Sanctity of the Physician-Patient Relationship | Physician-Patient Alliance for Health & Safety
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Considering the range of assessment measures and conceptual models developed to date, no single measure of doctor-patient concordance is likely to reflect all relevant components of the relationship.
In fact, it is thought to be at the core of the doctor-patient relationship and a critical component of modern quality care [ 14 ]. This relationship is also thought to be associated with important health-related outcomes. For instance, a collaborative doctor-patient relationship has previously been emphasized as critical to adherence in medical patients [ 5 ].
Thus, the questionnaire examined in the present study first aims at providing an efficient instrument that can be used among patients with a chronic illness, whereby medication adherence is paramount to treatment success and survival. HIV is one such illness. To date, mounting evidence has established a positive association between different components of the doctor-patient relationship and adherence behaviors among HIV-infected patients receiving antiretroviral therapy [ 6 - 15 ].
Overall, trust has consistently emerged as the most common correlate of adherence [ 671213 ] along with communication with the doctor [ 17 ] and accessibility [ 916 ]. Studies conducted among other medical populations have emphasized this relationship as well [ 1819 ], consequently giving this observation more credence.
Most of the evidence accumulated to date has relied on crosssectional studies, thus leaving a void for prospective studies to elucidate the proposed causal links. In addition, the range of health outcomes examined in relation to the doctor-patient relationship should be expanded beyond adherence, as suggested by a recent meta-analysis that highlighted the impact of the doctor-patient relationship on both subjective and objective health outcomes across diverse medical conditions [ 20 ].
Methods Overview Two studies were conducted as part of this investigation.
Physician-patient relationship and medication compliance: a primary care investigation.
Lauderdale and Los Angeles areas. Participants were included if they were HIV positive. Exclusion criteria included being under 18, being diagnosed with another life threatening illness, taking medications affecting stress hormones e. All participants provided written informed consent prior to entering the study.
Studies procedures were approved by the Institutional Review Board. The first study was a cross sectional study comparing a group of long survivors to normal course controls on psychosocial and biological variables, and medical outcomes for a study on stress and coping with HIV [ 22 ]. When followed longitudinally, normal course controls may become long survivors, this group thus represents a conservative control group.
Participants completed questionnaires including the DPR: Study 2 was a sub-study of Study 1 that prospectively followed the normal course controls mentioned above for a year. He speculates that caring as a sociophysiological engagement may provide a unitary concept for understanding the health consequences of social support and the doctor-patient relationship for both doctor and patient. In the present study our research question is, what are the sociocultural determinants of three dimensions concordance, trust, and patient enablement of the doctor-patient relationship and also what are the inter-relations between these three?
We defined doctor-patient concordance as an agreement measured by a set of questions suggested by Kerse et al. Due to rapid industrialization leading to rural-urban migration, the outpatients were comprised of a large number of migrant populations from rural areas. The timeframe to complete the data collection and entry was two months. Forty days was set aside for data collection, and 20 days for data entry. The study was conducted during May - June, A cross-sectional study design was used.
Both quantitative and qualitative methods were employed. A pilot study was carried out, before the main study, to ascertain the number of patients who could be interviewed properly in a day.
Physician-Patient Relationship and Medication Compliance: A Primary Care Investigation
Based on the findings of the pilot study the final sample size and methods of sampling were decided. For example, it was found that in a day, five patients could be interviewed properly, so given the 40 days for data collection, a sample size of subjects was planned. During the data collection period of 40 consecutive working days, five consecutive patients were approached daily in the waiting room of the Outpatient Department OPD of the medical college hospital.
They were explained the purpose of the study and then invited to give a written informed consent to participate in the study. The respondents were interviewed using the survey instruments immediately after their consultation with the doctor.
Quantitative methods Three dimensions of the doctor-patient relationship were examined, that is, physician-patient concordance agreementtrust, and patient enablement. Measurement techniques for these aspects are given below. Study instruments Part I of the survey instrument elicited health, demographic, and sociocultural information. Part II of the survey instrument assessed various aspects of the doctor-patient relationship, such as: The agreement between doctor and patient was assessed with the following questions: Results for all the six questions were then summed to give a cumulative score between 0 and 6, with higher scores indicating greater concordance.
In the present study those scoring 5 and 6 were taken as having complete agreement or concordance and the rest as partial concordance. Trust in physician Trust in the doctor was measured by the Trust in Physician Scale,  which yielded a score ranging from lowest to highest on the Likert Scale, with the higher scores indicating more trust. In the present study, the highest two possible values were taken as complete trust in the physician and the rest of the scores were categorized as partial trust.
Patient enablement This was measured by using the Enablement Index. This index, validated in primary care against patient satisfaction, asked whether the patients were more or less able to cope with life, understood and coped with their illness, and helped themselves as a result of the consultation with the physician.
The responses were scored from 1 to 4, with higher scores meaning more enablement. Here also, the highest two possible scores were taken as complete enablement, and the rest as partial enablement.
Qualitative methods The following qualitative methods were used: Participant observation Besides interviewing the patients, the patients were also observed unobtrusively, while they interacted among themselves in the waiting rooms of the Outpatient Departments, or while standing in queue for registration.
Some were also observed during consultation with the doctor. Focus group discussion Twelve senior physicians, with at least 20 years experience in clinical practice, were approached to take part in a session of focus group discussion. Out of these, 10 physicians agreed to participate in the focus group discussion on doctor-patient relationship. The senior investigator acted as a moderator during this focus group discussion and the second investigator took notes regarding the main themes that emerged during the discussion.
Demographic profile A total of outdoor patients were surveyed. The mean age of the respondents was Out of the participants in the study, The majority of Physician patient concordance Out of the total respondents, Trust in physician This was less than the physician-patient agreement. Out of the total of respondents, Patient enablement This measured the ability of the patient to cope with his illness after consultation with the doctor.
In spite of a slightly low score on the overall trust in a physician, a larger proportion, Association of the sociocultural factors with physician-patient concordance This is shown in [Table 1].
Males tended to have a better concordance with their doctors Higher socioeconomic status was related to better concordance. Urban residents had better concordance than rural residents. Surprisingly, those who believed in alternative medicine had more concordance than those who did not. People with higher education also showed better agreement with their doctors.
Another surprising finding was that having the same mother tongue as the doctor, did not show better concordance. Association of the sociocultural determinants with doctor-patient concordance Click here to view Sociocultural factors and trust in physician This is shown in [Table 2].
Patients from the lower socioeconomic status had higher trust Urban residents had higher trust People who shared a common mother tongue with the doctor had a higher trust However, apart from gender, association with other determinants did not reach statistical significance [Table 2]. Association of some sociocultural determinants with trust in physician Click here to view Impact of sociocultural factors on patient enablement This is shown in [Table 3]. After consultations with the physician, the males were more enabled Patients from the lower socioeconomic group were more benefited from the doctor-patient interaction Other sociocultural factors were only marginally related to trust in the physician.
Association of some sociocultural determinants with patient enablement Click here to view Whether good physician-Patient concordance leads to better trust in physician? The answer to this question is explored in [Table 4].
It will be seen from the Table that complete Physician Patient Concordance is associated with complete trust in the Physician. The association is strong ODDS ratio 5. Association between physician-patient concordance and trust in physician Click here to view Whether complete trust in the physician in turn leads to better patient enablement?
The answer to this question is given in [Table 5]. It will be seen that better trust in the physician was related to better patient enablement.
Physician-patient relationship and medication compliance: A primary care investigation
Again the association is strong ODDS ratio 3. Association between trust in physician and patient enablement Results of the qualitative study Participant observation Some of the salient points noted during participant observations were as follows: Patients from urban areas, who also tended to have more numbers of schooling than their rural counterparts, appeared more at ease in the intimidating surroundings of a large teaching hospital.
Patients from rural background found themselves out of their depth in the alien environment of a teaching hospital. They particularly found the referrals to different departments for investigations or consultations very confusing. This was obvious from the discussion that they had among themselves and their queries to the hospital staff.