Patients’ Commitment to Their Primary Physician and Why It Matters

Berry et al’s study should be commended for developing a conceptual model of the dynamics of physician-patient relationships, based on previous theory and research findings, and testing this model systematically. A key finding is that patients’ commitment is an essential and valuable element of the physician-patient relationship. The concept of commitment reflects patients’ willingness to invest effort in maintaining the relationship in the future. Other research has shown that the physician’s commitment to the patient is also important (1). An anticipation of ongoing interactions between individuals in the future is theorised to influence trust and cooperation (2), and the ‘future’ dimension of GP-patient relationships merits further research.

The findings of this study have implications for the provision of primary care in the UK. Recent changes in policy and in the organisation and delivery of primary care have lead to a shift away from ongoing doctor -patient relationships as the primary means of providing care. Under the new contract for general practice, patients no longer register with a specific general practitioner (GP), but with a practice (3). Most GPs no longer have 24- hour responsibility for their patients, with out-of-hours care generally being provided through deputising services. Modern primary care prioritises access and choice over continuity of care. All these changes mean that patients are increasingly likely to consult with unfamiliar health professionals, and indeed may no longer have the opportunity to develop a trusting relationship with their own personal GP. This study provides evidence that an ongoing relationship of trust between a patient and a doctor, to which the patient is committed to maintaining in the future, is associated with patient adherence to treatment and healthy eating behaviour. These findings should act as a wake-up call to policy-makers in the UK: not only do patients ‘love’ to have continuity of care from their own GP (4), but this study provides empirical evidence that such a relationship can have a beneficial impact on patients’ health- related behaviour. If GPs no longer have the opportunity to build up trusting relationships with patients over time, then the benefits gained through such relationships will be lost.

1. Schers H, van de Ven C, van den Hoogen H, Grol R, van den Bosch W. Patients’ needs for contact with their GP at the time of hospital admission and other life events. A quantitative and qualitative exploration. Ann Fam Med. 2004;2:462–468.

2. Axelrod, R. (1984). The evolution of cooperation. New York: Basic Books.

3. General Practitioners Committee and The NHS Confederation. (2003) Investing in General Practice: the New General Medical Services Contract. London: British Medical Association, 2003.

4. BBC (2008) One-stop clinics 'are the future'. 16 February 2008. http://news.bbc.co.uk/1/hi/health/7248132.stm

Competing interests:   None declared

In the article, Dr. Berry and his team identify many interesting points about the patient-physician relationship. From my perspective as a medical student, the concept of innovative delivery of health information stands out as a deficiency in present-day undergraduate medical education.

Suggestions listed by the authors include group appointments for patient education, physician and non-physician teams, and increased reimbursement of preventative and educational services. As a student of medicine, these progressive concepts appear worthwhile and focused on improving patient health. Innovation, however, is not what we are taught in medical school. Like any progressive skill, medical students learn and develop the process of interviewing a patient, performing a physical exam, and communicating an assessment and plan through repetition. These interactions are all one-on-one with a patient and, in testing settings, are timed where students are penalized if their patient encounter is too long.

In the Objective Structured Clinical Examination (OSCE) and the clinical skills portion of the US Medical Licensing Examination (Step II CS), medical students are limited to 10 to 15 minutes to complete a full patient consultation. This results in a testing environment that is more comparable to assembling widgets, than to a human interaction evaluating an important health issue. Although there are real consequences post- residency to taking “too long” to conduct patient appointments (delays to other patients, decreased practice revenue, etc.), teaching constricted or unilateral patient interview methods under timed circumstances may not be the best education model considering the information presented by Berry et al in the article. If the efforts suggested in this piece truly are effective, then these concepts should be taught from the beginning of a physician’s training so that they can be successfully implemented immediately following residency.

Like learning to ride a bike or speak a foreign language, we repeat what we practice over time. The patient interview, examination, and plan formation process is an acquired skill. If research, like this article, demonstrates that improved patient-physician relationships positively affect health outcomes, then a stronger emphasis should be placed on positive patient-student interactions than on 10 to 15 minute time limits.

Competing interests:   None declared

On behalf of all my co-authors, I thank you for your thoughtful comments. Below, we first respond to your comment about measuring the effect of physician-patient relationship on other outcomes, followed by the issue of “circular enquiry” that you raise.

At the outset, we agree that it is important to study the impact of patient-physician relationships on other outcomes such as patients’ compliance with medications. We also state in our paper (page 11) that future studies are warranted to both replicate and extend our findings to other patient related outcomes. Having said that, the focus of our study is to uncover the different aspects of physician patient relationships such as commitment and trust on an outcome that is important to patients, namely their (healthy) eating behavior. As stated in the paper (page 7), we chose to focus on healthy-eating behavior owing to its implications for risk of obesity and multiple diseases that stem from obesity. We not believe that this limits our findings of the physician-patient relationships. The findings that trust and commitment favorably influence patients’ health behaviors offer fine-grained insights on the physician patient relationships.

With respect to the possibility that the health outcome is more related to the underlying patient than the influence of the physician, we realize that it is important to control for patients’ intrinsic tendencies to eat healthy. The constant term in equation 1 indeed captures such patients’ intrinsic tendencies to eat healthy. Between the constant term, and the other patient-specific control variables (such as education, age and income), we believe that we are adequately controlling for the patients’ intrinsic propensity to eat healthy. The significant effects of patient-physician relationships on patients’ eating behavior, even after controlling for their intrinsic tendencies to eat healthy and other demographic characteristics, suggests that our findings are robust, and that they are not driven only by underlying patient behaviors.

Competing interests:   None declared

Berry et. al. concluded that the patient’s trust in the doctor and commitment to the doctor-patient relationship favorably influences patients’ health behaviors. This cross sectional survey actually shows that many doctor-patient attributes are related to each other. The potential for circular enquiry and confounding is substantial. There was no measure of physician’s views of the relationship and so the conclusion can only be based on the patient perception. Without an external measure of a health outcome, such as compliance with medication or weight it is difficult to make strong conclusions. What is clear is that the patient’s views are important to health behaviours.

It should not be surprising that the self perceived value of the doctor-patient relationship is important as other self-perception of other issues such as health and self-efficacy strongly predict outcomes. The expectations of the patient influences use of antibiotics [1] if not other medications.

So do physicians contribute to health outcomes of their patients. It is likely that ‘good’ patients will have ‘good’ relationships and the ‘good’ health outcome is more related to the underlying patient than the influence of the physician? Patient level characteristics, rather than physician characteristics or behaviour contribute to patient’s positive ratings of their physicians and thus positive health change [2]. This suggests that attributes of the patient drive compliance and health status more than the influence of their doctors.

Whatever the mechanism it is clear that the patients view of the relationship is crucial. The doctor’s behaviour does influence this view however. If doctors don't provide a positive, patient centered approach, patients will be less satisfied, less enabled, and may have greater symptom burden and higher rates of referral [3]. In addition there is very strong evidence that patterns of prescribing are driven by the physician controlling prescribing, regardless of patient level factors [4].

What is more important perhaps than trying to describe the quintessential element of the doctor patient relationship is to test efforts to improve patient outcomes through interventions aimed at the doctor patient relationship. These could be targeted to the doctor or the patient or to both. Communication skills and patient centeredness have been studied for some years [5].

Can the patient’s perception of the doctor be improved? And if so, is there measurable health benefit? This will be most important for those who are hard to reach, do not have a continuous relationship with a medical provider or live in areas where there is true constraint on choice of physicians, such as rural towns.

The body of literature is such that it is time to move on to well design studies examining interventions to impact the doctor-patient relationship.

1. Snell LM, Wilson RP, Oeffinger KC, Sargent C, Chen O, Corey KM. Patient and physician explanatory models for acute bronchitis. Journal of Family Practice. 2002 Dec;51(12):1035-40. 2. Franks P, Fiscella K, Shields CG, Meldrum SC, Duberstein P, Jerant AF, et al. Are Patients’ Ratings of Their Physicians Related to Health Outcomes? Ann Fam Med. 2005;3:229-34. DOI: 10.1370/afm.267. 3. Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, et al. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ. 2001 October 20, 2001;323(7318):908-11. 4. Davis P, Gribben B. Rational prescribing and interpractitioner variation. A multilevel approach. International Journal of Technology Assessment in Health Care. 1995;11(3):428-42. 5. Stewart M, Roter D, editors. Communicating with medical patients. Newbury Park: Sage Publications; 1898.

Competing interests:   None declared

Dr. Berry et al provide important evidence linking the intensity of the relationship commitment between patient and provider and healthy lifestyle choices. The primary care provider’s office is considered a critical link in the health information pathway. This study illustrates how the quality of the relationship in place at the time of the information transfer can affect the outcomes. Research that emphasizes the importance of this relationship in the uptake of healthy eating behaviors, specifically, is a key finding that will inform plans to address childhood obesity.

The article cites a study of the Diabetes Prevention Program reporting that “interventions are most effective when physicians are part of a larger team…” At Nemours, we are investing in a model of children’s health that creates that “larger team” with primary care as one of four major sectors of influence. We recognize that children’s health can be influenced by the environments found in their community, schools, child care centers and primary care offices. Messages about healthy eating and active living heard in the providers’ offices must be reinforced in the other sectors to achieve their greatest impact.

The article stresses the importance of finding methods that will help providers make counseling and education more available to their patients. Our research with primary care providers has found that providing education, on topics such as motivational interviewing, for the provider increases the likelihood that they will take the time to (1) assess if there is a problem, i.e. by measuring and classifying BMI and (2) provide appropriate counseling if necessary. At NHPS, we have also made patient education easier by offering providers a tool kit, available electronically and in hard copy, that includes materials for parents and children. An important next step is to assist providers in establishing a committed relationship with their patients to improve the uptake of the healthy behavior.

While the limitations of this study are well noted, the findings point to the need for further study in other populations, including pediatric populations. However, the basic findings of the article provide a substantial foundation upon which to build. Studies such as this are helpful in building and refining the evidence to support different models of intervention.

Nemours Health and Prevention Services (NHPS), a non-profit organization based in Newark, Delaware, works with families and community partners to help children grow up healthy. Our goal is to drive long-term changes in policies and practices that promote child health, and to leverage community strengths and resources to have the greatest impact on the most children. One of our initial areas of emphasis is childhood obesity prevention through promotion of 5-2-1-Almost None as a prescription for a healthier lifestyle.

Competing interests:   None declared

This article finally provides some evidence for the long theorized link between patients’ medical/lifestyle adherence and the relationship shared with their primary care physician. As with his previous work, Dr. Berry establishes the importance of not only medical competence and quality of care but also that of so called non-technical factors such as patient autonomy support in the form of respect and communication. The linkage established between patient trust and commitment to their physician with medical adherence and behavior modification is particularly striking considering the research that has shown that actual medical intervention has only a small impact on overall health. With genetics and modifiable behavior playing the largest role in overall health, this study would suggest that critical impact can be made by continued quality improvement in both technical and non-technical areas to strengthen patient trust and commitment to their physician.

While this study certainly has its limitations, many of which are detailed in the discussion, it is an important step forward to understanding some of the less tangible factors in health care.

Competing interests:   None declared

Thanks for your thoughtful comments. I certainly agree with your ideas about the criticality of a certain diagnosis such as heart disease, cancer, or strokes being a potential strong motivator that is independent of the doctor patient relationship when it comes to stimulating patient action towards healthy outcomes. I am not aware of literature that has examined that but I too have observed this in the clinical setting. I have also observed the sometimes very short lived duration of that motivation....for example the heart patient who resumes smoking and eating poorly within months of an acute event.

Your question about how to expedite a strong relationship in the critical care setting where you first meet a patient is important but not addressed in our study which looked at this relationship in the outpatient environment. I suspect there are many similarities in physician personal and communication qualities that lead to trust and better outcomes in both environments but would have to agree that this is a needed area of further study.

Similarly the economic question of what is the impact on health care consumption of a strong patient relationship also needs further study. We would surmise that a strong physician-patient relationship would reduce costs because the physician would know the patient better and be less likely to order unnecessary tests and other services and because the patient would be more likely to adhere to physician recommendations.

Submitted by Glen Couchman, MD, for the author team

Competing interests:   None declared