Unhappy patients will leave their physicians

A study in the Journal of Family Practice reports that doctors say managed care pressures keep them from relating better with patients.

By Leigh Page, amednews staff. March 19, 2001.

A new study shows that the relationship between primary care doctors and patients in Massachusetts is in decline, causing patients to leave their physicians at significant rates.

Published in the February Journal of Family Practice in two articles, the study is one of the few to closely examine that relationship and the first to show how it affects patients' decisions to switch doctors, the authors said.

They conjectured that they will find the same results in a nationwide survey of Medicare beneficiaries, which they are still tabulating and will release later in the year.

Surveying Massachusetts state employees, the study authors found declines from 1996 to 1999 of 10% to 15% in patient satisfaction with personal interactions, communication of information and trust for their primary care physicians.

The survey identified this dissatisfaction as the major reason for patients' switching plans, which they did at a rate of 20% over the three years studied.

Physicians told of the findings agreed that the doctor-patient relationship seems to be deteriorating nationwide, and blamed managed care for it.

"Managed care has put a tremendous barrier between the physician and the patient," said Neil Brooks, MD, a former president of the American Academy of Family Physicians, who practices in Rockville, Conn.

He pointed out that if physicians who are very satisfied with practicing are put into an atmosphere where autonomy is hampered, the result will be unhappy physicians.

Health plans have challenged physicians' authority, distracted them with paperwork and imposed efficiency quotas on them, he and other physicians said.

Under these new pressures, "you don't stop and talk to the patient -- you don't pay attention to the social level," Dr. Brooks added. For example, he said, "a patient's wife may have passed away but you don't say anything about it because you're too preoccupied by other things."

Peter S. Moskowitz, MD, director of the Center for Professional and Personal Renewal, in Palo Alto, Calif., which advises physicians who are tired of practicing medicine, said patients believe doctors have changed.

"It's common these days to hear patients complaining that their doctors don't listen any more," he said. "They can't have a conversation with their physicians. They can't get a word in edgewise."

Changes in patients may also be undermining the doctor-patient relationship, said Dana Gelb Safran, ScD, the lead author of the study and director of the Health Institute at New England Medical Center in Boston, which conducted the study. Many patients take a more active role in their treatment, prompted in part by direct-to-consumer drug ads and better access to medical information, she said.

The survey found that patients leave because of a failing doctor-patient relationship and not because of other elements of the practice, such as waiting room times, which physicians tend to focus on, Dr. Safran said.

Researchers studied eight aspects of medical care as defined by the Institute of Medicine Committee on the Future of Primary Care.

Four of these categories involved the doctor-patient relationship: personal interactions (patience, friendliness, caring, respect and time spent with patient), communication of information (the physician's questions and clarity of his or her explanations), trust (integrity, competence and role as the patient's agent) and physician's knowledge of the patient.

Four more involved other aspects of the practice: access to care (including ability to get through by phone or make appointments), visit-based continuity (being able to see the same doctor in each visit), financial access to care (patient's out-of-pocket costs) and integration (synthesizing care from specialists and the hospital).

The study found that access accounted for the greatest decline in satisfaction -- even greater than declines in the doctor-patient relationship -- but it was not linked to patients switching physicians, Dr. Safran said.

In the doctor-patient categories, the study found that personal interactions declined the most, or about 15%, followed by communication and then trust, which declined about 10%. Satisfaction rose on physicians' knowledge of the patient, but Dr. Safran said this was due to physicians becoming better acquainted with the patient over the three years studied.

Managed care was credited with one area of improvement -- increased patient satisfaction with continuity. Dr. Safran linked this to HMOs' assignments of patients to primary care doctors. She added that satisfaction with financial access to care and integration did not change appreciably.

Patients' 20% rate of switching doctors involved only voluntary decisions and not switches caused by retirement or moving of physicians or changes in plan offerings, Safran said. If the voluntary rate were extrapolated to all patients seen by a typical primary care physician, she said it would amount to a loss of 400 patients over the three years.

Dr. Safran said it is impossible to know whether patients' rate of switching or growing dissatisfaction with their doctors has continued since 1999, but "it would be pretty alarming if it did."