Roles Methodology, Validation, Writing – original draft * E-mail: Stefanie.Stark@uk-erlangen.de Affiliation Institute of General Practice, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
Roles Formal analysis Affiliation Institute of General Practice, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany ⨯
Roles Writing – review & editing Affiliation Institute of General Practice, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany ⨯
Roles Methodology, Supervision, Writing – review & editing Affiliation Institute of General Practice, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
Roles Conceptualization, Methodology, Supervision, Writing – review & editing Affiliation Institute of General Practice, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany ⨯
Primary care consultation is significantly influenced by communication between the General Practitioner (GP) and their patients. Hypothesising that patient satisfaction can be tested based on an expectation-experience comparison, the aim of this article is to discuss the influence of communication on patient satisfaction.
A standardised questionnaire was developed striving for a universal primary care survey tool that focuses on patient satisfaction in the context of patient-centred-communication. The sample consisted of 14 German GPs with 80 patients each (n = 1120). Due to the inclusion in an overarching cluster-randomised-study (CRT), the medical practices to be examined were divided into intervention and control groups. The intervention was developed as a reflective training on patient-centred communication.
The results in the present sample show no correlation between patient-centred-communication and patient satisfaction. There are also no significant differences between the intervention and control group.
The results raise the question to what extent patient satisfaction can be shaped significantly through patient-centred-communication. The presented project represents part of the basic research in general medical care research and contributes to the transparent processing of theoretical assumptions. With the results described here, communication models with a focus on patient centredness can be evaluated with regard to their practical relevance and transferability.
Citation: Stark S, Worm L, Kluge M, Roos M, Burggraf L (2021) The patient satisfaction in primary care consultation—Questionnaire (PiC): An instrument to assess the impact of patient-centred communication on patient satisfaction. PLoS ONE 16(7): e0254644. https://doi.org/10.1371/journal.pone.0254644
Editor: Paola Gremigni, University of Bologna, ITALY
Received: December 1, 2020; Accepted: June 30, 2021; Published: July 16, 2021
Copyright: © 2021 Stark et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data and syntaxes are within the paper and its Supporting Information files.
Funding: This survey was part of a project that was funded by the German Federal Ministry of Education and Research (Bundesministerium fuer Bildung und Forschung, BMBF), grant number 01GY1605. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
In recent years, the demand for patient-centredness has gained importance in primary care as well in general medical care research [1,2]. If one focuses on the primary care consultation, it can be stated that it is largely determined by communication skills. One of the key challenges that General Practitioners (GPs) currently face is to improve the doctor-patient communication to the best intelligibility and reliability as well as the best quality possible [3]. If one now relies on the hypothesis that the satisfaction of a patient can be guaranteed by the communication, paternalistic ways of implanting communication are assumed to unlikely satisfy patients [4]. Particularly nowadays in general medicine, great value is given to patient-centred communication [5,6].
Furthermore, Scholl et al. identified in their study (Integrative model of patient-centredness) the doctor-patient-communication as one of their dimensions of patient-centredness. They concluded that communication functions as an enabler [2]. Regarding the patient’s satisfaction with the communication, another study (Commonwealth Fund) found out that doctor-patient communication was assessed as deficient [7,8]. Another study dealing with patient-centred communication [9] tried to gain insights into the doctor-patient communication within clinics from the patient’s perspective and dealt with the examination atmosphere, the comprehensibility of the doctor’s statements, and the involvement in the decisions and the course of the conversation.
The relevance of examining patient satisfaction for the German primary care consultation arose from the ICE study [10] conducted by the research network PRO PRICARE (Preventing Overdiagnosis in Primary Care) of the Institute of General Practice of the University Hospital Erlangen. This cluster-randomised trial (CRT) focuses on the different medical communication methods and their implementation in the primary care consultation. One part of this study was to assess the patient’s emotional reaction to the communication by a target-actual comparison of the GPs consultation in order to analyse the effect of patient-centred communication regarding chronic low back pain (LBP) [11]. Therefore, a new quantitative survey tool, the Patient Satisfaction in Primary Care Consultation—Questionnaire (PiC) was developed by the authors to analyse the following research question: Does the implementation and application of patient-centred communication methods generate patient satisfaction in the primary care consultation?.
Based on the hypothesis that patient satisfaction within the primary care consultation is anchored to communication with the GP, the following central assumption is made: The better patient-centred communication is implemented and used, the better the patients’ satisfaction will be.
Regarding the German health care system, GPs occupy a special position as they are the first and most important point of contact for patients: The GPs act as a junction with a coordinating function in the medical care. This includes that they are available as the central point of contact for acute as well as continuous medical care of the patients. In accordance with the principles of participatory decision-making, the GPs assume responsibility for general medical care. No matter how much general medicine care changes, nothing will undermine the central role of the consultation between the GP and their patients. The importance gains even more weight in patient-centredness. Within the primary care consultation, the GP is the expert in the medical field with a deeper knowledge than the patient, visible in specialist terminology for instance. The consultation’s aim is to find out and understand why an individual patient has sought help and advice [12]. For that, all communication needs to overcome improbabilities: To communicate successfully, receiving, understanding and accepting a message are prerequisites in the interactional process [13]. In order to overcome these improbabilities in the GPs consultation, several medical communication concepts—so called success media [13]—were created and institutionalised [12].
Based on the literary examination of various patient-centred communication methods, the ones presented below, emerged as the most widely used and best-known communication tools and therefore served as the basis for creating the PiC-questionnaire and its items. The concepts presented have developed within the medical discourse and partly exist side by side, but also build on each other because they are logically interwoven. As a first communication concept, patient-centred communication (PCC) itself places the consideration of the patient’s perspective at the centre of the consultation and calls for a consideration of the patient from a biopsychosocial point of view. It entails understandable information about the diagnosis, treatment option and course of the disease with the focus on the aspect of language simplification. The most important element in the implementation of PCC is mutual listening and communicating between the GP and its patient. The GP should not only provide the patient with factual information, but also address the patient’s individual experience and needs. In addition, the common understanding and the division of responsibility in the medical discussion should be clarified [14,15]. In the case of the second concept, shared-decision-making (SDM), the expert competence lies not only with the doctor but also with the patient who plays an active role in the process of making a decision. Patients are given the opportunity to present their concepts of their illness and the possible treatment options in the consultation (sharing ideas). With this method, GP and patient should, if possible, come to a joint decision about treatment or therapy. This communication concept, which can also be found in the literature under the concept of participatory decision-making, was developed by Charles (1997) [16] and is an interaction process with the aim of sharing the active participation of patient and doctor with equal rights information to come to a jointly responsible agreement [16]. The objective of the third concept, the so-called ideas, concerns, and expectations (ICE) methodology according to Matthys [16], is to make patients aware of their personal ideas about their illness, their concerns about their symptoms, and their expectations of the treatment. Disclosing a patient’s ideas, concerns, and expectations can not only provide better insight into the reasons why a patient is visiting the GP, but can also help make the correct diagnosis faster. In addition, it places demands on the process of shared-decision-making and can have a positive effect on the patient’s cooperative behaviour in the context of their therapy and consequently optimise the patient’s compliance. In summary, it can be stated that the ICE method is exposed as a further medium, which increases the likelihood of understanding but also the acceptance of communication in the GP consultation [17,18].
The operationalisation of satisfaction of the PiC goes back to the confirmation-disconfirmation-paradigm (C/D paradigm) according to Yi (1990) [3,20], which deals with the recording of satisfaction resulting from a cognitive evaluation of a received achievement. Accordingly, the developed PiC is based on the following understanding of satisfaction: In order to be able to determine patient satisfaction as a measurable quantity in this study, it is of importance to first find out what is meant by satisfaction [19]. It can be assumed that every patient has certain individual expectations before a consultation, the fulfilment of which has a significant influence on their satisfaction. The construct of satisfaction is described as a cognitive assessment of expectations and actual experience, as a spontaneous or emotional reaction [19]. The term satisfaction, therefore, involves the comparison between an expectation and the actual experience. From this, expectations can be seen as an indispensable premise for satisfaction by which the quality of a service is estimated. If an emotional evaluation evolves, implying a strong positive or strong negative difference, satisfaction or dissatisfaction arises. It is presumed that a patient compares the experienced performance with the expected performance of the consultation. If the expected performance corresponds to the experienced performance, the patient feels neutral towards the communication, meaning that the patient is neither satisfied nor dissatisfied, and the communication has neither had a positive nor a negative influence on the satisfaction of the patient [3,20].
The ICE study aims to discuss the influence of patient-centred communication on patient satisfaction. The ethical approval of the ICE study was granted by the Ethics Committee of the Faculty of Medicine of the Friedrich-Alexander University Erlangen-Nürnberg (296_17B, 18.10.2017). The ethics committee does not raise any objections to the conduct of the study and approved it. The form of consent of the ethics statement was obtained written. As part of the ICE study a universal primary care survey tool, the PiC was developed by the authors for the purposes of this study, which focuses on patient satisfaction in the context of patient-centred-communication. According to the ethics statement, the participants in the study do not need to obtain a written declaration of consent. Oral information and consent from the patient are sufficient.
The PiC is based on the PREMS methodology (Patient Reported Experience Measures), which measures the perceived experience of the patient with the treatment process and was created on the basis of the target-actual-comparison according to Yi (1990) [3,20–22]. The aim of the PiC is not about evaluating the GPs, but rather to raise the issue to what extent communication really matters for shaping patient satisfaction in the primary care consultation and was therefore created for general medical advice purposes. Previous satisfaction surveys served as inspiration for the creation of the PiC, but did not meet the query of satisfaction based on a target-actual comparison, which underlines the necessity of a new developed questionnaire [3,20]. Items and modules of the PiC were operationalised and selected based on a literature research related to medical patient-centred communication methods. The PiC was created and validated in German language and programmed in a paper-based design with EvaSys Version 7.1 (S1 File). An unvalidated English version is also attached to this research paper as Supporting Information (S2 File).
The structure of the PiC is divided into four modules (A, B, C and D) which can be described as follows:
Module A examines the current state of primary care consultation with regard to the actual use of the medical patient-centred communication methods.
Module B explores the expectation of the patient about the applied communication methods in the GP consultation. In this way, the target-actual state of communication can be compared in a GP consultation.
The items of module A as well as of B are tabulated in a unipolar and ordinally scaled Likert scale: (1) Fully agree, (2) Agree, (3) Disagree, (4) Disagree completely, (5) Do not know. In module A, the patient was asked to please choose which answer is best for him/her after today’s conversation with his/her GP (current state of consultation). Module B asks the patient to please choose what he/she expects from a medical consultation with his/her GP (patient expectation regarding the consultation).
Module C concludes with a query of the overall satisfaction of the medical interview in the GP consultation: patients should be given the opportunity to make a clear statement about their satisfaction with the communication between them and the doctor in the GP consultation and were therefore asked: How satisfied were you with today’s general medical consultation? To answer this, the scale is structured in a four-stage satisfaction/dissatisfaction scale: (1) Very satisfied, (2) Satisfied, (3) Not satisfied, (4) Not satisfied at all, (5) Do not know. Furthermore, module C also deals with the time aspect of a GP consultation.
Moreover, this is followed by the query of expectation where the patient is asked about how much time he/she thinks should be planned for a doctor’s consultation, in order to assess his/her expectation (target state) on the time frame. A comparison of the target-actual state is determined by categorised response specifications with average values of the duration of general practitioner consultations. For that, the satisfaction with the time frame (actual state) was examined through the item: How did you find the duration of today’s doctor’s consultation? Participants were asked to indicate both their expectation as well as their satisfaction with the time frame on a five-stage two-dimensional scale.
The questionnaire ends in module D with additional demographic questions about the respondent’s age, gender, and insurance status.
The operationalisation of the questions and statements in module A and B (points 2 and 3 in the questionnaire) arose from the theoretical components of the medical communication methods such as PCC, SDM and ICE, which contribute to overcoming the improbabilities of communication in the primary care consultation. Those items build on each other in an actual-target comparison and are arranged as follows in the questionnaire (S1 and S2 Files):
The newly developed questionnaire was pretested through cognitive interviews [22]. A statistical validation was not previously carried out. Accordingly, this study can be viewed as a pilot study. The created PiC was tested with 11 volunteers (7 patients and 4 GPs) of the medical care centre of the University Hospital Erlangen. The volunteers were asked directly at the medical care centre to test the paper-based questionnaire that had been developed. The tested volunteers were 64% female (n = 7) and were all over 18 years old. Thus, the comprehensibility of the questions and the associated instructions for completing were checked. Furthermore, an exchange took place about the meaning of the question and answer items and the comprehensibility of their formulations. As a result of this pretest, it was found that the structure of the questionnaire and the question formulations were comprehensible. Some adjustments were made concerning the wording and the graphic representation.
The recruitment of the GPs in this CRT took place among German GPs belonging to four independent practice networks in Northern Bavaria/Germany. The building of the clusters involved two levels: GPs recruited to receive a training in patient-centred communication (intervention group) or no training (control group). To minimise contamination in the control group, randomisation to patient-centred communication training intervention took place at the practice level with units of randomisations being single-handed or group practices belonging to the research network Forschungspraxen Franken (a newly setup research network located in rural and urban areas of Franconia/Northern Bavaria comprising 119 GPs from 77 practices). This randomisation ensured that doctors being allocated to the control group will not be surrounded by colleagues having received the training intervention. Furthermore, all participants will be blinded towards the explicit purpose and design of the study. The communication training was offered to all participants: to GPs in the intervention group as a true intervention at the beginning of the CRT and to control GPs as a pretend intervention at the end of the trial. The clusters of the GPs were formed considering the number of participating GPs in a practice. This enabled a numerical balance between the intervention and control groups [11]. Accordingly, all GPs were randomly allocated to the respective study arm in intervention group with 5 GPs and control group with 9 GPs.
Regarding the sample size calculations, it confirmed the need for sample size inflation due to the cluster design so that each GP could form a cluster of clinical decisions that contain similar treatment decisions that are not independent of one another. The sample sizes also considered the intra-cluster correlation coefficient, number of events, expected effect, and study performance. Assuming a referral rate of 30% for acute LBP, as indicated in German routine data, an absolute change in referring patients of the order of 10% was considered clinically relevant. Assuming an intra-cluster correlation coefficient (ICC) of 0.05, a significance level of 0.05 and a potency of 0.8, 24 GPs, each with 40 patients (n = 1920), are required in each study group to achieve a 30% decrease in referrals in the Control group found to be 20% or less in the intervention group [11]. Alternative requirements for the sample size and the final sample were considered based on the actual referral rates and were adjusted accordingly. Therefore, the final sample consisted of 14 GPs in total with 80 patients each and a total n with 1120 patients [11]. In total, the response rate lay at 79% (n = 880).
Concerning the patients sampling, the medical assistants of the GP practices were responsible for the transmission of patients and returning the PiC-questionnaire to the Institute of General Practice in Erlangen. The patient data collection took place by the medical assistant within the GP practice assuring patient anonymity of the collected data. Regarding the ethics statement a written informed consent from the patients was therefore not required. The data being transferred to the Institute of General Practice in Erlangen did not allow the detection of patient identity [11]. Every third patient (men and women) over the age of 18 who presented themselves to their GP within the three-month period was included in the survey. Inclusion criteria were consultations involving patients consulting their doctor for uncomplicated acute LBP. After the consultation, the paper-based questionnaire was immediately filled out anonymously by the patient in the practice–none was handed home. The time frame of the data collection was from November 2018 to January 2019 and was collected by the practices within 4–8 weeks [10,11]. In general, the PiC can be used as a representative instrument for patients with general consultation needs in a GPs practice and does not refer to any specific sociodemographic sample.
Beyond that, the intervention group attended a training on patient-centred communication. This one-day training was held at the Institute of General Practice in Erlangen. The concept was designed in an open manner and was based on the methodology of group discussions. Thus, there was a high proportion of speeches by the participants and only stimuli from the training moderator were given. The training was aimed at a small number of participants in order to create the highest possible level of trust. The training consisted of an introductory round followed by a discussion in which the participating GPs could exchange information about their practiced communication. This was followed by a refresher of already known communication methods such as SDM and continued with learning about the ICE technique. The intervention group completed the training before receiving the questionnaire, the control group afterwards. In close association with recommendations of the national guidelines for acute LBP, the training provided clues on how to encourage patients to report their ICE and offers communication skills training through standardised patient scenarios [11].
All analyses of this study, as well as the described validation, were carried out with IBM SPSS Statistics 24. All relevant data and syntaxes are within the paper and its Supporting Information Files (S3–S5 Files).
As the PiC is a new developed instrument, the following tests for validation were made and have proven the PiC to be a valid reliable instrument. The factor analysis shows the following results: Kaiser-Meyer-Olkin criterion (KMO) shows in our data set that it is significant at 0.932; i.e. the recommended values should be at a minimum of 0.5 [23]. That is followed by the Bartlett’s sphericity test that tests the null hypothesis (H0) of whether the correlation matrix is an identity matrix. In our data set there is a high significance on the relationship between the variables at 0.000. Results can be seen in Table 1.