ORIGINAL PAPER

Exploration of the relationship between continuity, trust in regular doctors and patient satisfaction with consultations with family doctors
Richard Baker1, Arch G. Mainous III2, Denis Pereira Gray3 and Margaret M. Love4
Clinical Governance Research & Development Unit, Department of General Practice & Primary Health Care, University of Leicester, UK, 2Department of Family Medicine, Medical University of South Carolina, Charleston, SC, USA, 3Institute of General Practice, School of Postgraduate Medicine and Health Sciences, University of Exeter, UK, 4Department of Family Practice, University of Kentucky, Lexington, KY, USA.
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Scand J Prim Health Care 2003;21:2732. ISSN 0281-3432 Objecti7e To determine the inuence of longitudinal continuity and trust in patients regular family doctors on patient satisfaction with consultations. Design Observational questionnaire study. Setting Three family practice centres in the USA and four general practices in the UK. Subjects 418 patients in the USA and 650 in the UK who were consulting family doctors. Main outcome measures A pre-consultation questionnaire sought information about the patients experience of continuity and trust in their regular doctor; a post-consultation questionnaire measured satisfaction with the consultation. Results 78.8% of patients rated seeing the same doctor every time they had a health problem as important or very important. Trust in

the regular doctor, consulting the regular doctor and country were the strongest predictors of satisfaction. Patients who had a high level of trust in their regular doctor and consulted that doctor had the highest levels of satisfaction with their consultations. Among patients with relatively low levels of trust in regular doctor, levels of satisfaction were similar whether or not they consulted their regular doctor. Conclusions Consulting the regular doctor, trust and satisfaction with consultations are associated, and patients who consult a doctor they trust report the highest levels of satisfaction with consultations. Key words: family practice, patient satisfaction, patient trust. Richard Baker, Clinical Go7ernance Research & De7elopment Unit, Department of General Practice & Primary Health Care, Uni7ersity of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK. E -mail: [email protected]

Trust has been dened as the expectation that institutions and professionals will act in ones interests (1). Patients trust in their doctors has seldom been researched (2), but recent events, such as the activities of the serial killer Harold Shipman, present a potential threat to trust (3). Although demonstration of the doctors trustworthiness through certication and regulation may sometimes be important to some patients (1), personal experience of the doctor is of more direct relevance to most patients, and therefore trust can be regarded as a feature of the relationship between doctor and patient (4). The relationship is important in patient satisfaction (5), and continuity of care plays a key role in this process. A longitudinal relationship between patients and doctors should lead to increased knowledge and promote interpersonal trust (6), but trust may itself inuence the duration of a patient doctor relationship. Longitudinal continuity of care has been associated with patient satisfaction (7), and patient trust increases with increased continuity (8), even though in primary care continuity has been declining (9). On the basis of this evidence it is possible to hypothesise that patients who consult a doctor they trust are

more likely to be satised with their consultation than those who consult a doctor in whom they have less trust, and that those who see their regular doctor would also be more satised. Other factors inuencing the relationship between longitudinal continuity, trust and satisfaction include patient age, sex, health, education, income, health problem and clinical outcome, and attributes of the doctor, such as communication style or skill in examining the patient. In addition, the structure of the healthcare system and patient expectations may inuence the relationship. In the UK, demand for primary care exceeds supply. In contrast, in the US, the

Patient satisfaction is known to increase if the patient consults a regular doctor, but the role played by trust is not clear.

When asking patients, satisfaction was highest among those who trusted their regular doctor and consulted that doctor. Among patients with low trust in their regular doctor, satisfaction did not increase if they had consulted the regular doctor.
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patient is more able to choose and change doctors and there is competition for patients (10). Since several factors can inuence patient trust, and trust in turn can inuence the doctor patient relationship, studies are needed to enable the development of more complete theories about the role of trust and how it can be maintained. Therefore, the aim of our study was to explore the relationships between longitudinal continuity of care, patient trust in their regular doctor and satisfaction with consultations, in the context of a comparison between patients seen in primary care in the US and the UK.

2. A second construct of continuity of care is the longitudinality of the relationship with the regular provider. The respondents were asked to assess the length of time they had been attending that provider (i.e. How long had you been seeing this doctor?). 3. An additional measure assessed if the doctor the patient was seeing that day was the doctor they usually see. A nal measure relating to continuity of care assessed the patients valuation of how important it was that they see the same doctor every time they have a health problem (1 = not important at all, 5 = very important). Trust. Interpersonal trust in the primary provider was measured by the Trust in Physician Scale (1,12). This scale consists of 11 Likert-type items; it has been shown to have reliability and validity and is distinct from patient satisfaction with the physician (13,14). The dimensions of trust included in the scale have been replicated as important in a qualitative study of patient physician trust (15). The scale is scored from 11 to 55, higher scores indicating greater trust in the doctor. Only individuals who completed all of the items in the trust scale had a score computed. Post -consultation questionnaire Patient satisfaction. Immediately after their consultation, patients were asked to complete the Consultation Satisfaction Questionnaire (CSQ) (16), which has been shown to be reliable and valid. It has four scales general satisfaction, professional aspects of care, depth of relationship and length of consultation (17). It has 18 questions, but 3 were omitted to reduce respondent burden, one from each scale except general satisfaction. Responses to each question were invited in a Likert 5-point response format (strongly agree to strongly disagree), and higher scale scores indicated higher satisfaction (0 = minimum, 100 = maximum satisfaction). Demographics Information was sought about the patients income and educational attainment. Income in the US was transformed from dollars to pounds using the exchange rate corresponding to time of completion of data collection (April, 2000) to allow for comparison between countries. Analysis Univariate descriptive statistics were initially computed. Pearsons correlations were computed between the satisfaction dimensions and the trust scale.

MATERIAL AND METHODS Design The US practices were a family medicine residency and faculty practice in Charleston, South Carolina, and a family medicine residency and faculty practice in Lexington, Kentucky. In the UK, they were three general practices (one solo, two group) in Leicester and a group practice in Exeter. Consecutively attending adults ( ] 18 years of age) were invited to take part in the study and given a two-part survey with questions to be completed before their consultation and others to be completed afterwards. The questionnaires were anonymous, and the study was approved by the research ethics committees or institutional review boards at each site. Pre -consultation questionnaire Access to care. Patients were asked whether they had a usual source of care. The questions included: Is there one particular place that you go if you are sick or need advice about your health? and Is there a regular doctor you usually see at this place? Subsequent questions about trust in the regular doctor were asked only of patients who indicated that they had a regular doctor. Continuity of care. Longitudinal continuity was assessed in three ways that emphasised related but differing constructs. 1. Many continuity measures assess the proportion of all consultations that were with the regular doctor in a dened period (6,11). This has been termed the usual provider continuity (UPC). Respondents were asked to report all the encounters they had had with the healthcare system in the past year (ambulatory visits, emergency department visits, hospital outpatients, hospital admissions, home visits) and how many were with their regular doctor.
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The trust scale scores were grouped into quartiles, and the mean satisfaction score for each quartile was calculated for patients who did and did not see their regular doctor at the consultations studied. Linear regressions with the four satisfaction subscales as the dependent variables were computed with seeing ones regular doctor, continuity of care, trust in regular doctor and country of residence, controlling for other patient factors that might inuence the patient physician relationship (age, sex, race, education, income, presence of a chronic disease, and number of ofce visits in the previous 12 months). Educational attainment was dichotomised as remaining in full-time education to at least 17 years of age or higher. Race was dichotomised into white or non-white.

Table II. Respondents reported level of access to and continuity of care, and level of trust in their regular doctor (n=1068). Access to care Is there one particular place that you usually go if you are sick or need advice about your health? (% yes = 94.2) Is there a regular doctor you usually see at this place? (% yes = 83.7) Continuity1 Is the doctor you are seeing today your regular doctor? (% yes = 74.9) Length of time with regular doctor (%) B1 year 13.6 12 years 21.1 35 years 18.4 610 years 17.5 \10 years 29.5 UPC Mean (SD) Trust Trust scale Mean (SD)
1

0.75 (0.28)

RESULTS Altogether 1068 patients entered the study: 650 from the UK and 418 from the US completed the pre- and

45.5 (6.0)

Data relate only to those patients who reported having a regular doctor (894).

Table I. Characteristics of the participating patients (n = 1068). Gender Male Female Age, years Mean (SD) Country UK US Income Less than 3,000 3,00014,999 15,000 or more Education 1516 years old prior to leaving school1 At least 17 years old prior to leaving school1 Higher education, teaching or nursing without degree1 First degree1 Higher degree1 Race Black White (not Hispanic) Hispanic Asian, Pacic Islander, or Asian British Have a chronic disease (% Yes) (% No) No. of ofce visits in the past year Mean (SD)
1

324 (33.9%) 632 (66.1%) 46.5 (15.9) 650 (60.9%) 418 (39.1%) 74 (9.0%) 432 (52.4%) 318 (38.6%) 328 (36.5%) 254 (28.3%) 132 (14.7%) 99 (11.0%) 85 (9.5%) 168 761 4 11 (17.8%) (80.6%) (0.4%) (1.2%)

341 (36.4%) 597 (63.6%) 5.4 (5.6)

(or equivalent).

post-consultation questionnaires (Table I). Less than 5% of data were missing on any variable; 83.7% of patients reported having a regular doctor, of whom three quarters were consulting that doctor (Table II); 842 (78.8%) patients rated seeing the same doctor every time they have a health problem as important or very important. Trust had a signicant moderate correlation with each of the dimensions of patient satisfaction ranging from r = 0.22 for length of visit to r = 0.59 for perceptions of professional care (Table III). No signicant difference was found between patients in the US and UK in trust in their regular doctor (8), although satisfaction was lower among patients attending the US providers. There was no difference in reported satisfaction between males and females. Satisfaction tended to be higher if patients saw their regular doctor (Table IV), but the condence intervals indicate that this was most consistent when the patient had a relatively high level of trust in their regular doctor. Levels of satisfaction were highest if patients had a high level of trust in their regular doctor and had consulted that doctor. There were no differences in satisfaction between patients who did or did not see their regular doctor among those reporting low trust in their regular doctor. In the multiple regressions on the satisfaction dimensions, the variables with the strongest independent relationships to general satisfaction were trust in the regular doctor, country of care and seeing the
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Table III. Correlations between pre-consultation Trust in Physician scale scores and post-consultation Consultation Satisfaction Questionnaire scale scores (n = 732 patients who reported having a regular doctor and completed all the satisfaction questions). Total sample Saw regular doctor Did not see regular doctor Trust 0.15 0.36 0.15 0.05 p 0.04 0.0001 0.04 0.52

Trust General satisfaction Satisfaction with professional care Satisfaction with depth of relationship Satisfaction with perceived length of consultation 0.45 0.59 0.49 0.22

p 0.0001 0.0001 0.0001 0.0001

Trust 0.53 0.66 0.57 0.26

p 0.0001 0.0001 0.0001 0.0001

Table IV. Mean (95% condence intervals) levels of satisfaction with consultations for individuals who saw or did not see their regular doctor at the consultation, related to the quartiles of trust in regular doctor (1 lowest and 4 highest quartiles). N = 732 (those patients who reported having a regular doctor and completed all satisfaction questions). Trust quartiles Regular n Gen sat (mean) 95% CI Depth (mean) 95% CI Pr. care (mean) 95% CI Perceived Length (mean) 95% CI 89 64.6 59.6, 69.6 55.9 51.1, 60.7 70.1 66.1, 74.1 55.1 50.0, 60.1 1 Not 57 65.3 60.3,70.3 50.1 44.4, 55.8 66.1 62.0, 70.1 53.9 47.6, 60.3 Regular 129 71.2 68.7, 73.6 63.7 60.5, 66.9 76.4 74.8, 78.1 55.3 51.1, 59.4 2 Not 63 66.5 62.0, 71.0 53.7 49.4, 58.0 72.8 69.5, 76.1 50.8 44.8, 56.8 Regular 172 78.2 75.7, 80.8 71.7 69.1, 74.4 83.0 81.2, 84.8 59.4 55.1, 63.6 3 Not 53 68.6 63.7, 73.5 57.7 51.3, 64.1 76.2 72.2, 80.3 49.1 43.0, 55.1 Regular 147 91.0 88.8, 93.2 86.7 84.3, 89.1 94.5 93.2, 95.8 72.3 67.6, 77.0 4 Not 22 76.3 65.3, 87.2 60.4 46.5, 74.4 84.8 77.9, 91.6 63.1 48.8, 77.3

Table V. Multiple regression with continuity, trust, country of residence and demographic variables on the four scales of the Consultation Satisfaction Questionnaire (n = 732). Variable General satisfaction Professional care Depth of relationship Beta 0.44 0.24 0.05 0.04 0.02 0.15 0.02 0.04 0.03 0.01 0.01 0.06 0.02 0.37 p-value 0.0001 0.0001 0.18 0.45 0.61 0.009 0.71 0.25 0.57 0.84 0.74 0.13 0.62 Length of consultation Beta 0.24 0.01 0.08 0.03 0.01 0.41 0.01 0.04 0.08 0.12 0.04 0.01 0.01 0.30 p-value 0.0001 0.79 0.054 0.55 0.79 0.0001 0.88 0.28 0.07 0.006 0.35 0.89 0.89

Beta Trust scale Saw regular doctor UPC Length of time with regular doctor Importance of seeing regular doctor US residence Age Sex Race Education Income Chronic disease No. of outpatient visits in 12 months R2 0.49 0.10 0.02 0.05 0.03 0.25 0.5 0.09 0.7 0.00 0.92 0.29 0.01 0.38

p-value 0.0001 0.0082 0.57 0.26 0.38 0.0001 0.23 0.01 0.12 0.96 0.02 0.44 0.86

Beta 0.59 0.14 0.04 0.12 0.05 0.14 0.10 0.02 0.00 0.00 0.03 0.03 0.00 0.44

p-value 0.0001 0.0002 0.33 0.007 0.16 0.008 0.01 0.62 0.97 0.99 0.39 0.48 0.98

regular doctor on the index visit (Table V). Similar ndings emerged from the regressions on professional care and depth of relationship, with trust in doctor, country and seeing the regular doctor on the index visit as the three strongest independent predictors. In
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the regression on satisfaction with the perceived length of the visit, the strongest independent predictors were trust, country of care and education, with a positive relationship between higher levels of education and satisfaction.

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DISCUSSION The limitations of our study should be noted. The ndings relate to consecutively consulting patients and we do not have information about the numbers or characteristics of those who did not respond. Furthermore, the patients in our samples cannot be assumed to be representative of all patients in the UK and US. Nevertheless, the levels of trust are similar to those reported in other studies using the trust in physician scale (13,18), and the levels of satisfaction are comparable to those in another study involving a random sample of patients (19). It is unlikely, therefore, that the patients in our study were particularly atypical. The data were based on self-reports, and although measures with demonstrated reliability and validity were used, some biases inherent in self-reports (e.g. recall, social desirability) may have affected the results. The study was observational, and cannot conrm a causative relationship between continuity, trust and satisfaction. However, the relationship between continuity, trust and satisfaction has seldom been investigated, and the ndings contribute to the development of a theory of trust in the doctor patient relationship and raise issues relevant to the planning of primary healthcare services. The strongest predictors of patient satisfaction with consultations were found to be trust in regular doctor, consulting the regular doctor and country of residence. Among patients who reported relatively low levels of trust in their regular doctor, satisfaction was similar whether or not they consulted their regular doctor. Continuity does not improve satisfaction unless the patient trusts the doctor. Patients who had high levels of trust in their regular doctor and saw that doctor had the highest level of satisfaction. Whether the patient was consulting their regular doctor was more important in explaining satisfaction than how long they had been attending their doctor, or the proportion of consultations in the past year with the regular doctor. These results suggest that new ways of providing care may inuence patient trust and satisfaction with consultations. For example, organisational developments such as 24-h nurse telephone access, walk-in centres, and substitution of doctors by nurses may restrict patients opportunities to develop relationships that include trust in their doctors, and this question should be addressed in evaluations of these services (20,21). With respect to a theory of trust, the ndings indicate that trust is inuenced by past experience of the doctor, and in turn inuences preferences for consulting the doctor again. The theory suggests that discontinuity reduces the opportunity for trust to develop, and also that when levels of trust are low,

discontinuity may be relatively acceptable. It is also important to note that trust cannot be regarded as the patients judgment on the technical competence of the doctor. Patients are not well placed to judge a doctors technical competence, but are better placed to judge interpersonal care and empathy. It is therefore logical when constructing measures of quality to include both technical and human outcomes. However good the human outcomes, there is an obligation for the medical profession, educators and health-service planners to ensure technical competence as well (22,23). ACKNOWLEDGEMENTS We thank the patients and practices that took part in the study, which was partly supported by a grant from the Burroughs Wellcome Fund. The Exeter Institute has received nancial support from the Fetzer Institute, USA, to research trust/continuity. REFERENCES
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