understanding your patients’ wishes? (scale: 1 = not at all, 3 = somewhat, 5 = a lot)

Domains of The following questions address theoretical attributes of primary Primary Care care. Rate how well these apply in the real world of your practice: (scale: 1 = strongly disagree, 3 = neutral, 5 = strongly agree)

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Category Items My patients are aware of the comprehensive range of medical problems I am trained to address I know about medical care my patients receive at other places It is my role to coordinate all the health care my patients receive My office has very effective mechanisms to ensure continuity of care for my patients The information loop between the specialists my patients see and myself is not as complete as I would like I don’t always communicate with my patients as well as I could I believe that the length of time I have been seeing a patient affects the quality of care I can provide I know a lot about my patients’ communities I am aware of the lifestyles and values of almost all of my patients I am the primary source of care for all of my patients

RBRVS These questions test the validity of the Resource Based Relative Value System (RVRBS) method of billing patient visits. The RVRBS method is used to determine the Medicare reimbursement for different specialties, but its validity has never been determined compared to direct observation of real world patient care. Answer these questions about 3 hypothetical patients from the Harvard RBRVS Study and 3 of the patients you saw today.

A. Service Time For the following office visits, estimate the average amount of time you spend with the patient. In addition, estimate the total time you spend performing services for the patient related to the visit. The total time includes the time during and before and after the service, including time spent reviewing records and results of studies, arranging for other services, telephone calls about the visit, and discussions with other professionals. a) Follow-up visit with 55 year old male for management of hypertension, mild fatigue, on beta blockers/thiazide regimen b) Office visit, established patient, 6 year old child with sore throat and headache c) Routine periodic gynecologic exam, by primary care physician, 24 year old established patient, without complaint d) through f) Physician’s choice of three patients that day

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Category Items For patients d through f, how well do you know this patient? (scale: 1 = not well, 5 = very well)

B. Service Work Next, we’d like you to rate how much work is involved in caring for different types of patients. The reference case for all the ratings will be the work during a follow-up visit of a 55 year old male for management of hypertension, mild fatigue, on beta blocker/thiazide regimen. Call this 100. Now with the reference case as 100, compare it to each of the other patient visits. If a visit is twice as much work, then your answer would be 200. A service half as much work would be 50, five times as much work would be 500, and so on. In your estimation of work, consider the time it takes to perform the service and 3 dimensions that reflect the intensity of that time – technical skills and physical effort, mental effort and judgment, and stress. For each service, estimate the work during the visit and the total service work. a) Follow-up visit with 55 year old male for management of hypertension, mild fatigue, on beta blockers/thiazide regimen b) Office visit, established patient, 6 year old child with sore throat and headache c) Routine periodic gynecologic exam, by primary care physician, 24 year old established patient, without complaint d) through f) Physician’s patients that day from item A

Appendix C

Human Subjects Oversight

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Protocol 08-756 is a Level 1 and does not require an annual review (Laurie Kiehl, January 18, 2011).