Are physicians’ attitudes of respect accurately perceived by patients and associated with more positive communication behaviors?

Abstract

Objective

To explore the domain of physician-reported respect for individual patients by investigating the following questions: How variable is physician-reported respect for patients? What patient characteristics are associated with greater physician-reported respect? Do patients accurately perceive levels of physician respect? Are there specific communication behaviors associated with physician-reported respect for patients?

Methods

We audiotaped 215 patient–physician encounters with 30 different physicians in primary care. After each encounter, the physician rated the level of respect that s/he had for that patient using the following item: “Compared to other patients, I have a great deal of respect for this patient” on a five-point scale between strongly agree and strongly disagree. Patients completed a post-visit questionnaire that included a parallel respect item: “This doctor has a great deal of respect for me.”

Audiotapes of the patient visits were analyzed using the Roter Interaction Analysis System (RIAS) to characterize communication behaviors. Outcome variables included four physician communication behaviors: information-giving, rapport-building, global affect, and verbal dominance. A linear mixed effects modeling approach that accounts for clustering of patients within physicians was used to compare varying levels of physician-reported respect for patients with physician communication behaviors and patient perceptions of being respected.

Results

: Physician-reported respect varied across patients. Physicians strongly agreed that they had a great deal of respect for 73 patients (34%), agreed for 96 patients (45%) and were either neutral or disagreed for 46 patients (21%). Physicians reported higher levels of respect for older patients and for patients they knew well. The level of respect that physicians reported for individual patients was not significantly associated with that patient's gender, race, education, or health status; was not associated with the physician's gender, race, or number of years in practice; and was not associated with race concordance between patient and physician.

While 45% of patients overestimated physician respect, 38% reported respect precisely as rated by the physician, and 16% underestimated physician respect (r = 0.18, p = 0.007). Those who were the least respected by their physician were the least likely to perceive themselves as being highly respected; only 36% of the least respected patients compared to 59% and 61% of the highly and moderately respected patients perceived themselves to be highly respected (p = 0.012). Compared with the least-respected patients, physicians were more affectively positive with highly respected patients (p = 0.034) and provided more information to highly and moderately respected patients (p = 0.018).

Conclusion

Physicians’ ratings of respect vary across patients and are primarily associated with familiarity rather than sociodemographic characteristics. Patients are able to perceive when they are respected by their physicians, although when they are not accurate, they tend to overestimate physician respect. Physicians who are more respectful towards particular patients provide more information and express more positive affect in visits with those patients.

Practice implications

Physician respectful attitudes may be important to target in improving communication with patients.

Introduction

While there is much written in the medical literature about the sorts of attitudes that physicians ought to have [1], [2], [3], there is little empirical data to assess whether physician attitudes are accurately perceived by patients or make a difference in patient care. There are at least two classes of physician attitudes which could plausibly influence healthcare quality: general attitudes towards patient care and attitudes towards particular patients. While a number of studies have addressed the former, many fewer have addressed the latter.

In terms of general attitudes towards patient care, for example, one study found that a measure of physician attitudes towards the psychosocial aspects of patient care, the Physician Belief Scale (PBS) [4], was related to visit communication with patients [5]. Among the 50 physicians studied, those with stronger psychosocial attitudes engaged in more explicitly emotional exchanges with their patients and used fewer closed-ended questions during their visits. These physicians were also judged to be more interested, dominant, and responsive by coders, suggesting greater animation and involvement in the interaction. Not only were physician attitudes related to physician communication, but patients of these physicians also used a distinct pattern of communication; they offered more psychosocial (and less biomedical) information to their physicians, were more emotionally expressive (i.e., expressed feelings, showed concern, and asked for reassurance) and were more engaged in the dialogue both verbally and non-verbally.

Other attitude measures have also been used to explore physicians’ psychosocial and patient-centered orientation to patient care. Krupat et al. developed the Patient–Practitioner Orientation Scale (PPOS) in a somewhat similar way to reflect the patient-centeredness of medical students and physicians [6]. In two studies using the PPOS found that physicians with patient-centered attitudes had patients with higher levels of trust and satisfaction [7], and that students with patient-centered attitudes were rated more highly by standardized patients on their ‘humanism’ performance [8].

In contrast to studies of physician attitudes towards patient care, the range of attitudes that a physician might have towards particular patients has been less well studied. An exception is a group of studies addressing liking in the physician–patient relationship [9], [10], [11], [12]. Findings from these studies suggest that both patients and physicians are similarly aware of how much each is liked by the other. While statistically significant, the correlation between the two is weak (r = 0.21, p < 0.001) indicating that both patients and physicians are more accurate than chance in their perceptions of how well they are liked, but that the predictions are not strong [11]. Nevertheless, patients who are better ‘liked’ by their physicians (as measured by physician self-report) are more satisfied with their care [9], [10], [11], [12] and less likely to have thought about changing doctors for as long as 1 year [11].

Both the literature on medical professionalism [13], [14], [15], [16] and the literature on cultural competence [17], [18], [19] hold that health professionals’ attitudes of respect for patients are fundamental to understanding and thinking about how patients should be treated. Despite the importance of respect, there has been little theoretical work to ground the concept, and considerable ambiguity in its possible interpretation. It is not clear how the theoretical ideal of respect is translated by health professionals into concrete attitudes and behaviors. Presumably, people can have very different ideas about what it means to respect a person. In the discourse of medical ethics, respect is commonly manifested by the protection of patient autonomy (for example, by providing information to patients about their treatment and involving them in making decisions about their care). A second perspective, largely appearing in the psychoanalytic literature, proposes unconditional positive regard as the appropriate manifestation of respect, in that it recognizes, accepts, and values patients as persons. While both unconditional positive regard and protecting and honoring patients’ autonomy can be considered observable expressions of respect, no studies have investigated the extent to which patients accurately perceive physician respect or how respect might be communicated in medical visits.

In the current study, we explore the domain of physician-reported respect for individual patients by investigating the following questions: How variable is physician-reported respect for patients? What patient characteristics are associated with greater physician-reported respect? Do patients accurately perceive levels of physician respect? Are there specific communication behaviors associated with physician-reported respect for patients?