In 20 years of practice, I rarely received a report on patient satisfaction that I found useful. Like many of my colleagues, I felt ambivalent about patient satisfaction and wondered why so many organizations seemed to value it so highly. The irony, of course, is that providing care to patients that is respectful and helps them maximize their health is among the most important things we must do.

This article reviews the literature on patient satisfaction most relevant to family physicians. While the literature isn't earth-shattering, it does offer some practical take-away lessons and can help give us a proper view of patient satisfaction.

What's being measured?

A review of the medical literature relating to the term “patient satisfaction” shows little research on the topic in the 1960s and 1970s. However, things began to pick up dramatically in the early 1980s. Between 1980 and 1996, there was a five-fold increase in the number of articles devoted to this topic. Why this burgeoning interest? Perhaps it was a natural outgrowth of the consumer movement begun in the 1960s and 1970s. Or maybe it reflected the maturation of the family medicine research agenda. Equally plausible might be the emerging competitiveness of managed care, which led HMOs to begin using patient satisfaction surveys to distinguish between providers.

It is worth noting that most patient-satisfaction studies are based on patients' experiences at one-time encounters rather than their experiences over time. In addition, discussions in the literature make it clear that quality of care is not what is being measured in patient surveys. In fact, many surveys intentionally avoid asking patients how they feel about the quality of their care, presumably because patients are not in a position to judge their physician's technical skill. It appears that what's being measured is typically a combination of the patient's expectation before the visit, the patient's experience at the visit and the extent to which the patient experienced a resolution of the symptoms that led him or her to make the visit.

Patient-related factors

The literature appears mixed on the importance of patients' demographic and social factors in determining satisfaction. Some studies stated that patient demographics are a minor factor in patient satisfaction, ¹ while others concluded that demographics represent 90 percent to 95 percent of the variance in rates of satisfaction.² Nevertheless, the literature does shed some light on how particular demographic factors affect patient satisfaction.

Age. The most consistent finding has been related to age: Older patients tend to be more satisfied with their health care.

Ethnicity. Studies that have looked at ethnicity have generally held that being a member of a minority group is associated with lower rates of satisfaction. In a ranking of degrees of satisfaction, non-Hispanic whites had the highest satisfaction, followed by African Americans, Asian/Pacific Islanders and Hispanics. The lowest degree of satisfaction was found in Indians/Alaskan natives.³

Gender. Studies on the effect of gender are contradictory, with some studies showing that women tend to be less satisfied and other studies showing the opposite.

Socioeconomic status. Most studies have found that individuals of lower socioeconomic status and less education tend to be less satisfied with their health care. However, one study found that frequent visitors to a family practice had lower educational status, lower perceived quality of life, and higher anxiety and depression scores and were more satisfied with their family physician.⁴ Other studies have shown that poorer satisfaction with care is associated with experiencing worry, depression, fear or hopelessness, ⁵ as is having a psychiatric diagnosis such as schizophrenia, post-traumatic stress disorder or drug abuse.⁶

Health status. Looking at patients with chronic disease has shown some consistent patterns. Patients with poorly controlled diabetes were less satisfied with their care, ⁷ as were migraine sufferers who reported more migraine-related disability.⁸ Dissatisfied migraine sufferers were less likely to use triptans currently, were more than two times more likely to have stopped them and were less likely to have their medications paid for by their insurance. Patients with two or more chronic illnesses reported more hassles with the health care system than those with a single chronic illness.⁹ In this study, when communication and coordination of care increased, the patients' perception of hassle decreased and satisfaction improved.

Physician-related factors

Physicians can promote higher rates of satisfaction by improving the way they interact with their patients, according to the literature.

Expectations. Perhaps the most important lesson for physicians is to take the time and effort to elicit patients' expectations. When physicians recognize and address patient expectations, satisfaction is higher not only for the patient but also for the physician; it may help to remember that patients often show up at a visit desiring information more than they desire a specific action.¹⁰ In addition, approximately 10 percent of patients in one study had one or more unvoiced desires in a visit with their physician.¹¹ The desire for a referral or for physical therapy were the most common. Young and undereducated patients were more likely to experience unmet needs at their visit, and they demonstrated less symptom improvement and evaluated their visit less positively.

Communication. Doctor-patient communication can also affect rates of satisfaction. When patients who presented to their family physician for work-related, low-back pain felt that communication with the physician was positive (i.e., the physician took the problem seriously, explained the condition clearly, tried to understand the patient's job and gave advice to prevent reinjury), their rates of satisfaction were higher than could be explained by symptom relief.¹²

Control. Physicians can also improve patient satisfaction by relinquishing some control over the encounter. Studies have found that when physicians exhibited less dominance by encouraging patients to express their ideas, concerns and expectations, patients were more satisfied with their visits and more likely to adhere to physicians' advice.¹³

Decision-making. Patient satisfaction can also be influenced by physicians' medical decision making. Patients expressed a preference for physicians who recognized the importance of their social and mental functioning as much as their physical functioning.¹⁴

Time spent. Time spent during a visit plays a role in patient satisfaction, with satisfaction rates improving as visit length increases.¹⁵ Time spent chatting during the visit was also related to higher rates of satisfaction. Physicians with high-volume practices were more efficient with their time but had lower rates of patient satisfaction, offered fewer preventive services and were viewed as less sensitive in the doctor-patient relationship.¹⁶

Interestingly, one study showed that while physicians felt rushed 10 percent of the time, patients felt that way only 3 percent of the time. Patient satisfaction was identical whether the physician did or did not feel rushed.¹⁷ This suggests that physicians may be more sensitive to feelings of being rushed and their feelings may not reflect the actual time spent during the visit.

Technical skills. Several studies have looked at patients' assessment of their physicians' technical skills and the effect on satisfaction, but the findings are contradictory. In a survey of 236 “vulnerable” older patients, better communication skills were linked to higher patient satisfaction but technical expertise was not.¹⁸ However, another study found that when forced to make a trade-off, participants expressed a strong preference for physicians who have high technical skills.¹⁹ Patients also indicated that a physician's ability to make the correct diagnosis and craft an effective treatment plan were more important than his or her “bedside manner.”²⁰

Appearance. Patients also appear to respond to a physician's appearance. In one study from New Zealand, patients indicated that they preferred “semiformal” attire and a smile. Next, in order of preference, were “semi-formal” dress without a smile, a white coat, a formal suit, jeans and casual dress.²¹ They were less comfortable with facial piercings, short tops, or earrings on men. In addition, most patients wanted to be called by their first name, be introduced to the doctor by his full name and title, and see a name badge.

System-related factors

Patient satisfaction is not simply a product of the patient's demographics and the physician's skills. It is also affected by the system in which care is provided.

The clinical team. Although it's clear that patients' first concern is their doctor, they also value the team with which the doctor works. One study found that while physician care was most influential to patients' satisfaction, the compassion, willingness to help and promptness of the physician's staff were next in importance.²⁰ In another large database of surveys, nurses were the next most important source of satisfaction, ahead of access-to-care issues.²² Patients who had remained in a practice for more than 15 years attributed their loyalty to their physician first and to the “team concept” second.²³

Referrals. Effective referrals play a role in patient satisfaction. One study looked at referrals from the standpoint of the family physician, the referral physician and the patient, and found that satisfaction with the referral's outcome was higher when the family physician initiated the referral.²⁴ Similarly, a study of patients treated for recurring headaches revealed that those who self-referred to a neurologist were less satisfied than those whose primary doctor had referred them.²⁵ A survey of cancer patients found that they valued their family physician highly and wanted to maintain contact with him or her, even when they were receiving cancer care elsewhere.²⁶

Continuity of care. Continuity of care, one of the pillars of family medicine, is felt to have suffered under managed care. While it is unclear to what degree patients in general value continuity of care, it is clear that patients who have been followed by their physician for more than two years are more satisfied with their care²⁷ – particularly when they are able to see their own physician.

Why bother?

While the literature contains a number of contradictions on the subject of patient satisfaction, it also offers a number of compelling reasons for working to improve satisfaction among our patients. Studies support the idea that patients who get better are (not surprisingly) satisfied with their care. One study, in which researchers followed up with patients three weeks after they were seen, found that most were better, but those who were still symptomatic were still worried, had unmet expectations and had lower satisfaction.²⁸ African Americans with type-2 diabetes who were most satisfied with the helpfulness of their physicians and nurses were significantly less likely to use the emergency room.²⁹ Patients who reported being treated with dignity and who were involved in decisions were more satisfied and more adherent to their doctor's recommendations.³⁰ Patient satisfaction surveys of inpatient physician performance showed an inverse relationship between satisfaction and risk management episodes.³¹

In addition, physicians can find practical take-away lessons in the literature, such as the following:

• Treat patients with dignity and include them in decision making;

• Work with a team you can be proud of and invest in their ongoing development;

• Elicit patients' concerns by asking questions such as “What do you think is going on?” or “What are you afraid of?”

• Dress in semiformal attire – and don't forget to smile.

Lastly, while it may not be as easy as the above lessons, find pleasure in what you do. Physicians who report high professional satisfaction have patients who are more satisfied with their care.³²