Soc. Sci. & Med. Vol. 10. p p 20 to 32. Pergamon Press 1976. Printed in Grea! Britain.
PHYSICIAN ROLE PERFORMANCE AND PATIENT SATISFACTION DONALD E. LARSEN* Faculty of Medicine, The University of Calgary, Calgary, Alberta, Canada T2N 1N4 and IRVING ROOTMAN Non-Medical Use of Drugs Directorate, Health and Welfare Canada, Ottawa, Canada Abstract--This study tests the assumption that the overall level of a patient's satisfaction with medical services is influenced by the degree to which a physician's perceived role performance meets the patient's expectations. The data are taken from a survey of the public's expectations and perceptions of primary care physicians, which was based on a probability sample of 907 adults in a Canadian city. The findings strongly support the assumption•
ible on the basis of both practice and theory, it has not been tested systematically. The proposition, nevertheless, is commonly incorporated in analytical descriptions of physician-patient interaction, as illustrated by Mechanic's observations: "The patient, when he visits a physician, comes with an image of the physician's role and how it should be performed. This image reflects the societal definition of the physician's role, and sub-cultural expectations, as well as the conceptions formed by the patient through prior experience or from hearing about experiences of other people. It is within this frame of reference that the patient attempts to evaluate the professional qualifications and capabilities of the d o c t o r . . . The compatibility of patient expectations and the physician's performance.., has important implications for the success of the relationship Patient complaints about the physician may or may not attest to his competence, but they usually reflect a serious failure to fulfill expectations in some important way. Whether it be the patient who expects the physician to take a hand in his problem and tell him how to live, or the patient who insists that the doctor give him a prescription, the failure to conform to expectations is likely to raise doubts as to the doctor's adequacy and helpfulness" [13: 163,164].
Social scientists have had a long-standing analytical interest in the roles of the physician and patient and their mutual relationship [1-3]. One dimension of this relationship that is currently of interest to both researchers and health professionals is patients' satisfactions and dissatisfactions with medical services. This interest stems from the realization that patient satisfaction is a potentially important factor in health care in that it may influence whether or not a patient seeks medical help, whether the patient complies with a therapeutic regimen and whether the patient maintains a continuing relationship with a physician [4,5]. The attitudes of patients toward physicians and health services are also of interest to those who are studying the growth of consumerism as a social movement in the delivery of health services, as illustrated by the inclusion of citizens on governing boards of local health centers and by efforts to protect patients' interests by means of a "Patient's Bill of Rights" [6]. In their efforts to identify factors that influence the overall level of patient satisfaction, investigators have concentrated their analyses on sociodemographic and health-related characteristics of patients, such as their age, sex. social class, family size, health status and illness behavior [5,7-12]. Few studies have systematically and explicitly analyzed the impact of factors within the physician-patient relationship on a patient's overall level of satisfaction with medical care, A prominent study in this area has focused on actual interactions between a pediatrician and a patient's mother in one episode of medical care [4]. Among the communication barriers that were found to be associated with a mother's dissatisfaction with that care was the failure of the physician to satisfy her expectations that she would learn about the cause and nature of her child's disease.. In this paper, data are presented which test the basic assumption that a patient's overall satisfaction with medical services is influenced by the degree to which a physician's role performance lives up to the patient's expectations. While this proposition is plaus-
•
.
.
From a more general perspective, the assumption that a patient's general level of satisfaction is influenced by a physician's role performance is derived from role theory, as formulated, for example, by Gross et al. [14] and Sarbin and Allen [15]. Stated briefly, this theory holds that a role consists of a set of behavioral expectations, which contain a normative (ought or should) component, applied to an incumbent of a particular social position. In the medical care situation, for example, both the physician and patient hold expectations of their own and the other's role. However, both parties may not fully agree on definitions of their respective roles, nor may their behavior fully conform to each other's expectations. Because of the normative quality of role expectations, one consequence of non-conformity t9 the other's role expectations is some form of negative reaction, such as disapproval or dissatisfaction with the other's role enactment. The hypothesis that will be tested in this paper is
* Address during 1975-76:8 Meh'ille Road. Barnes, London S~'13 9R,I. U.K, 29
30
DONALD E. LARSEN and IRVING ROOTMAN
stated as follows: The more a physician's role performance meets a patient's expectations, the more satisfied the patient will be with the physician's services. METHOD
The data reported here are taken from a survey of the public's perceptions and expectations of primary care physicians. The study was conducted in Calgary, Alberta (population = 400000) at a time (1971) when a universal prepaid health insurance plan was in effect in the community, as elsewhere in Canada. A systematic random sample of I000 households was drawn from a master file of all residences in the city. One adult, who was either the head of the household or his/her spouse, was contacted; male and female respondents were selected at alternate addresses. Questionnaires were completed at 91% of the selected households (N = 907); 6~o of the sample refused to participate in the study; and 3°/0 were unable to participate for various personal reasons, such as inability to speak English. Compared to the 1971 Canadian Census, the completed sample is reasonably representative of the adult population in the community. There are 6~o more females in the sample than in the general population. Younger persons (under 35 yr) are under-represented in the sample by 7°/0, while middle-aged persons (35-54 years) are over-represented by that amount. The proportion of persons 55 yr and older in the sample is the same as in the general population. Presently-married persons are over-represented in the sample by 1I/o" o~. The questionnaire used in this study consisted entirely of pre-tested "fixed-choice" questions, of which two-thirds were self-administered by the respondent in the interviewer's presence. The questions focused on the respondents' personal and family characteristics, health status, illness behavior, health-related attitudes and knowledge, role expectations of their personal physician and perceptions of their own physician's role performance. The questions about a physician's role covered a wide variety of clinical, professional and administrative behavior or activities. The independent variable in this study is called "physician conformity", which refers to the degree to which a physician's perceived role behavior conforms to an individual's expectations of the physician. This variable was measured by comparing a respondent's answers to a set of "role expectation" items with an identical set of "role performance" items and then calculating their degree of correspondence. More specifically, for any item of behavior, "physician conformity" can empirically occur in one of two ways: If the respondent believes that his or her physician .should engage in behavior X and the physician reportedly behaves that way, or if the respondent believes that the physician should not engage in behavior X and the physician does not do so. On the other hand, ~'non-conformity" exists when the physician's behavior is opposite to the respondent's expectation. A "'physician conformity" index was calculated for each respondent on the basis of replies to 18 questionnaire items. These items referred to relatively concrete behavior or activities related to a physician's manage-
Table 1. Physician role behavior Patient illtnlagellletl[
Encourage you to take steps to preserve your health [e.g.. stop smoking, eat proper foods, exercise regularly). Give you a chance to tell him exactly what your trouble is. Explain exactly what your health problem is. Call you {or have his nurse call yout to find out how you are feeling if you have been ill. Avoid giving advice over the telephone. Be responsible for calling me in for a regular check-up. Be strict with me about following his advice or treatment. Let me know about the results of my laboratory tests. even if they are normal. Office management
Be available to you after hours and on weekends. Make house calls. Have special material [games, books) and furniture for children in his office. Have a comfortable waiting room. Have up-to-date equipment. See you within about 15 min of your arrival at his office. Require patients to make an appointment. Not have an unlisted home telephone number. Use an answering service. Be allowed to charge more than what is allowed by the Provincial insurance plan.
ment of health problems and to the operation of an office practice (see Table 1). The selection of items was based on pragmatic considerations: they were believed to be of concern to a general population and they were easily adapted to the conceptual aims and questionnaire format of the broader study. The items were interspersed among other items in both the ~'role expectation" and the "role performance" sections of the questionnaire. In the former section, for example, respondents were asked either to "agree" or "disagree" with this statement: "My doctor should be responsible for calling me in for a regular check-up." In the latter section, they were asked to reply either "yes", "no", or "don't know" to this question: "Does your doctor call you in for a regular check-up?" [-16]. Some respondents replied "don't know" to one or both of these questions and therefore "physician conformity" was indeterminate with respect to that specific behavior. It was decided arbitrarily that if this occurred on ten or more of the 18 items, a "physician conformity" index would not be calculated for a respondent. About 16°,o of the sample wag excluded for this reason, which includes 10°,o of the sample who had no regular physician to whom they turned for help and therefore could not supply information about the role performance of their physician. The next step in calculating the "physician conformity" index for respondents who provided complete information on ten or more items was to determine the proportion of items on which a physician's perceived behavior conforms to a respondent's expectations. The quotients thus obtained ranged from 0"19 to 1"00 for 765 respondents (Mean = 0.79; M e d i a n = 0 - 8 1 : S.D.=0-15). Finally, respondents were divided into three groups of approximately the
Physician role performance and patient satisfaction same size, representing relatively "'low" (index scores = 0.19 to 0.731, "medium" (0.74 to 0-86), and "high" (0.87 to 1'00/levels of physician conformity. The dependent variable in this study, "satisfaction with a physician's services", was measured by means of a one-item global self-rating of satisfaction. After answering a variety of questions about their physician's role performance, respondents were asked: "'Taking all things into consideration, how satisfied are you with the service your doctor provides?" The response categories were "very satisfied", "satisfied", "'not too satisfied", and "'not satisfied at all". Due to relatively low response frequencies, the latter two response categories were collapsed and designated as "low satisfaction", while the first two categories were called "'high" and "'medium" satisfaction, respectively. The reliability of this satisfaction scale was judged to be relatively high. A comparison was made between the self-rating score and replies to 15 other items in the physician role performance section which could express criticism of a physician (e.g. "My doctor seems rushed when he treats me"). Persons who rated their satisfaction more highly tended to express less criticism of their physician (7 = -0.60). In testing the basic relationship between level of satisfaction and degree of "physician conformity", each of the following variables was controlled: Sex: Age (15-34 yr, 35-54 yr, 55 yr and over); Marital status (married. not married): Education (less than high school graduate, high school graduate, some university or greater}: Occupation ("low": unskilled, semi-skilled, skilled, clerical and sales: "high": proprietors, managers, officials, professionals): Specialty of regular doctor [general practitioner, specialist): Frequency of contact with regular doctor in past year Inone, one or two times, three or more timesl: Number of different doctors seen in the past year mone. one or two, three or more~: Number of different regular doctors in the city (none, one, two or morel: Number of chronic conditions in the last 12 months (none, one or two, three or more): Respondent's health rating (very poor or fair, good, very goodl: Level of health knowledge on a 13 item scale (low. medium, high}: and Exposure to health topics in the mass media (low. medium, high). FINDINGS The data in Table 2 strongly support the hypothesis that the more a physician's role performance meets a patient's expectations, the more satisfied the patient will be with the physician's services (Z2= 118"27, 1' < 0-001). Moreover, the table shows that the strength of the association between patient satisfaction and physician conformity is substantial U = 0.546}. Additional analyses reveal that the relationship between phy,sician conformity and patient satisfaction remains statistically" significant and strong when each of the twelve test factors mentioned in the previous section is controlled. These data lend further support to the conclusion that an inherent link exists between a ph3sician's role performance and the level of a patient's satisfaction. The)' also suggest that the observed relationship holds for a number of different sub-groups in the population,
31
Table 2. Patient satisfaction with a physician's services and physician's conformity to a patient's expectations Satisfaction
Conformity Low
Medium
High
N
"~,
N
",,
N
",,
Low Medium High
42 I 17 72
18.2 50.6 31.2
12 98 157
4.5 36.7 58.8
3 62 194
1.2 23-9 74.9
Total
231
100-0
267
100.0
259
100.0
Z2 = 118.27, 4 df p < 0.001. ~, = 0.546. DISCUSSION Using survey data, this study has systematically examined the relationship between a patient's overall level of satisfaction with medical services and the degree to which a physician's perceived role performance corresponds to a patient's definition of that role. The fact that a strong statistical association was found between these variables lends support to the assumption that an important source of patient satisfaction is the degree to which a physician fulfills a patient's expectations. Although this general finding was anticipated on theoretical and practical grounds, it was not expected that the statistical relationship would remain consistently strong when each of a number of control factors was introduced in the statistical analysis. This indicates that the basic relationship between physician conformity and patient satisfaction very likely applies to a variety of socio-economic groups and to persons whose experiences and orientations related to health matters are quite varied. A possible limitation of this study is that the measure of a physician's role performance was based on replies to only 18 items of relatively specific role behavior, each of which was assumed to be of equal importance to a respondent in calculating an index of "physician conformity." Some aspects of a physidan's role performance may, of course, have more influence on a patient's overall satisfaction than others. Only further research can determine whether the findings of this study obtain when other areas or specific behavior associated with a physician's role are considered and the relative importance of these areas or behavior are taken into account. From a practical standpoint, the findings of this study raise the question of whether and how the gap between a patient's expectations and a physician's role performance can be reduced in the interest of improving a patient's satisfaction and thereby possibly improving the overall impact of medical care, as indicated in the introduction. Historically, patients have confronted this issue by "shopping around" for a physician who optimally fulfills their expectations. This strategy is feasible when there are sufficient physicians from whom to choose. Other strategies include changing a patient's expectations and, or alternatively, modifying a physiciata's behavior to conform more closely to a patient's expectations. These alternatives are possible. However. it should be borne in mind. as Freidson has noted [2]. that a certain
32
DONALD E. LARSEY and IRVING ROOTMAN
a m o u n t of conflict between physician a n d patient is inevitable, due to their different experiences a n d reference groups a n d it would be u n r e a s o n a b l e to expect a total absence of conflict between these two interacting role partners. Acknowledgement--The research on which this paper is based was supported by National Health Grants No, 609-7-134 and No. 609-22-12, made by the Department of National Health and Welfare. The authors gratefully acknowledge the helpful advice and assistance of Cecile Greene, Douglas Norris, Merlin Brinkerhoff. John Read, and Val MacMurray.
REFERENCES
1. Parsons T. The Social System. Glencoe, IL, Free Press, 1951. 2. Freidson E. Patients" Views of Medical Practice. Russell Sage Foundation, New York, 1961. ,,3. Bloom S. W. The Doctor and his Patient. Russell Sage Foundation, New York, 1963. 4. Korsch B. M., Gozzi E. K. and Francis V. Gaps in doctor-patient communication. Pediatrics 42~ 855, 1968.
5. Sussman M. R. et al. The Walking Patient. The Press of Western Reserve University, Cleveland, 1967.
6. Reeder L. G. The patient-client as a consumer: Some observations on the changing professional-client relationship, J. HIth Soc. Behav. 13, 406. 1972. 7. Koos E. L. The Health of Regiom'ille. Hafner, New York, 1954. 8. Mechanic D. The influences of mothers on their children's health attitudes and behavior. Pediatrics 33, 444, 1964. 9. Apostle D. and Oder F. Factors that influence the publie's view of medical care. J. Am. Med. Ass. 202, 140. 1967. 10. Cartwright A. Patients and their Doctors: A Study ~! General Practice. Routledge & Kegan Paul. London, 1967. I I. Hulka B. S.. Zyzanski S. J.. Casell J. C. and Thompson S. J, Satisfaction with medical care in a low income population. J. Chron. Dis. 24, 661. 1971. 12. National Analysts. A Study of Health Practices and Opinions. 400 Market Street, Philadelphia, PA. 13. Mechanic D. Medical Sociology. New York, Free Press, 1968. 14. Gross N., Mason W. L. and McEachern A. W. Explorations in Role Analysis. New York., Wiley, 1958. 15. Sarbin J. R. and Allen V. L. Role theory. In Handbook of Social Psychology (Edited by Lindzey G. and Aronson E.), Vol. 1, pp. 488-567. Addison-Wesley, Reading MA, 1968. 16. A copy of the questions and response categories is available from the authors.
PHYSICIAN ROLE PERFORMANCE AND PATIENT SATISFACTION DONALD E. LARSEN* Faculty of Medicine, The University of Calgary, Calgary, Alberta, Canada T2N 1N4 and IRVING ROOTMAN Non-Medical Use of Drugs Directorate, Health and Welfare Canada, Ottawa, Canada Abstract--This study tests the assumption that the overall level of a patient's satisfaction with medical services is influenced by the degree to which a physician's perceived role performance meets the patient's expectations. The data are taken from a survey of the public's expectations and perceptions of primary care physicians, which was based on a probability sample of 907 adults in a Canadian city. The findings strongly support the assumption•
ible on the basis of both practice and theory, it has not been tested systematically. The proposition, nevertheless, is commonly incorporated in analytical descriptions of physician-patient interaction, as illustrated by Mechanic's observations: "The patient, when he visits a physician, comes with an image of the physician's role and how it should be performed. This image reflects the societal definition of the physician's role, and sub-cultural expectations, as well as the conceptions formed by the patient through prior experience or from hearing about experiences of other people. It is within this frame of reference that the patient attempts to evaluate the professional qualifications and capabilities of the d o c t o r . . . The compatibility of patient expectations and the physician's performance.., has important implications for the success of the relationship Patient complaints about the physician may or may not attest to his competence, but they usually reflect a serious failure to fulfill expectations in some important way. Whether it be the patient who expects the physician to take a hand in his problem and tell him how to live, or the patient who insists that the doctor give him a prescription, the failure to conform to expectations is likely to raise doubts as to the doctor's adequacy and helpfulness" [13: 163,164].
Social scientists have had a long-standing analytical interest in the roles of the physician and patient and their mutual relationship [1-3]. One dimension of this relationship that is currently of interest to both researchers and health professionals is patients' satisfactions and dissatisfactions with medical services. This interest stems from the realization that patient satisfaction is a potentially important factor in health care in that it may influence whether or not a patient seeks medical help, whether the patient complies with a therapeutic regimen and whether the patient maintains a continuing relationship with a physician [4,5]. The attitudes of patients toward physicians and health services are also of interest to those who are studying the growth of consumerism as a social movement in the delivery of health services, as illustrated by the inclusion of citizens on governing boards of local health centers and by efforts to protect patients' interests by means of a "Patient's Bill of Rights" [6]. In their efforts to identify factors that influence the overall level of patient satisfaction, investigators have concentrated their analyses on sociodemographic and health-related characteristics of patients, such as their age, sex. social class, family size, health status and illness behavior [5,7-12]. Few studies have systematically and explicitly analyzed the impact of factors within the physician-patient relationship on a patient's overall level of satisfaction with medical care, A prominent study in this area has focused on actual interactions between a pediatrician and a patient's mother in one episode of medical care [4]. Among the communication barriers that were found to be associated with a mother's dissatisfaction with that care was the failure of the physician to satisfy her expectations that she would learn about the cause and nature of her child's disease.. In this paper, data are presented which test the basic assumption that a patient's overall satisfaction with medical services is influenced by the degree to which a physician's role performance lives up to the patient's expectations. While this proposition is plaus-
•
.
.
From a more general perspective, the assumption that a patient's general level of satisfaction is influenced by a physician's role performance is derived from role theory, as formulated, for example, by Gross et al. [14] and Sarbin and Allen [15]. Stated briefly, this theory holds that a role consists of a set of behavioral expectations, which contain a normative (ought or should) component, applied to an incumbent of a particular social position. In the medical care situation, for example, both the physician and patient hold expectations of their own and the other's role. However, both parties may not fully agree on definitions of their respective roles, nor may their behavior fully conform to each other's expectations. Because of the normative quality of role expectations, one consequence of non-conformity t9 the other's role expectations is some form of negative reaction, such as disapproval or dissatisfaction with the other's role enactment. The hypothesis that will be tested in this paper is
* Address during 1975-76:8 Meh'ille Road. Barnes, London S~'13 9R,I. U.K, 29
30
DONALD E. LARSEN and IRVING ROOTMAN
stated as follows: The more a physician's role performance meets a patient's expectations, the more satisfied the patient will be with the physician's services. METHOD
The data reported here are taken from a survey of the public's perceptions and expectations of primary care physicians. The study was conducted in Calgary, Alberta (population = 400000) at a time (1971) when a universal prepaid health insurance plan was in effect in the community, as elsewhere in Canada. A systematic random sample of I000 households was drawn from a master file of all residences in the city. One adult, who was either the head of the household or his/her spouse, was contacted; male and female respondents were selected at alternate addresses. Questionnaires were completed at 91% of the selected households (N = 907); 6~o of the sample refused to participate in the study; and 3°/0 were unable to participate for various personal reasons, such as inability to speak English. Compared to the 1971 Canadian Census, the completed sample is reasonably representative of the adult population in the community. There are 6~o more females in the sample than in the general population. Younger persons (under 35 yr) are under-represented in the sample by 7°/0, while middle-aged persons (35-54 years) are over-represented by that amount. The proportion of persons 55 yr and older in the sample is the same as in the general population. Presently-married persons are over-represented in the sample by 1I/o" o~. The questionnaire used in this study consisted entirely of pre-tested "fixed-choice" questions, of which two-thirds were self-administered by the respondent in the interviewer's presence. The questions focused on the respondents' personal and family characteristics, health status, illness behavior, health-related attitudes and knowledge, role expectations of their personal physician and perceptions of their own physician's role performance. The questions about a physician's role covered a wide variety of clinical, professional and administrative behavior or activities. The independent variable in this study is called "physician conformity", which refers to the degree to which a physician's perceived role behavior conforms to an individual's expectations of the physician. This variable was measured by comparing a respondent's answers to a set of "role expectation" items with an identical set of "role performance" items and then calculating their degree of correspondence. More specifically, for any item of behavior, "physician conformity" can empirically occur in one of two ways: If the respondent believes that his or her physician .should engage in behavior X and the physician reportedly behaves that way, or if the respondent believes that the physician should not engage in behavior X and the physician does not do so. On the other hand, ~'non-conformity" exists when the physician's behavior is opposite to the respondent's expectation. A "'physician conformity" index was calculated for each respondent on the basis of replies to 18 questionnaire items. These items referred to relatively concrete behavior or activities related to a physician's manage-
Table 1. Physician role behavior Patient illtnlagellletl[
Encourage you to take steps to preserve your health [e.g.. stop smoking, eat proper foods, exercise regularly). Give you a chance to tell him exactly what your trouble is. Explain exactly what your health problem is. Call you {or have his nurse call yout to find out how you are feeling if you have been ill. Avoid giving advice over the telephone. Be responsible for calling me in for a regular check-up. Be strict with me about following his advice or treatment. Let me know about the results of my laboratory tests. even if they are normal. Office management
Be available to you after hours and on weekends. Make house calls. Have special material [games, books) and furniture for children in his office. Have a comfortable waiting room. Have up-to-date equipment. See you within about 15 min of your arrival at his office. Require patients to make an appointment. Not have an unlisted home telephone number. Use an answering service. Be allowed to charge more than what is allowed by the Provincial insurance plan.
ment of health problems and to the operation of an office practice (see Table 1). The selection of items was based on pragmatic considerations: they were believed to be of concern to a general population and they were easily adapted to the conceptual aims and questionnaire format of the broader study. The items were interspersed among other items in both the ~'role expectation" and the "role performance" sections of the questionnaire. In the former section, for example, respondents were asked either to "agree" or "disagree" with this statement: "My doctor should be responsible for calling me in for a regular check-up." In the latter section, they were asked to reply either "yes", "no", or "don't know" to this question: "Does your doctor call you in for a regular check-up?" [-16]. Some respondents replied "don't know" to one or both of these questions and therefore "physician conformity" was indeterminate with respect to that specific behavior. It was decided arbitrarily that if this occurred on ten or more of the 18 items, a "physician conformity" index would not be calculated for a respondent. About 16°,o of the sample wag excluded for this reason, which includes 10°,o of the sample who had no regular physician to whom they turned for help and therefore could not supply information about the role performance of their physician. The next step in calculating the "physician conformity" index for respondents who provided complete information on ten or more items was to determine the proportion of items on which a physician's perceived behavior conforms to a respondent's expectations. The quotients thus obtained ranged from 0"19 to 1"00 for 765 respondents (Mean = 0.79; M e d i a n = 0 - 8 1 : S.D.=0-15). Finally, respondents were divided into three groups of approximately the
Physician role performance and patient satisfaction same size, representing relatively "'low" (index scores = 0.19 to 0.731, "medium" (0.74 to 0-86), and "high" (0.87 to 1'00/levels of physician conformity. The dependent variable in this study, "satisfaction with a physician's services", was measured by means of a one-item global self-rating of satisfaction. After answering a variety of questions about their physician's role performance, respondents were asked: "'Taking all things into consideration, how satisfied are you with the service your doctor provides?" The response categories were "very satisfied", "satisfied", "'not too satisfied", and "'not satisfied at all". Due to relatively low response frequencies, the latter two response categories were collapsed and designated as "low satisfaction", while the first two categories were called "'high" and "'medium" satisfaction, respectively. The reliability of this satisfaction scale was judged to be relatively high. A comparison was made between the self-rating score and replies to 15 other items in the physician role performance section which could express criticism of a physician (e.g. "My doctor seems rushed when he treats me"). Persons who rated their satisfaction more highly tended to express less criticism of their physician (7 = -0.60). In testing the basic relationship between level of satisfaction and degree of "physician conformity", each of the following variables was controlled: Sex: Age (15-34 yr, 35-54 yr, 55 yr and over); Marital status (married. not married): Education (less than high school graduate, high school graduate, some university or greater}: Occupation ("low": unskilled, semi-skilled, skilled, clerical and sales: "high": proprietors, managers, officials, professionals): Specialty of regular doctor [general practitioner, specialist): Frequency of contact with regular doctor in past year Inone, one or two times, three or more timesl: Number of different doctors seen in the past year mone. one or two, three or more~: Number of different regular doctors in the city (none, one, two or morel: Number of chronic conditions in the last 12 months (none, one or two, three or more): Respondent's health rating (very poor or fair, good, very goodl: Level of health knowledge on a 13 item scale (low. medium, high}: and Exposure to health topics in the mass media (low. medium, high). FINDINGS The data in Table 2 strongly support the hypothesis that the more a physician's role performance meets a patient's expectations, the more satisfied the patient will be with the physician's services (Z2= 118"27, 1' < 0-001). Moreover, the table shows that the strength of the association between patient satisfaction and physician conformity is substantial U = 0.546}. Additional analyses reveal that the relationship between phy,sician conformity and patient satisfaction remains statistically" significant and strong when each of the twelve test factors mentioned in the previous section is controlled. These data lend further support to the conclusion that an inherent link exists between a ph3sician's role performance and the level of a patient's satisfaction. The)' also suggest that the observed relationship holds for a number of different sub-groups in the population,
31
Table 2. Patient satisfaction with a physician's services and physician's conformity to a patient's expectations Satisfaction
Conformity Low
Medium
High
N
"~,
N
",,
N
",,
Low Medium High
42 I 17 72
18.2 50.6 31.2
12 98 157
4.5 36.7 58.8
3 62 194
1.2 23-9 74.9
Total
231
100-0
267
100.0
259
100.0
Z2 = 118.27, 4 df p < 0.001. ~, = 0.546. DISCUSSION Using survey data, this study has systematically examined the relationship between a patient's overall level of satisfaction with medical services and the degree to which a physician's perceived role performance corresponds to a patient's definition of that role. The fact that a strong statistical association was found between these variables lends support to the assumption that an important source of patient satisfaction is the degree to which a physician fulfills a patient's expectations. Although this general finding was anticipated on theoretical and practical grounds, it was not expected that the statistical relationship would remain consistently strong when each of a number of control factors was introduced in the statistical analysis. This indicates that the basic relationship between physician conformity and patient satisfaction very likely applies to a variety of socio-economic groups and to persons whose experiences and orientations related to health matters are quite varied. A possible limitation of this study is that the measure of a physician's role performance was based on replies to only 18 items of relatively specific role behavior, each of which was assumed to be of equal importance to a respondent in calculating an index of "physician conformity." Some aspects of a physidan's role performance may, of course, have more influence on a patient's overall satisfaction than others. Only further research can determine whether the findings of this study obtain when other areas or specific behavior associated with a physician's role are considered and the relative importance of these areas or behavior are taken into account. From a practical standpoint, the findings of this study raise the question of whether and how the gap between a patient's expectations and a physician's role performance can be reduced in the interest of improving a patient's satisfaction and thereby possibly improving the overall impact of medical care, as indicated in the introduction. Historically, patients have confronted this issue by "shopping around" for a physician who optimally fulfills their expectations. This strategy is feasible when there are sufficient physicians from whom to choose. Other strategies include changing a patient's expectations and, or alternatively, modifying a physiciata's behavior to conform more closely to a patient's expectations. These alternatives are possible. However. it should be borne in mind. as Freidson has noted [2]. that a certain
32
DONALD E. LARSEY and IRVING ROOTMAN
a m o u n t of conflict between physician a n d patient is inevitable, due to their different experiences a n d reference groups a n d it would be u n r e a s o n a b l e to expect a total absence of conflict between these two interacting role partners. Acknowledgement--The research on which this paper is based was supported by National Health Grants No, 609-7-134 and No. 609-22-12, made by the Department of National Health and Welfare. The authors gratefully acknowledge the helpful advice and assistance of Cecile Greene, Douglas Norris, Merlin Brinkerhoff. John Read, and Val MacMurray.
REFERENCES
1. Parsons T. The Social System. Glencoe, IL, Free Press, 1951. 2. Freidson E. Patients" Views of Medical Practice. Russell Sage Foundation, New York, 1961. ,,3. Bloom S. W. The Doctor and his Patient. Russell Sage Foundation, New York, 1963. 4. Korsch B. M., Gozzi E. K. and Francis V. Gaps in doctor-patient communication. Pediatrics 42~ 855, 1968.
5. Sussman M. R. et al. The Walking Patient. The Press of Western Reserve University, Cleveland, 1967.
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