Patient-Doctor Depth-of-Relationship Scale: Development and Validation

Thank you to Mathew Ridd and his colleagues for providing us with a user-friendly, patient-focused and conceptually grounded measure of relational continuity and associated personal features of primary care including being 'accepted' by one's health care provider, being 'really cared for' and 'feeling relaxed' in doctor-patient consultations. Measures such as the Patient-Doctor Depth-of-Relationship Scale are especially important at a time when modernization policies and continued restructuring of primary care services may lead to what has been referred to as 'forced' or 'involuntary' discontinuity of care [1] with negative outcomes for service users particularly those with complex chronic conditions or problematic illness trajectories [2]. The authors acknowledge however, that the patient- doctor relationship is a complex concept and we agree. With this in mind, we suggest that further longitudinal, theoretically informed qualitative research which attempts to elucidate 'thick descriptions' of the multi-layered perspectives of what it means to be 'known' by a doctor and 'know' a doctor will be important in advancing existing quantitative measures of relationship continuity. Such research should explore relationship continuity in the context of the patient's journey or 'trajectory' through illness and care experiences. This will help us understand which aspects of 'being known' and 'knowing' are particularly valued in general practice consultations. Such insights may also help us unpack further the meanings and interpretations of previously cited concepts presented in the relational continuity of care literature, such as 'biographical knowledge' [3] and the conception of 'whole person knowledge' [4] and, from there, inform our understanding of any causal relationship between longitudinal continuity of care and depth of relationship.

Niamh A. Gallagher, niamhagallagher74@gmail.com, PhD Graduate and Honorary Research Fellow, Department of General Practice, National University of Ireland, Galway, Ireland.

Anne MacFarlane, anne.macfarlane@ul.ie, Professor of Primary Healthcare Research, Graduate Entry Medical School, University of Limerick, Limerick, Ireland.

1. Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity of care on the delivery of primary care. Journal of Family Practice 1997;45(2):129-135.

2. Gallagher N. The perspectives of patients with chronic illness on continuity of care in an out-of-hours general practice co-operative: a qualitative case study. Unpublished PhD thesis, 2010. National University of Ireland, Galway.

3. Fairhurst K, May C. Knowing patients and knowledge about patients: Evidence of modes of reasoning in the consultation? Family Practice 2001;18(5):501-505.

4. Kim TW, Samet JH, Cheng DM, Winter RM, Safran DG, Saitz R. Primary care quality and addiction severity: a prospective cohort study. Health Services Research 2007;42(4):755-772.

Competing interests:   None declared

We are grateful to Dr Uijen and colleagues for drawing our attention to their recently published instrument, the Nijmegen Continuity Questionnaire (NCQ), parts of which appear to address similar issues to that assessed by our Patient-Doctor Depth of Relationship instrument. We look forward to reading their (forthcoming?) review of existing continuity of care instruments, upon which it was based. We note that in contrast to our scale, the draft items in the NCQ were selected to "fit the Dutch situation"; and the instrument was piloted in a single patient population by getting general practitioner (GP) trainees to hand it out to patients "with one or more chronic diseases", who completed it at home (responders were more likely to be male). This could raise questions about the generalisability of their findings.

We agree with Dr Uijen and colleagues that the quality of longitudinal patient-doctor relationships probably depends on more than just shared knowledge, yet they chose to remove two items relating to trust and relationship in a draft version of the NCQ before undertaking principal component analysis, on the grounds that they were "not distinctive for measuring continuity of care". While work developing the NCQ suggests that patient-GP relationships comprise "knowledge" and "commitment" aspects, we do not yet know whether measuring the relationship on these two scales results in a great spread of data than that which we observed on a single "depth" scale.

Competing interests:   Authors of the paper.

McWhinney (1996)(1) stated that general practice is the "only discipline to define itself in terms of relationships - especially the doctor-patient relationship."

The key problem in researching the patient-doctor relationship is the inability to do prospective randomised controlled trials, and it may not be ethical to break existing relationships. Hence, although there is considerable evidence supporting the importance of this relationship, the evidence is essentially a series of associations. Although associations cannot prove causation, multiple associations can indicate probability of an effect.

Ridd et al. (2011) (2) state there is an "absence of research showing that continuity improves patient care ..." and that ... "research has consistently linked continuity of care with patient satisfaction, but evidence of its impact on patient outcomes is mixed". This is a doctor- orientated perspective. Patient satisfaction is itself a clinical outcome.

Continuity of care has been consistently associated with patient satisfaction,(3) better compliance, (4,5) more disclosure of symptoms, (6) the provision of more health education advice, (7) better care for people with diabetes, (8) less use of hospital services, (9,10) a positive 'context effect', (11) and the development of trust in medical generalists by patients.(12)

The evidence is not in equipoise. Most studies on continuity of care have either shown benefit for patients as above or found no significant effects. Only two studies worldwide have shown harm for patients from continuity. (13,14) This evidence, for us, indicates that the balance of probability is that continuity of care benefits patients. Important research from some of the same authors shows that patients will trade off as long as five days wait to see the general practitioner of their choice. (15) Moreover, there is strong evidence that patients benefit from longer consultations. (16-18) Continuity of care is the main mechanism through which patients gain more time with their family physicians.

The need for a measure of the patient-doctor relationship in general practice and its depth is obvious. The methods used by Ridd et al. (2011) (2) are impressive, with 541 patients returning questionnaires and a rigorous approach to deriving a practicably short list of statements. The Cronbach Alpha is excellent.

One major new finding is that the probability of developing a deep patient- doctor relationship was associated with continuity of care. The authors summarise this in a quadratic model showing that the probability of a deep relationship increases with each additional consultation with the same doctor.

There are however some methodological issues. The continuity definition was defined as merely "12 months or ten encounters before the index consultation". This means the authors undervalue patients with many years of continuity of care in general practice, especially patients with 100-plus consultations with the same doctor, and those in families seen in several generations. In the St Leonard's Practice, Exeter (80 miles west of Bristol) the median duration of registration is 8.9 years and the mean as long as 13 years (Langley, P: personal communication, 2011). The authors however recognise that they may have under-researched long lengths of continuity.

The work is not as "novel" as the authors claim and nor are all their statements. Research by a multidisciplinary team funded by the Fetzer Institute in the USA used similar methods in deriving an instrument measuring "Physician Responsiveness", (19) which academic psychologists consider a key component of depth in human relationships. This, instrument too, was from the patients' perspective (although uncited by Ridd et al. (2)) and was an earlier measure of the patient-doctor relationship, which was developed with patients of family physicians in UK, Canada and the USA.

The second in Ridd et al.'s statements(2) is "The doctor knows me as a person" and Reis et al. (19) have "My doctor knows me as a person". Ridd et al. have "This doctor really cares for me" and Reis et al. have "My doctor really cares about my welfare". Ridd et al. have "This doctor takes me seriously" and Reis et al. have "My doctor takes my concerns seriously".

A major review on patient-doctor relationships by the King's Fund, London(20,21) (also uncited by Ridd et al) highlighted Reis et al. (2008) (19) as one of three measures of the patient-doctor relationship. It is disappointing that a major article from a leading UK academic department omits such relevant references, but it is encouraging that the statements in Reis et al. (2008) and Ridd et al. (2011) are so similar. This increases the validity of both instruments.

The authors are over-cautious about the difficulties in providing continuity of care. They do not mention personal lists, (7) which increase continuity of care(22) and also patient satisfaction. (3)

This report represents a substantial advance. Quantifying increased depth in patient-doctor relationships with each additional consultation is a discovery of international importance, which justifies the long-held views of practising medical generalists.

Denis J Pereira Gray, OBE FMedSci, Philip H Evans, MPhil FRCGP, Christine Wright, PhD, Peter Langley, PhD

St Leonard's Research Practice, Athelstan Road, Exeter EX1 1SB, United Kingdom

References

1. McWhinney IR. William Pickles Lecture 1996. The importance of being different. Br J Gen Pract. 1996; 46: 433-436.

2. Ridd MJ, Lewis G, Peters TJ, Salisbury C. Patient-Doctor Depth-of- Relationship Scale: Development and validation. Ann Fam Med. 2011; 9: 538- 545.

3. Baker R, Streatfield J. What type of general practice do patients prefer? Exploration of practice characteristics influencing patient satisfaction. Br J Gen Pract. 1995; 45: 645-659.

4. Charney E, Bynum R, Eldridge DE, et al. How well do patients take oral penicillin? A collaborative study in private practice. Pediatrics.1967; 40:188 -195.

5. Ettlinger PR, Freeman GK. General practice compliance study: is it worth being a personal doctor? BMJ.1981; 282:1192 -1194.

6. Becker MH, Drachman RH, Kirscht JP. A field experiment to evaluate various outcomes of continuity of physician care. Am J Public Health. 1974; 64:1062-1070.

7. Pereira Gray DJ. The key to personal care. J R Coll Gen Pract. 1979; 29: 666-678.

8. O'Connor PJ, Desai J, Rush WA, et al. Is having a regular provider of diabetes care related to intensity of care and glycemic control? J Fam Pract. 1998; 47: 290-297.

9. Mainous AG, Gill JM. The importance of continuity of care in the likelihood of future hospitalization: Is site of care equivalent to a primary clinician? Am J Public Health. 1998; 88: 1539-1541.

10. Menec VH, Sirski M, Attawar D, Katz A. Does continuity of care with a family physician reduce hospitalizations among older adults? J Health Serv Res Policy. 2006; 11: 196-201.

11. Blasi D, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet. 2001; 357: 757-62.

12. Mainous AG III, Baker R, Love M, Pereira Gray DJ, Gill JM (2001) Continuity of care and trust in one's physician. Evidence from primary care in the United States and the United Kingdom. Fam Med. 2001; 33(1): 22-27.

13. Hanninen J, Takala J, Keinannen-Kiukaanniemi S. Good continuity may improve quality of life in type 2 diabetes. Diabetes Res Clin Pract. 2001; 51: 21-27.

14. Overland J, Yue DK, Mira M. Continuity of care in diabetes: to whom does it matter? Diabetes Res Clin Pract. 2001; 52: 55-61.

15. Gerard K, Salisbury C, Street D, Pope C, Baxter H. Is fast access to general practice all that should matter? A discrete choice experiment of patients' preferences. J Health Serv Res Policy. 2008; 13 (Supp 2): 3-10.

16. Morrell DC, Evans ME, Morris RW, Roland MO. The "five minute" consultation: effect of time constraint on clinical content and patient satisfaction. BMJ. 1986; 292: 870-873.

17. Roland MO, Bartholomew J, Courtenay MJ, Morris RW, Morrell DC. The "five minute" consultation: effect of time constraint on verbal communication BMJ, 1986; 292: 874-876.

18. Wilson A, Childs S. The relationship between consultation length, process and outcomes in general practice: a systematic review Br J Gen Pract. 2002; 52: 1012-1020.

19. Reis HT, Clark MS, Pereira Gray DJ, et al. Measuring Responsiveness in the Therapeutic Relationship: a Patient Perspective. Basic and Applied Psychology. 2008; 30: 339-548.

20. Greenhalgh T, Heath I. Measuring quality in the therapeutic relationship. London: King's Fund, 2010.

21. Greenhalgh T, Heath I. Measuring quality in the therapeutic relationship--Part 1: objective approaches. Qual Saf Health Care. 2010; 19: 475-78.

22. Roland M, Mayor V, Morris R. Factors associated with achieving continuity of care in general practice. J Roy Coll Gen Pract. 1986; 36: 102-104.

Competing interests:   DJPG is a co-author of Reis et al. (2008) and is the Patron of the National Association for Patient Participation. All other authors: no competing interests declared.

We compliment Ridd et al. on this interesting paper developing an instrument to measure the depth of the patient-doctor relationship in primary care. The instrument is designed to measure this from the patient perspective, which we believe is very important.[1]

The patient-doctor relationship is an important theme in general practice. Having a personal care provider (personal continuity) is related to more confidence in the care provider, more patient satisfaction and higher quality of patients life.[2-4] Ridd et al. developed an instrument that more extensively measures the patient-doctor relationship. Not just a single item ('Having a personal care provider') but several items are included in this measure. In this way, the aim of the measure of Ridd et al. resembles the aim of more extensive measures of personal continuity.[5 -7] However, we do miss a few aspects that refer to the strength of the GP -patient relationship as well.

Recently, we developed the Nijmegen Continuity Questionnaire (NCQ): an instrument that measures patients' experienced continuity of care regardless of morbidity and across multiple care settings.[5] The NCQ includes several questions on personal continuity. In the development phase, we performed a systematic literature review and analysed patient interviews to identify all themes that are important in experiencing personal continuity, and constitute the strength of the relationship. We found two themes that we miss in the instrument of Ridd et al.: (1) whether the GP contacts patients by him/herself if it is needed (the patient does not has to ask) and (2) whether the GP keeps in contact sufficiently when the patient sees a variety of care providers. We think that these themes are important as well for measuring the depth of the patient-doctor relationship. Moreover, these themes might help to better discriminate between different depths of relationship, particularly at the deeper end of the spectrum. Looking at their results, which include a substantial ceiling effect for patients who have seen their doctor before, this certainly seems a limitation of the questionnaire of Ridd et al.

In spite of these comments, we would like to congratulate the authors with this paper, which contributes to our knowledge on one of the core concepts in general practice.

References

1. Uijen AA, Schers HJ, van Weel C. Continuity of care preferably measured from the patients' perspective. J Clin Epidemiol 2010; 63(9):998- 999.

2. Schers H, van den Hoogen H., Bor H, Grol R, van den Bosch W. Familiarity with a GP and patients' evaluations of care. A cross-sectional study. Fam Pract 2005; 22(1):15-19.

3. Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med 2004; 2(5):445-451

4. Freeman G, Hjortdahl P. What future for continuity of care in general practice? BMJ 1997; 314(28):1870-1873

5. Uijen AA, Schellevis FG, Bosch van den WJHM, Mokkink HGA, Weel van C, Schers HJ. Nijmegen Continuity Questionnaire (NCQ): development and testing of a questionnaire that measures continuity of care. J Clin Epidemiol 2011;64(12):1391-1399

6. Gulliford MC, Naithani S, Morgan M. Measuring continuity of care in diabetes mellitus: an experience-based measure. Ann Fam Med 2006;4(6):548-55

7. Hadjistavropoulos HD, Biem H, Sharpe D, Bourgault-Fagnou M, Janzen J. Patient perceptions of hospital discharge: reliability and validity of a patient continuity of care questionnaire. Int J Qual Health Care 2008;20(5):314-323

Competing interests:   None declared

We are very grateful to Dr Tarrant for taking the time to comment on our publication and for her complimentary statements. However, we think that the scale does measure personal knowledge.

We were very conscious during the scale's development that knowledge appears to be a key aspect of longitudinal patient-doctor relationships (see our paper upon which the question items are based: BJGP 2009; 59: 268) and four of the final eight items relate to knowledge. More items relating to personal knowledge were included in the initial draft and the original 32 item versions of the instrument (the link to the supplemental data, http://www.annfammed.org/content/9/6/538/suppl/DC1, may not have been working for Dr Tarrant), but as the paper details, the questionnaire was distilled down to eight items.

A longer questionnaire, containing more personal knowledge-type questions, may have produced a greater spread of patient-doctor relational depth, but this would have been at the cost of ease of/time to completion. Trying to quantify what in many people's minds is a qualitative concept, human (albeit professional) relationships, is challenging, and further work of the type suggested by Dr Tarrant may provide some further insight into how successful we've been in this endeavour. Meanwhile, we offer this scale as an advance on existing measures and a means by which to further explore the value of continuity to patient care.

Competing interests:   Authors of the paper