Abstract
Objective: To investigate GPs’ perceptions of consultation outcomes and to investigate the associations between these and outcomes perceived by the patients. Design: 25 GPs and 10 patients for each GP filled in a questionnaire about the outcome of the same consultation. The questions in the questionnaires were formulated from concepts found in preceding qualitative studies. Their answers were analysed and compared. Setting: GPs and patients from 16 group practices in Norrbotten, Sweden. Results: The GPs had the apprehension that their consultations would lead to cure/symptom relief in half of their consultations. They believed that their patients were satisfied up to 90% and that up to 75% had been reassured, understood more or could cope better. The GPs were satisfied themselves with up to 95% of the consultations, they enhanced their relationship to their patient up to 70%. Their affirmative concordance with their patients was high regarding satisfaction, intermediate regarding patient reassurance and patient understanding and lowest regarding cure/symptom relief.
Conclusion: The GPs’ were lacking in their ability to assess the patients’ increased understanding and the concordance between their own and the patients’ expectation of cure/symptom relief was low.
Introduction
Mutual understanding between physician and patient is essential for good quality of care (Citation1) as is also the patient-practitioner agreement about what is the core of the patient's problem (Citation2). How well do GPs’ perceptions of consultation outcomes agree with those of the patients?
Outcomes from GPs’ consultations have above all been evaluated with disease specific measures such as HbA1c and patient questionnaires on health, satisfaction, and enablement (Citation3). During the last decade quality of care has been evaluated through questionnaires where patients have been asked to assess outcome together with the structure and process of care, such as Europep (Citation4).
Lack of concordance between GPs and patients in their evaluations of consultation outcomes has been shown. In one study correlation between GPs’ and patients’ satisfaction was low, they were neither satisfied with the same things, nor with the same consultations (Citation5). In other studies weak or moderate correlation was found between GPs’ assessments of patient satisfaction and patient satisfaction evaluated with Consultation Satisfaction Questinnaire (CSQ) (Citation6,Citation7).
The background for this study was two different interview-studies performed with the intention of finding out how patients and GPs really experienced outcomes from their consultations in practice, paying interest to their different perspectives. Patients were interviewed within a week after their latest consultation about its outcomes (Citation8). GPs described, when asked, what they thought their recent consultations would lead to (Citation9).
Three types of differences between GPs’ and patients’ perceptions of outcomes were found. They used different concepts to describe outcomes, they could give different meaning to the concept used and they could experience the outcome of the consultation differently.
They used mostly the same but sometimes different concepts to describe outcomes: Patients and GPs both perceived that a consultation could lead to cure/symptom relief, reassurance, increased patient understanding and patient satisfaction. The patients also described outcome as confirmation and an outcome that had hitherto not been described, change in self-perception (Citation8,Citation9). The GPs alone described the patient outcomes coping and check-up of a disease or a risk factor (Citation9). The GPs, besides looking at the patients’ outcomes, also regarded a self-evaluation, relationship-building and the discovery of a need to change surgery routines as outcomes (Citation9).
Patients and GPs could give a different meaning to the same concept: Satisfaction for the patients was a feeling assigned to what had happened to them (Citation8), while the GPs both assessed the patient's satisfaction and referred satisfaction to their own success of achievement. Their self-evaluations were related to what they experienced as a collegial consensus about right and wrong (Citation9). Understanding was another concept that was given a somewhat different meaning. The patients meant that they had understood what they needed to know and increased their knowledge however, for the GPs patient understanding was believed to have increased if the patient had understood the doctor's words when given information. In literature understanding has also been used to describe mutual understanding; that GP and patient have understood each other (Citation10).
Patients and GPs can experience the outcome of the same consultation in different ways which was dealt with in this study. When comparing GPs’ and patients’ experiences of outcomes as they are in real life, it is necessary not to eradicate all these differences by using a common questionnaire, but rather to include them.
The consultations described in the interviews could have started with one problem but during the talk another more demanding problem took over. This change of problem focus is in accordance with the work of a ‘practitioner in action’ (Citation11). Therefore, the consultation outcomes were not related to the initial problem or expectations of the consultation.
The aim of this study was to examine how GPs experience consultation outcomes in quantitative measures and to compare GPs’ and patients’ perceptions of outcomes from the same consultations, using the outcome concepts found in the qualitative studies. Doing this there was not only an interest to look for similarities and differences but also to find out whether a certain experience of the GP could be experienced in another well-defined term by the patient.
Methods
25 GPs in Norrbotten, chosen with the help of a random table list, were asked to take part in the study. 7 of these could not participate and were replaced by the next seven on the list. The 25 GPs worked at 16 group practices. They were asked to invite and inform 10 consecutive patients each about participation in the study. All GPs in Norrbotten have both pre-booked and emergency patients, and by asking for consecutive patients we were sure to get a mixture.
The GPs were given oral and written information by the researcher (AA) and the patients were handed out oral and written information by the GP. Both GPs and patients were informed that they would be anonymous and that participation was voluntary. Children and non-autonomous patients were to be represented by their companion, but the few patients who did not speak Swedish were not to be recruited.
The patients left their completed questionnaires in a closed box at the reception desk, having been ensured that the GP would never see their answers. The questionnaires were coded so that the researchers could compare the GPs’ answers with the patients’.
The questions were formulated from the qualitative studies. The GPs’ and the patients’ own wording in everyday language was used to formulate statements, and . The concept coping was, however, initially conceptualized by the GPs as support. The questions were to be answered by yes/no/ I don't know. The ‘I don't know’ alternative was necessary so that the patients should not feel forced to choose an alternative when uncertain.
Table I. GPs' perceptions of consultation outcomes.
Table II. Patients, perceptions of consultation outcomes.
The questionnaire was piloted on 2 GPs and 20 patients and evaluated before the study was carried out.
Analyses
The GPs were chosen with the help of a random number table and simple statistics were performed in Microsoft Excel 2003 SP3. The testing of significance was made in Minitab 14.20 with χ2 test, or Fisher's exact test when appropriate. P < 0.02 was set as limit for significance testing. When comparing the similar questions for the GP and the patient we analysed only the answers from consultations where both had answered. Index of validity, Iv—a measure to compare an assessment of a phenomenon with another assessment of the same phenomenon—was also counted for these questions. When questions that were different for GPs and patients were compared the ‘don't know’ answers were removed.
The study was approved by the Regional Ethical Review Board in Umeå.
Results
Out of 250 questionnaires, 249 were received from the GPs and 245—one of which was blank—from the patients. Both GPs and patients had answered most of the questions; the maximal internal drop-out was 3% for patient reassurance.
The GPs were very positive, . In some questions uncertainty was great, especially about cure/symptom relief, enhancement of the relationship and about patient reassurance and coping.
Different degrees of concordance were found between the GPs and their patients on comparing their answers from the same consultations. The GPs’ perception of patient satisfaction was in agreement with the patients’ satisfaction to the rate of 84%, and GP and patient satisfaction corresponded to 89%. In 69% of the consultations the GP and the patient assessed patient reassurance similarly and the same went for increased patient understanding in 62% of the consultations. However, the belief in patient cure/symptom-relief was shared in only 51% of the consultations, and furthermore the patients believed in cure/symptom relief when the GP did not, or was uncertain, in 24% of all consultations .
Table III. Concordant and discordant answers when GP and patient answered similar questions after the same consultation.
When comparing the yes/no answers for the questions that were different for GPs and patients, we found a positive association between the GPs’ perceptions of the outcomes cure/symptom relief, reassurance, understanding and satisfaction and the patient's perception of increased understanding (P < 0.02). When we redid the calculations putting ‘yes’ against the combination of ‘no’ and ‘I don't know’ the same pattern of associations was seen with one exception—an association between the GPs’ relationship-building and change in the patients’ self-perception (P < 0.012).
Discussion
The GPs were very affirmative. They were mostly satisfied and believed the patients to be so as well, they had high expectations about the patients having been reassured, that they understood more and were able to cope better. They believed that half of the patients would be cured or relieved.
Concordance between GPs and their patients was highest regarding satisfaction, intermediate regarding reassurance and understanding and low regarding cure/symptom relief. There were statistically significant associations between the GP's belief in patient reassurance, understanding, coping and satisfaction and the patient's perception of increased understanding. No other clear connections were found.
Methods
A strength of the study was that the GPs were selected at random and that their patients were consecutive thus resulting in a variation of both GPs and patients. Furthermore the questions were formulated from the GPs’ and patients’ own words. The drop-out was very small. Different questions for GPs and patients, each derived from concepts found important in the real life situation of respective groups was also a strength. The concept check-up was not defined as a medical check-up, which made the question unclear for the GPs. Thus the answers to this question should be interpreted with care.
Ethnical and cultural differences can decrease the degree of mutual understanding between GP and patient (Citation1). Our study was performed in a culturally and ethnically homogenous context, but there were still obvious differences between GPs and patients.
The answer alternatives could have been graded. With the aim of investigating the answers on a coherent level and with the ambition to compare positive aspects with negative ones we chose to limit the alternatives to yes/no/I don't know. When questions that were different for GPs and patients were compared the ‘I don't know’ answers were removed, as they could mean different things when answering different questions; either they had no definite opinion or they did not understand the question. For cure/symptom relief the outcome was to occur in the future and, therefore, uncertainty was quite realistic.
We had not expected this amount of affirmative answers regarding satisfaction. In a review about patient satisfaction Hall has shown that a mean of 80% of the patients were satisfied (Citation12). The material was so skewed that it was impossible to come to any conclusions on a statistical basis from the few negative answers. To gain knowledge about the negative answers a larger study would have been necessary.
The concept support from the qualitative GP outcome study was described with the intention of getting patients to cope. Thus coping was asked for in this study. This was supported by the fact that in PEI, Patient Enablement Instrument, coping is being asked for (Citation13). The other questions were formulated from the words in the descriptions in the qualitative interviews.
Results
Concordance between GPs and patients was highest regarding satisfaction. In our study concordance both between GPs’ and patients’ own satisfaction, and their respective assessment of patient satisfaction was higher than in other studies (Citation5–7).
The GP and the patient were in agreement on enhanced patient understanding in only around half of the consultations. In our preceding qualitative patient study the patients emphasized the need for knowledge of what was happening in their bodies each after his/her prerequisites and adapted to his/her individual circumstances (Citation8). Correlations between understanding and patient satisfaction was shown in the preparatory work for the PEI instrument. Understanding has been shown to be important also in other studies (Citation14–17). Roter described that patients seldom reveal their explanatory models to the doctor. As these can be very different from the professional perspective of the doctor there is a great risk that the doctor will be unable to understand what the patient is really wondering about (Citation18). The low concordance for understanding suggests that the GP should not trust his/her own perception of patient understanding but rather ask actively about it.
Concordance was lowest regarding belief in cure/symptom relief, 38%. The patients were much more optimistic than their GPs even though among these answers the highest share of ‘I don't know answers’ was found. If the patients expect cure or symptom relief to a substantially higher degree than the GPs this could be a source of disappointment to both parties.
The hope of finding clear patterns between GPs’ and patients’ different concepts was frustrated.
Enhancing the doctor patient relationship is one of the corner-stones in the patient-centred clinical model (Citation10,Citation19). The GPs perceived that they had enhanced relationship in 70% of the consultations. The significance of the GPs’ enhancing of the relationship deserves further studies.
Understanding the patients’ world helps the GP to help his patients. He needs to know that patients often believe in cure/symptom relief where he himself holds this to be out of reach. A GP should be aware that he might not realize what the patient needs to understand. An understanding grounded on the patient's own premises is highly valued by patients. A GP also needs to know that a consultation can lead to a change in the patient's self-perception, enhancing his/her ability to accept the changes that illness and ageing will bring. To get an idea of the patient's possible perceptions and expectations of outcome it might be enough to ask them.
It is also important to realize that patients alone cannot evaluate the health care they get. Patients are bad at assessing doctors’ technical skills. Patients have been found to be satisfied with consultations where measures of good clinical practice were not fulfilled (Citation20,Citation21). GPs and patients have different points of departure when assessing consultation outcomes. Our study has shed light on such differences.
Conclusions
The GPs had the apprehension that their consultations would lead to cure/symptom relief in half of their consultations. They believed that their patients were satisfied up to 90% and that up to 75% had been reassured, understood more or could cope better.
The GPs were satisfied themselves with up to 95% of the consultations, they enhanced their relationship to their patient up to 70% and discovered to a certain degree a need to change surgery routines.
Their concordance with their patients was high regarding satisfaction, intermediate regarding patient reassurance and patient understanding and lowest regarding cure/symptom relief.
There was a positive association between when the GP was affirmative to patient cure/symptom relief, reassurance, understanding and satisfaction and when the patient had understood more.
The study pointed out two important areas where the GPs and their patients’ perceptions of outcomes were discordant. The GPs’ were lacking in their ability to assess the patients’ increased understanding and the concordance between their own and the patients’ expectation of cure/symptom relief was low.
Acknowledgements
The study received financial support from the FOU unit at Norrbotten County Council.
Declaration of interest: There are no conflicts of interest.
References
- Harmsen JA, Bernsen RM, Meeuwesen L, Pinto D, Bruijnzeels MA. Assessment of mutual understanding of physician patient encounters: Development and validation of a mutual understanding scale (MUS) in a multicultural general practice setting. Patient Educ Couns. 2005;59:171–81.
- Gabbay M, Shiels C, Bower P, Sibbald B, King M, Ward E. Patient-practitioner agreement: does it matter? Psychol Med 2003;33:241–51.
- Anden A, Andersson SO, Rudebeck CE. Concepts underlying outcome measures in studies of consultations in general practice. Scand J Prim Health Care 2006;24:218–23.
- Grol R, Wensing M, for the Europep Group. Patients evaluate general/family practice. The Europep instrument. Wonca. Nijmegen: Wonca/Equip; 2000.
- Winefield HR, Murrell TG, Clifford J. Process and outcomes in general practice consultations: Problems in defining high quality care. Soc Sci Med. 1995;41:969–75.
- Cannon B, Usherwood TP. General practice consultations— how well do doctors predict patient satisfaction? Aust Fam Physician 2007;36:185–6, 92.
- McKinstry B, Colthart I, Walker J. Can doctors predict patients’ satisfaction and enablement? A cross-sectional observational study. Fam Pract. 2006;23:240–5.
- Anden A, Andersson SO, Rudebeck CE. Satisfaction is not all—patients’ perceptions of outcome of general practice consultations, a qualitative study. BMC Fam Pract. 2005;6:43.
- Anden A, Andersson SO, Rudebeck CE. To make a difference—how GPs conceive consultation outcomes. A phenom-enographic study. BMC Fam Pract. 2009;10:4.
- Stewart M. Patient-centered medicine. Abdington, USA; 2003. 11.
- Schön D. The reflective practitioner. How professionals think in action. Books NYB. New York: Aldershot: Arena; 1983.
- Hall JA, Dornan MC. Meta-analysis of satisfaction with medical care: Description of research domain and analysis of overall satisfaction levels. Soc Sci Med. 1988;27:637–44.
- Howie JG, Heaney DJ, Maxwell M, Walker JJ. A comparison of a patient enablement instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations. Fam Pract. 1998;15:165–71.
- Grol R, Wensing M, Mainz J, Ferreira P, Hearnshaw H, Hjortdahl P, . Patients’ priorities with respect to general practice care: An international comparison. European Task Force on Patient Evaluations of General Practice (EUROPEP). Fam Pract. 1999;16:4–11.
- Coulter A, Elwyn G. What do patients want from high-quality general practice and how do we involve them in improvement? Br J Gen Pract 2002;52 Suppl.:S22–6.
- van den Brink-Muinen A, Verhaak PF, Bensing JM, Bahrs O, Deveugele M, Gask L, . Doctor–patient communication in different European health care systems: relevance and performance from the patients’ perspective. Patient Educ Couns. 2000;39:115–27.
- Halling A, Berglund J. Concordance between elderly patients’ understanding of and their primary healthcare physician's diagnosis of heart failure. Scand J Prim Health Care. 2006;24:110–4.
- Roter D HJ. Doctors Talking with patients/patients talking with doctors. Westport: Auburn House; 1992.
- McWhinney IR. A textbook of family medicine. Second ed. New York: Oxford University Press; 1997.
- Chang JT, Hays RD, Shekelle PG, MacLean CH, Solomon DH, Reuben DB, . Patients’ global ratings of their health care are not associated with the technical quality of their care. Ann Intern Med. 2006;144:665–72.
- Rao M, Clarke A, Sanderson C, Hammersley R. Patients’ own assessments of quality of primary care compared with objective records based measures of technical quality of care: Cross sectional study. BMJ 2006;333:19.