Abstract
OBJECTIVE: To assess whether primary care performance of low-income women’s primary care delivery sites is associated with the strength of their relationships with their physicians.
DESIGN: Random-digit-dial and targeted household telephone survey of a population-based sample.
SETTING: Washington, D.C. census tracts with ≥30% of households below 200% of federal poverty threshold.
PARTICIPANTS: Women over age 40 (N=1,205), 82% of whom were African American.
MEASUREMENTS AND MAIN RESULTS: The response rate was 85%. Primary care performance was assessed using women’s ratings of their systems’ accessibility (organizational, geographic, and financial), continuity, comprehensiveness, and coordination. Respondents’ ratings of trust in their physicians, communication with their physicians, and compassion shown by their physicians were used to operationalize the patient-physician relationship. Controlling for population and insurance characteristics, 4 primary care features were positively associated with women’s trust in and communication with their physicians: continuity with a single clinician, organizational accessibility of the practice, comprehensive care, and coordination of specialty care services. Better organizational access, but not geographic or financial access, was associated with greater levels of trust, compassion, and communication (odds ratios [ORs], 3.2, 7.4, and 6.9, respectively; P≤.01). Women who rated highest their doctor’s ability to take care of all of their health care needs (highest level of comprehensiveness) had 11 times the odds of trusting their physician (P≤.01) and 6 times the odds of finding their physicians compassionate and communicative (P≤.01), compared to those with the lowest level of comprehensiveness.
CONCLUSIONS: Primary care delivery sites organized to be more accessible, to link patients with the same clinician for their visits, to provide for all of a woman’s health care needs, and to coordinate specialty care services are associated with stronger relationships between low-income women and their physicians. Primary care systems that fail to emphasize these features of primary care may jeopardize the clinician-patient relationship and indirectly the quality of care and health outcomes.
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References
Szasz TS, Hollander MH. A contribution to the philosophy of medicine: the basic models of the doctor-patient relationship. Arch Intern Med. 1956;97:585–92.
Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992;267:2221–6.
Quill TE. Partnerships in patient care. A contractual approach. Ann Intern Med. 1983;98:228–34.
Thom DH, Campbell B. Patient-physician trust: an exploratory study. J Fam Pract. 1997;44:169–76.
Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA. 1995;273:323–9.
Safran DG, Kosinski M, Tarlov AR, et al. Primary Care Assessment Survey. Tests of data quality and measurement performance. Med Care. 1998;36:728–39.
Hulka BS, Kupper LL, Cassel JC, Babineau RA. Practice characteristics and quality of primary medical care: the doctor-patient relationship. Med Care. 1975;10:808–20.
Flocke S. Measuring attributes of primary care: development of a new instrument. J Fam Pract. 1997;45:64–74.
O’Malley AS, Forrest CB, O’Malley PG. Low-income women’s prioirites for primary care. J Fam Pract. 2000;49:141–6.
Goold SD, Lipkin M Jr. The doctor-patient relationship. J Gen Intern Med. 1999; 14:26S-32S.
O’Malley AS, Forrest CB, Mandelblatt J. Adherence of low-income women to cancer screening recommendations: the roles of primary care. Health insurance and HMOs. J Gen Intern Med. In press.
Fletcher RH, O’Malley MS, Earp JA, et al. Patients’ priorities for medical care. Med Care. 1983;2:234–42.
Grumbach K, Selby JV, Damberg C, et al. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. JAMA. 1999;282:261–6.
Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213–20.
Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract. 1991;32:175–81.
Roter DL, Hall JA, Katz NR. Relationship between physicians’ behaviors and analogue patients’ satisfaction, recall and impressions. Med Care. 1987;25:437–51.
Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27:110S-27S.
Starfield B, Wray C, Hess K, Gross R, Birk PS, D’Lugoff BC. The influence of patient-practitioner agreement on outcome of care. Am J Public Health. 1981;71:127–31.
Stewart MA, McWhinney IR, Buck CW. The doctor-patient relationship and its effect upon outcome. JR Coll Gen Pract. 1979;29:77–81.
Bass MI, Buck C, Turner L, Dickie G, Pratt G, Robinson HC. The physician’s actions and the outcome of illness in family practice. J Fam Pract. 1986;23:43–7.
The Headache Study Group of the University of Western Ontario. The predictors of outcome in headache patients presenting to family physicians: a one-year prospective study. Headache. 1986;26:285–94.
Greenfield S, Kaplan SH, Ware JE Jr, Yano EM, Frank HJ. Patients’ participation in medical care: effects on blood sugar and quality of life in diabetes. J Gen Intern Med. 1988;3:448–57.
DiMatteo MR. Enhancing patient adherence to medical recommendations. JAMA. 1994;271:79–83.
Charney E, Bynum R, Eldridge D, et al. How well do patients take oral penicillin? A collaborative study in private practice. Pediatrics. 1967;40:188–95.
Becker MH, Drachman RH, Kirscht JP. A new approach to explaining sick-role behavior in low-income populations. Am J Public Health. 1974;64:205–16.
Francis V, Korsch BM, Morris MJ. Gaps in doctor-patient communication: patients’ response to medical advice. New Engl J Med. 1969;280:535–40.
Eraker SA, Kirscht JP, Becker MH. Understanding and improving patient compliance. Ann Intern Med. 1984;100:258–68.
Blumenthal D, Mort E, Edwards J. The efficacy of primary care for vulnerable population groups. Health Serv Res. 1995;30:253–73.
Millis JS. The Millis Commission Report. Report of the Citizens Commission on Graduate Medical Education. Chicago Ill: American Medical Association; 1966.
Institute of Medicine. Primary Care: America’s Health in a New Era. Washington, D.C.: National Academy of Sciences; 1996.
Alpert J, Charney E. The Education of Physicians for Primary Care. Washington, D.C.: U.S. Department of Health Education, and Welfare; 1973.
Starfield B. Primary Care. Balancing Health Needs, Services and Technology. New York: Oxford University Press; 1998.
Safran DG, Tarlov AR, Rogers WH. Primary care performance in fee-for-service and prepaid health care systems. Results from the Medical Outcomes Study. JAMA. 1994;271:1579–86.
HHS. The 1999 HHS Poverty Guidelines. Federal Register, Vol. 64, No. 52, March 18, 1999, pp. 13428–30. http://aspe.hhs.gov/poverty/99poverty.htm.
National Health Interview Survey. (NHIS). National Center for Health Statistics. www.cdc.gov/nchs/nhis.htm.
Forrest CB, Starfield B. Entry into primary care and continuity: the effects of access. Am J Public Health. 1998;9:1330–6.
Hosmer DW, Lemeshow S. Applied Logistic Regression. New York: John Wiley and Sons; 1989.
Kahn HA, Sempos CT. Statistical Methods in Epidemiology. New York: Oxford University Press; 1989.
Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA. 1998;280:1690–1.
Current Population Survey, March 1999 CPS data. Annual Demographic Survey (March CPS Supplement) Methodology and Documentation. Washington, D.C.: U.S. Bureau of the Census; 1999.
Murphy J, Chang H, Montgomery JE, Rogers WH, Safran DG. The quality of physician-patient relationships. Patients’ experiences 1996–1999. J Fam Pract. 2001;2:123–9.
Scott RA, Aiker LH, Mechanic D, Moravcsik J. Organizational aspects of caring. Milbank Q. 1995;73:77–95.
Lee Y, Kasper JD. Assessment of medical care by elderly people: general satisfaction and physician quality. Health Serv Res. 1998;32:741–57.
Hargraves JL. Patients Concerned About Insurer Influences. Data Bulletin Results from HSC Research. Center for Studying Health Systems Change and the Robert Wood Johnson Foundation; June 2000, Number 17.
Kasteller J, Kane RL, Olsen D. Issues underlying prevalence of doctor-shopping behavior. J Health Soc Behav. 1975;17:328–39.
Mechanic D, Weiss N, Cleary PD. The growth of HMOs: issues of enrollment and disenrollment. Med Care. 1983;21:338–47.
Marquis MS, Davies AR, Ware JE Jr. Patient satisfaction and change in medical care provider: a longitudinal study. Med Care. 1983;21:821–9.
Safran DG, Montgomery JE, Chang H, Murphy J, Rogers WH. Switching doctors: predictors of voluntary disenrollment from a primary physician’s practice. J Fam Pract. 2001;2:130–6.
Schmittdiel J, Selby JV, Grumbach K, Quesenberry CP Jr. Choice of a personal physician and patient satisfaction in a health maintenance organization. JAMA. 1997;278:1596–9.
Love MM, Mainous AG III, Talbert JC, Hager GL. Continuity of care and the physician-patient relationship: the importance of continuity for adult patients with asthma. J Fam Pract. 2000;49:998–1004.
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This work was funded in part by DAMD 17-97-1-7131 from the U.S. Department of Army (ASO) and by NC1-RO3 CA83338-02 (ASO).
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O’Malley, A.S., Forrest, C.B. Beyond the examination room. J GEN INTERN MED 17, 66–74 (2002). https://doi.org/10.1046/j.1525-1497.2002.10338.x
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DOI: https://doi.org/10.1046/j.1525-1497.2002.10338.x