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Background and Objectives: Third-year family medicine clerkship students at our urban medical school are assigned to clinics in diverse settings, where they are required to video record one patient interview. Our research goals were to describe student communication behaviors and compare the frequency of these behaviors at clinics serving primarily uninsured patients to clinics with primarily insured patients., Methods: Eighty-seven student-patient recordings were reviewed and analyzed., Results: Seventy-two percent of students performed general interviewing skills at an adequate or outstanding level; however, only a small number of students asked contextual questions about patients' use of social services (7%), barriers to care (6%), or patients' cultural/spiritual values and health concerns (13%), regardless of clinic type (underserved or insured). In visits with female patients, all students were more likely to show a personal interest in the patient (88% versus 71%). In visits where there was gender concordance between the patient and student, the students were more likely to face the patient (98% versus 73%)., Conclusions: This study indicates that, even though third-year students may have adequate general interviewing skills, they may need additional training and practice in obtaining contextual information about patients in all clinical settings. These findings also suggest that the gender of the patient, as well as gender concordance between patient and student, play a role in student-patient interactions.

Objective: To evaluate the impact of an intervention designed to help patients choose a new primary care provider (PCP) compared with the usual method of assigning patients to a new PCP., Design: Randomized controlled trial conducted between November 1998 and June 2000., Intervention: Provision of telephone or web-based provider-specific information to aid in the selection of a provider., Setting: Medical center within a large HMO., Patients: One thousand and ninety patients who were >/=30 years old, whose previous PCP had retired and who responded to a mailed questionnaire 1 year after linkage with a new PCP., Measurements and Main Results: The questionnaire assessed perceptions of choice, satisfaction, trust, and retention of the PCP. During the intervention period, 85% of subjects obtained a new PCP. Intervention subjects were more likely to perceive that they chose their PCP (78% vs 22%; P <.001), to retain their PCP at 1 year (93% vs 69%; P <.001), and to report greater overall satisfaction with the PCP (67% vs 57%; P <.01), compared to control subjects who were assigned to a PCP. The intervention subjects also reported greater trust in their PCP on most measures, but these differences did not remain statistically significant after adjustments for patient age, gender, ethnicity, education, and health status., Conclusions: Encouraging patients to choose their PCP can result in mutually beneficial outcomes for both patients and providers, such as greater overall satisfaction and duration of the relationship. Further research is needed to identify the types of information most useful in making this choice and to understand the relevant underlying patient expectations.

Objective: To profile patients likely to have unmet expectations for care, examine the effects of such expectations, and investigate how physicians' responses to patients' requests affect the development of unfulfilled expectations., Design: Patient and physician questionnaires were administered before and after outpatient visits. A follow-up telephone survey was administered 2 weeks post visit., Setting: The offices of 45 family practice, internal medicine, and cardiology physicians., Patients: Nine hundred nine adults reporting a health problem or concern., Measurements and Main Results: Before their visits, patients rated their general health and trust in the index physician. After the visit, patients reported upon 8 types of unmet expectations and any request they made. Two weeks thereafter, patients rated their visit satisfaction, improvement, and intention to adhere to the physician's advice. They also reported any postvisit health system contacts. Overall, 11.6% of patients reported >/=1 unmet expectation. Visits in which a patient held an unmet expectation were rated by physicians as less satisfying and more effortful. At follow-up, patients who perceived an unmet expectation for care also reported less satisfaction with their visits, less improvement, and weaker intentions to adhere. Patients with an unmet expectation related to clinical resource allocation had more postvisit health system contacts. Unmet expectations were typically reported by a patient whose request for a resource was not fulfilled., Conclusions: Unmet expectations adversely affect patients and physicians alike. Physicians' nonfulfillment of patients' requests plays a significant role in patients' beliefs that their physicians did not meet their expectations for care.

Background: Patients communicate their desires and expectations largely by making requests. However, the antecedents and consequences of request fulfillment have received limited attention., Objective: To describe patient and physician characteristics associated with request fulfillment and to understand the consequences of request fulfillment and nonfulfillment on visit evaluations by patients and physicians, self-reported health care use, and health outcomes., Design: Data were gathered from patient and physician surveys administered at several points before and after problem-driven outpatient visits., Setting: The study was carried out in the office practices of 45 family practice, internal medicine, and cardiology physicians working either in a large multispecialty group practice or in a group-model health maintenance organization., Patients: Data were collected at the index visit from 909 patients (cooperation rate, 68%; net response rate, 32%). A telephone follow-up survey was administered to 887 (98%) of these patients 2 weeks after the visit., Measurements: Before the visit, patients provided ratings of their health concerns, physical functioning, role limitations, general health perceptions, and trust in the index physician. After the visit, patients reported on any request that they made, physician responses to these requests, and their satisfaction with care. At the 2-week follow-up evaluation, patients again reported on satisfaction, health concerns, health status, and self-reported postvisit health care use., Results: Patients reported making at least one request in 84% of encounters; requests for medical information, examination, and tests or procedures were most common. Four-fifths of patients who made at least one request reported complete fulfillment of all requests. Perceived request fulfillment was significantly lower among patients with relatively low pr-visit trust in the treating physician. Higher request fulfillment was predictive of more positive patient evaluations of care. Visits in which requests could not be completely fulfilled were rated by physicians as more demanding and less satisfying. Request fulfillment was also positively associated with fewer health concerns and greater symptom improvement at follow up. Nonfulfillment of patient requests did not predict postvisit health care use., Conclusions: Request fulfillment affects patient and physician satisfaction and perceptions of health outcomes. New approaches that efficiently recognize and respond to patient requests are needed.

Objective: Our goal was to identify physician and patient characteristics associated with patient-centered beliefs about the sharing of information and power, and to determine how these beliefs and the congruence of beliefs between patients and physicians affect patients' evaluations., Study Design: Physicians completed a scale assessing their beliefs about sharing information and power, and provided demographic information. A sample of their patients filled out the same scale and made evaluations of their physicians before and after a target visit., Population: Physicians and patients in a large multispecialty group practice and a group model health maintenance organization were included. Forty-five physicians in internal medicine, family practice, and cardiology participated, as well as 909 of their patients who had a significant concern., Outcomes Measured: Trust in the physician was measured previsit, and visit satisfaction and physician endorsement were measured immediately postvisit., Results: Among patients, patient-centered beliefs (a preference for information and control) were associated with being women, white, younger, more educated, and having a higher income; among physicians these beliefs were unrelated to sex, ethnicity, or experience. The patients of patient-centered physicians were no more trusting or endorsing of their physicians, and they were not more satisfied with the target visit. However, patients whose beliefs were congruent with their physicians' beliefs were more likely to trust and endorse their physicians, even though they were not more satisfied with the target visit., Conclusions: The extent of congruence between physicians' and patients' beliefs plays an important role in determining how patients evaluate their physicians, although satisfaction with a specific visit and overall trust may be determined differently.

Objectives: To examine patient, physician, and health care system characteristics associated with unvoiced desires for action, as well as the consequences of these unspoken requests., Patients and Methods: Patient surveys were administered before, immediately after, and 2 weeks after outpatient visits in the practices of 45 family practice, internal medicine, and cardiology physicians working in a multispecialty group practice or group model health maintenance organization. Data were collected at the index visit from 909 patients, of whom 97.6% were surveyed 2 weeks after the outpatient visit. Before the visit, patients rated their trust in the physician, health concerns, and health status. After the visit, patients reported on various types of unexpressed desires and rated their visit satisfaction. At follow-up, patients rated their satisfaction, health concerns, and health status, and also described their postvisit health care use. Evaluations of the visit were also obtained from physicians., Results: Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician. Patients with unvoiced desires evaluated the physician and visit less positively; these encounters were evaluated by physicians as requiring more effort. Holding an unvoiced desire was associated with less symptom improvement, but did not affect postvisit health care use., Conclusions: Patients' unvoiced needs affect patients' and physicians' visit evaluations and patients' subjective perceptions of improvement. Implications of these findings for clinical practice are examined.

Objective: The goal for this study was to assess the relative strength of the association between physician behaviors and patient trust. STUDY DESIGN AND POPULATION: Patients (N=414) enrolled from 20 community-based family practices rated 18 physician behaviors and completed the Trust in Physician Scale immediately after their visits. Trust was also measured at 1 and 6 months after the visit. The association between physician behaviors and trust was examined in regard to patient sex, age, and length of relationship with the physician., Results: All behaviors were significantly associated with trust (P<.0001), with Pearson correlation coefficients (r) ranging from 0.46 to 0.64. Being comforting and caring, demonstrating competency, encouraging and answering questions, and explaining were associated with trust among all groups. However, referring to a specialist if needed was strongly associated with trust only among women (r=0.61), more established patients (r=0.62), and younger patients (r=0.63). The behaviors least important for trust were gentleness during the examination, discussing options/asking opinions, looking in the eye, and treating as an equal., Conclusions: Caring and comfort, technical competency, and communication are the physician behaviors most strongly associated with patient trust. Further research is needed to test the hypothesis that changes in identified physician behaviors can lead to changes in the level of patient trust.

Patient trust in the physician is an important aspect of the patient-physician relationship that has recently become a focus of interest, in part due to the rise of managed care in the US healthcare system. In a previous study, we identified physician behaviours reported by patients as important to establishing their trust in the physician. The current study attempted to modify these behaviours via a short training programme and thereby to increase patient trust and improve associated outcomes. After baseline measurements, 10 physicians were randomized to the intervention group and 10 remained as a control group. While intervention physicians showed a net improvement in 16 of 19 specific patient-reported behaviours when compared to control physicians, these differences were not statistically significant. There was also no significant difference in patient trust, patient satisfaction, continuity, self-reported adherence, number of referrals or number of diagnostic tests ordered. This short training course in a group of self-selected physicians was not a sufficiently strong intervention to achieve the desired effect. Suggestions are given for designing a stronger training intervention.

Objectives: To further validate and assess the reliability and validity of the Trust in Physician Scale., Methods: Consecutive adult patients (n = 414) from 20 community-based, primary care practices were enrolled in a prospective, 6-month study. At enrollment, subjects completed the 11-item Trust in Physician Scale plus measures of demographics, preferences for care, and satisfaction with care received from the physician. Continuity, satisfaction with care, and self-reported adherence to treatment were measured at 6 months. Reliability, construct validity, and predictive validity were assessed using correlation coefficients and analysis of variance techniques., Results: The Trust in Physician Scale showed high internal consistency (Cronbach's alpha = .89) and good 1-month test-retest reliability (intraclass correlation coefficient = .77). As expected, trust increased with the length of the relationship and was higher among patients who actively chose their physician, who preferred more physician involvement, and who expected their physician to care for a larger proportion of their problems (P < 0.001 for all associations). Baseline trust predicted continuity with the physician, self-reported adherence to medication, and satisfaction at 6 months after adjustment for gender, age, education, length of the relationship, active choice of the physician, and preferences for care. After additional adjustment for baseline satisfaction with physician care, trust remained a significant predictor of continuity, adherence, and satisfaction., Conclusions: The Trust in Physician Scale has desirable psychometric characteristics and demonstrates construct and predictive validity. It appears to be related to, but still distinct from, patient satisfaction with the physician and, thus, provides a valuable additional measure for assessment of the quality of the patient-physician relationship.

Purpose: To investigate the effect of a one-day workshop in which physicians were taught trust-building behaviors on their patients' levels of trust and on outcomes of care., Method: In 1994, the study recruited 20 community-based family physicians and enrolled 412 consecutive adult patients from those physicians' practices. Ten of the physicians (the intervention group) were randomly assigned to receive a one-day training course in building and maintaining patients' trust. Outcomes were patients' trust in their physicians, patients' and physicians' satisfaction with the office visit, continuity in the patient-physician relationship, patients' adherence to their treatment plans, and the numbers of diagnostic tests and referrals., Results: Physicians and patients in the intervention and control groups were similar in demographic and other data. There was no significant difference in any outcome. Although their overall ratings were not statistically significantly different, the patients of physicians in the intervention group reported more positive physician behaviors than did the patients of physicians in the control group., Conclusions: The trust-building workshop had no measurable effect on patients' trust or on outcomes hypothesized to be related to trust.

Background: Patients' trust in their physicians has recently become a focus of concern, largely owing to the rise of managed care, yet the subject remains largely unstudied. We undertook a qualitative research study of patients' self-reported experiences with trust in a physician to gain further understanding of the components of trust in the context of the patient-physician relationship., Methods: Twenty-nine patients participants, aged 26 to 72, were recruited from three diverse practice sites. Four focus groups, each lasting 1.5 to 2 hours, were conducted to explore patients' experiences with trust. Focus groups were audio-recorded, transcribed, and coded by four readers, using principles of grounded theory., Results: The resulting consensus codes were grouped into seven categories of physician behavior, two of which related primarily to technical competence (thoroughness in evaluation and providing appropriate and effective treatment) and five of which were interpersonal (understanding patient's individual experience, expressing caring, communicating clearly and completely, building partnership/sharing power and honesty/respect for patient). Two additional categories were predisposing factors and structural/staffing factors. Each major category had multiple subcategories. Specific examples from each major category are provided., Conclusions: These nine categories of physician behavior encompassed the trust experiences related by the 29 patients. These categories and the specific examples provided by patients provide insights into the process of trust formation and suggest ways in which physicians could be more effective in building and maintaining trust.