INTRODUCTION: 

The medical field has become a largely integrated part of American society, and the interactions shared between doctors and patients play a significantly large role in the flow of patient care. Professor of Public Health at the Central University of Kerala, Matthew George, explains that “the interaction between doctors and patients becomes cardinal not only in the process of medical care but also within the institution of medicine” further stating that through this interaction, basic components of medical care are accomplished (George, 2010). However, the formation of this idea is one that can be attributed to Hungarian Psychoanalysts, Michael Balint, who presented the definition of the doctor-patient interaction, or DPI, as a two person situation (between a doctor and patient) where the illness as it progresses, changes, or develops is “always the result of a compromise… between the analyst and his patient.” This view created the general definition for the DPI (Balint, 1955). The recognition of the DPI has since been subject to understanding beyond its direct definition, leading to research on interruptions to the interaction, and hypotheses on successful patient care and satisfaction. 

LITERATURE REVIEW:

Voice and Status: 

The definition of the DPI and its understanding of relevance to medicine created room for interruptions to the interaction. One understood interruption and aspect of the interaction is voice and status. Doctor of Philosophy, Sally Wilde, explains the shift in the DPI, with the change of medical technology and knowledge in the 1960’s and 1970’s. Within her piece ‘The Elephant in the Doctor- Patient Relationship’ Wilde states that the approach “encapsulated in Erwin Ackerknecht’s tri-partite progression from eighteenth-century bedside medicine to early-nineteenth century hospital medicine” led to discussion around the change in how doctors behaved and believed, especially in relation to how the patient was viewed (Wilde, 2007). The knowledge surrounding the shift from bedside manner to hospital medicine, changing how doctors viewed patients, created a basis for understanding a power difference in status of doctor versus the patient. The status difference also creates room for impacts to patient voice. Professor of Sociology, Virginia Gill, of Illinois State University explains in her 1998 piece ‘Doing Attributions in Medical Interaction’ the impact that status holds on patient voice. Gill states that “when patients offer explanations for their health problems, they exhibit sensitivity” which combines with the degree of uncertainty in personal confidence and knowledge held by the patient, to invite a doctor’s interruption and assessment (Gill, 1998). The idea of patient voice and status, however, was combined and expanded upon by professors B. Mitchelle Peck and Sonya Conner within the 2011 piece ‘Talking with Me or Talking at Me’ where one influence on the DPI is accredited to an asymmetry in power that expresses a “paternalistic nature” in the interaction where the physician is the dominant paternal figure making decisions that are believed to be in the patients best interest. Peck and Conner explain the situationally dependent nature of the interaction and the higher power demonstrated by a doctor’s professional prestige (Peck & Conner, 2011). It is due to the dominance within a hospital setting combined with patient vulnerability, where asymmetry is created, and patient voice is interrupted. 

Communication Style:

A second identified interruption to the DPI is presented through the style of communication. Angela Coulter of the University of Oxford explains “the most highly rated aspect of care was humanness (Coulter. 2022).” Coulter goes beyond status characteristics to understand patients’ perceptions of an interaction, exemplifying humanness as a part of communication within this interaction. An additional point of view is presented by Korsch and Negrete of the Children’s Hospital of Los Angeles, explaining a major deterrent from genuine communication to be “focused predominantly on technical knowledge” further stating “the physician may be engrossed in technical concerns and arcane terminology that mystify the patient (Korsch & Negrete, 1972).” Korsch and Negrete also present that long-term relationships with a family doctor are now replaced by short-term encounters with specialists. With a similar understanding in mind, professors and students at several universities including Harvard University, University of South Florida, Texas Tech University, and Ohio State University, explain the implications of a poor patient-doctor interactions stating “poor communication during healthcare encounters leads to mistrust, misunderstandings, poor shared decision making, and subsequent poor patient outcomes (Gittner et al., 2015).”

Patient Health Outcomes and Satisfaction:

Using survey and interview-based understandings, researchers created a general understanding of the flow of patient outcomes and satisfaction. Paul D Cleary of Yale and Barbara J McNeil of Harvard define patient satisfaction to be an indicator of quality of care, defining satisfaction to be “a health care recipients’ reaction to salient aspects of his or her experience (Cleary & McNeil, 1988).” Although similar in topic, James G Wright and Pamela Hudak of Oxford University present a somewhat alternative view, on patient satisfaction, by creating that care is entirely reliant on satisfaction, rather than care influencing satisfaction. Wright and Hudak explain that if a patient is dissatisfied, they have the power to make their care less effective, with the characteristics of satisfaction being based on content and method of care (Wright & Hudak, 2000). In contrast, Mary and David Buller of research institution Klein Buendel Inc., explain that despite satisfaction, there is potential to report dissatisfaction due to the physicians attempts to exert control in medical interactions (Buller & Buller, 1987).

GAP IN RESEARCH: 

Despite a general understanding of potential interruptions to doctor-patient interaction, and the aspects of patient satisfaction, these phenomena occur individually. The information and research provided under the ‘Voice and Status’ and ‘Communication Style’ sub sections help understand the aspects of the DPI, being built upon by previous definitions (Balint, 1955). Individually, the understanding of patient satisfaction provides occurrence without correlation, lacking research on interaction aspects in correlation to patient health outcome. 

DESIGN AND METHODOLOGY:

Methodology:

The methodology and research design aim to answer the question “How does the patient- doctor interaction with acutely and chronically ill patients lead to implications in patient care?” in which it is hypothesized that a poor interaction will lead to poor care, and a positive interaction will lead to positive care. The data collected from my research design followed two forms of methodology. A mixed method comparative analysis approach was utilized, which allowed collection of both qualitative and quantitative data to be gathered. The use of a mixed method approach allowed me to gain direct opinions from the patients themselves, about their voice, with the understanding that the patients themselves were experts on their own illnesses and thus demanded a voice (Tuckett, 1985). However, the mixed-method approach also allowed me to gather data on the quantitative aspects of the DPI. Beyond the mixed-method comparative analysis, the data gathered was further implemented into a thematic analysis. A thematic analysis allowed me to create general connections and correlations of the DPI, as the comparative analysis only found correlations between the aspects of care. By further implementing a thematic analysis, the aspects of care could be directly connected to the care outcomes.

Research Design:

Following approval from the International Review Board, my survey began being distributed to a broad population (including individuals older than 15 years of age) throughout a nearby school and community. In several previous scholarly research pertaining to the DPI, surveys or interviews were used, however, in this case I chose a survey because of an interviews potential to compromise confidential patient medical information, making the patient uncomfortable as they would have to respond directly to another individual, rather than simply on an anonymous survey. Initially, the age range was set to be smaller, however, the range was expanded to include up to ages 55 and older, because the patient doctor interaction applies to all ages (anybody who goes to the doctor). Within the survey, participants were asked to recall an appointment that they had attended within the past year. The choice of an appointment from no longer than a year prior to the date of survey completion was due to memories predisposition to become less accurate when recollected after extended periods of time, and that visual memories fade over time, contributing to our accurate ability to ‘vividly’ recollect (Kensinger et al., 2019). In order to fully understand potential limitations to my research (that will be addressed later in this paper), the final question of my survey asked patients how accurate they feel the data they provided is on a 10-point scale (0= ‘not accurate’ and 10= ‘very accurate’). Beyond their data’s accuracy (asked as the last question of the survey) participants were asked their age at the start of the survey (given options ranging from 15 to 55+) which were broken up into increments to help analyze the data in a more organized manner. It was at this point that participants were asked both qualitative and quantitative questions, which were both presented open-endedly and in the form of multiple-choice questions. 

The participants were then asked if they had a chronic condition, which was created using the understanding that a chronic condition is long lasting and generally requires continuous medical care (World Health Organization [WHO], 2025). This knowledge was made clear to participants by stating “ongoing medical care” as part of the question by asking “do you have a chronic condition requiring ongoing medical care? to help better define and was measured in a multiple-choice format (yes/no). The following eleven questions were qualitative in nature to allow for the patient’s full expression of their attitudes towards the visit recalled. Of these eleven questions, seven were multiple choice. To begin the first round of qualitative questions, patients were asked to recall a visit within the past year and explain the reason behind the visit, allowing me to understand the context behind the visit when analysis began. Questions 5 through 7 broke down the quality of the visit (asking about time, interest, and listening skills in regard to the doctor). And the next three questions discussed if any referrals or further testing was conducted and if the patient was satisfied with this decision in regard to their concern. The choice of yes or no to the referrals branched off to questions about care (either directly from visit, or from referral). Multiple choice questions were used until this point because it allowed for general responses about feelings and facts, however, following questions did allow for open-ended responses on patient opinion. At this point, patients were asked their opinions on the care they did/ did not receive, and to provide any additional information about the visit. The questions up until this point allowed for an understanding of the visit itself, by allowing for qualitative responses directly from patient voice to ensure the survey was not limited to the results I expected, and instead entirely to the patient, to avoid bias. Questions 15 through 22 focused on patient outcome. Patients were asked to provide a numerical value of new care received (medications, procedures, testing, etc.) allowing for names if comfortable. This would help me to differentiate patients in my analysis by connecting reason for visit to outcomes, analyzed by the patients opinion on the logic and emotion behind this process. The use of the word ‘new’ in this question gave clarification that the response should include care following only the visit recalled in the survey. The participant was now asked to choose a value on a 10-point scale that best demonstrates the overall experience of the visit (0= very poor and 10= very good) with an explanation of this choice. These two questions were placed at this point, as it allowed the participant to recall all aspects of the visit up to this point and how analyzing each portion influenced experience. This placement also gave me understanding of the responses, and the value that was chosen. 

The following questions considered time, cost, and willingness to see a doctor after the visit, in both numerical and qualitative terms. Chronic illness’ influence on the care was also analyzed to understand a potential confounding variable to the visit and care received by asking patients the question “If you answered yes for having a chronic condition requiring ongoing care, do you feel this impacted your overall experience with your doctor and the treatment received? Why or why not?” This survey was distributed over a 2-week period where participants were given unrestricted time to address each question. (See Appendix A Figure 1 for full list of questions and response options).  

Figure 1- Thematic Analysis Categories 

Figure 2- Thematic Analysis Subcategories 

Thematic Analysis Defined: 

With the use of a thematic analysis for data interpretation, it is important to understand the definition of the created thematic analysis. The thematic analysis had 4 main categories to it. Dismissive Encounters and Detrimental Care, Empathetic Engagement and Enhanced Care, Various Interactions and Ambiguous Outcomes, and Dismissed (see Figure 1 above). To fall within the Dismissive and Detrimental category, participants had to have one or several negative views on the subcategories (which will be further defined at a later point), as well as had no care, care that did not address concerns, or care that did not neutralize symptoms. Additionally, participants had to have answered below neutral on the question regarding how well their doctor listened and how much interest was shown. To fall into the Empathetic and Enhanced category, participants had to have one or several positive views on the subcategories, with relevant care that addressed concerns. Additionally, they had to have answered above neutral for the questions on doctor listening and interest. To fall under the Various and Ambiguous Category, participant interaction and care were not clearly defined to fit into other categories. They could have mixed views on the subcategories, with positive or negative care, and mixed or neutral responses to the questions on doctor interest and listening. To fall under the Dismissed category, participants had to have given no consent or did not fit the criteria of recalling a visit within the past year. Thematic analysis subcategories were simply the aspects of the interaction with the doctor looked at most by participants (see Figure 2 above).  Addressing of concerns relates to initial concerns brought up by patient and how well they were addressed, active listening and engagement relates to how well the doctor listened and engaged, allowing for questions and conversation, doctor attitude relates to the sympathy and power differences that related to the attitude given to patient by the doctor, time constraints relates to the time spent with the doctor, such as  too rushed, too long, no issues with time. It was also possible for participants to fall into the ‘several’ subcategory, simply meaning they had feelings tied to more than one category. The thematic analysis definition allowed me to use compared qualitative and quantitative data (from the mixed method comparative analysis) to categorize my data by correlation to understand relationships. 

Figure 3- How well provider listened 

Figure 4- Provider Interest Level

Figure 5- Age Pie Chart 

RESULTS:

Survey Data:

This survey received a total of 55 responses. Of these 55, three did not give consent, and one responded with a visit beyond the given time frame of a year. Figure 5 above depicts the age range of participants. Of these 51 respondents, 81% were aged 15-25, 6% were 26-35, 2% were 36-45, 6% were 45-55, and 6% were aged 55 and older. Additionally, 21% of respondents had a chronic illness requiring ongoing care, and 79% did not have a chronic illness. Within the second section of the survey, eleven questions were multiple choice. Figure 3 above depicts participant response to the question ‘choose a response that relates most to how well you feel your provider listened.’ 40% responded extremely well, 31% responded somewhat well, 17% responded neutral, 10% responded somewhat not well, and 2% responded extremely not well. Additionally, Figure 4 above demonstrates responses to the question ‘Choose a response that relates the most to how much interest you felt your provider showed in your concerns.’ 38% responded extreme interest, 29% responded some interest, 15% responded neutral, 15% responded little interest, and 2% responded no interest. The participants were then asked to choose a response that relates to how rushed you felt the visit was, and 29 participants (56%) felt their visit was not rushed at all, 20 participants (38%) felt the visit was somewhat rushed with time considered, and 3 participants (6%) felt the visit was very rushed with the visit hurried. Furthermore, 6% of participants received referrals they did not feel were necessary, 27% received referrals they felt were necessary, 10% did not receive referrals but felt they needed one, and 58% did not receive referrals but were okay with this. 

Of the 17 who received referrals, only 10 of the referrals led to further care. Regarding care, 50% received care that neutralized symptoms, 23% received care that did not neutralized symptoms, and 27% did not receive care. 26 participants had symptoms that persisted, and 11 of them received further care to help neutralize symptoms. When asked to choose a number that demonstrated their overall visit on a ten-point Likert scale (0= very poor, 10= very good) 45 participants (86.53%) chose a number above the neutral 5, and 6 participants chose a number below the neutral 5, with only 1 person choosing 5. When participants were asked if their experience with provider impacted attitude about going to the doctor 62% chose no and 38% chose yes. Finally, when asked to choose a number that most accurately corresponds to how accurate they feel their data is, 50 participants (96.15%) chose a value above the neutral 5, and 2 participants (3.84%) chose a 5. 

Additionally, the second section had 9 free response questions. The first of the 9 questions instructed participants to recall a visit from the past year and explain what the purpose of this visit was. The responses received included checkups, eye appointments, concerns (such as headaches, wrist pain, stomach pain, medications, etc.), referrals (such as cardiology and dermatology), and mental health. The remaining 8 free response-based questions were sorted into the three themes explained in table 2. When the participant was asked if they felt the care received were relevant to their initial concerns, 6 (15.78%) participants fell under the “dismissive encounters and detrimental care” with 5 of these participants falling into the ‘addressing relevant concerns and failure to address concerns’ subcategory, and one falling under the ‘doctor attitude’ category. Additionally, (21 55.26%) of these participants fell under the “empathetic engagement and enhanced care” category, with 1 participant falling under the ‘doctor attitude’ subcategory, 3 participants falling under the ‘follow up care’ subcategory, and 17 participants falling under the ‘relevant care’ subcategory. Additionally, 11 participants fell under the “variable interaction and ambiguous outcome category” which varied based on the vagueness of response and the care’s relevancy to concerns or the lack of initial concerns. Finally, participants who had not received care were asked if they felt overlooked. In this case, 14 responses were received and 3 participants (21.42%) felt overlooked, with the remaining 11 (78.57%) not needing care or feeling their concerns did not require care. Furthermore, participants were asked to provide additional information on their visit, of the 52 respondents, 12 fell under the dismissive encounters and detriment care (3 of which fell under time constraint, 5 falling under patient care and relevancy, 4 falling under doctor attitude), 28 fell under the empathetic engagement and enhanced care category (10 falling under listening and engagement, 12 falling under doctor attitude, 1 falling under follow up care, and 5 falling under relevant care).

Thematic Analysis Data: 

The pie chart titled ‘Thematic Analysis’ demonstrates the number of respondents in each thematic analysis category. Of the 51 respondents, 27 fell under Empathetic Engagement and Enhanced Care, 22 fell under Variable Interaction and Ambiguous Outcome, 2 fell under Dismissive Encounters and Detrimental Care, and 4 fell under dismissed (see Appendix B Figure 1). Table pie chart titled ‘Empathetic Engagement and Enhanced Care’ examines the subcategories to the main category empathetic engagement and enhanced care. Of the 29 participants in this main category, 15 participants fell under the several subcategories, 6 fell under doctor attitude, and 8 fell under active listening and engagement (see Appendix B Figure 2). The pie chart titled ‘Dismissive Encounters and Detrimental Care’ examines the subcategories to the main category dismissive encounters and detrimental care. Of the 2 participants under this category, both participants fell under the several categories (see Appendix B Figure 3). Finally, the pie chart titled ‘Variable Interactions and Ambiguous Outcomes’ examines the subcategories under the main category variable interactions and ambiguous outcomes. Of the 20 participants under this category, 14 fell under several, 1 fell under time constraint, 3 fell under doctor attitude and listening and engagement, and 2 fell under addressing of care (see Appendix B Figure 4). 

Confounding Data: 

 The pie chart titled ‘Chronic Illness Impact on Interaction and Care’ demonstrates the data from two questions. The first question simply asked if a participant had a chronic illness, and the second question asked if the participant felt their chronic illness impacted their overall experience and care received. The data in the table looks to find the number of individuals who leaned towards it impacting interaction and care positively, negatively, or unclear. 6 participants who answered yes to having a chronic illness leaned towards a positive impact, with 2 leaning negative, and 3 being unclear (see Appendix B Figure 5). Data in the pie chart titled ‘Future Visit’ 1 looks at participants who responded yes when asked if their willingness to see a doctor was impacted. Of the 20 who answered yes, 15 felt their willingness was impacted positively by the interaction, with 4 feeling willingness was impacted negatively, and 1 individual being unclear about impact (see Appendix B Figure 6).

ANALYSIS: 

In 27 situations, participants fell under the category Empathetic Engagement and Enhanced Care. This category demonstrates the instances in which a positively defined interaction (via subcategory results) directly correlated to a positive health care outcome, with all needs met. In 2 situations, participants fell under the category Dismissive Encounters and Detrimental Care, directly demonstrating the instances in which negative interaction led to negative care. Both instances were defined by subcategories (addressing of concerns, listening and engagement, doctor attitude, time constraint, and several) which represented the top aspects of the interaction observed by a patient. In 22 situations, participants fell under Variable Interaction and Ambiguous Care, meaning the data gathered was not clearly defined to allow participants into other categories, however, the most prevalent relationships within this category were interactions leaning toward positive also leaning toward positive care and interactions leaning toward negative also leaning toward negative care. These relationships did not meet the criteria of the other categories; however, they followed similar themes. In 4 cases, data was dismissed for lack of consent or not fitting proper criteria (see Appendix B Figure 1). It is also important to note the confounding data that demonstrate how interaction implements care, with 15 participants positively impacted in willingness to see a doctor in the future due to their visit, and 4 negatively impacted (see Appendix B Figure 6). Willingness to see a doctor in the future can impact care, as care goes beyond what was received the day of the visit and can include future care at the hands of the visit. It is also crucial to note the role chronic illnesses play, as 6 participants felt their chronic illness enhanced the visit and care received, with 2 feeling their illness interrupted the visit and care received (see Appendix B Figure 5).

Findings:

In 27 cases, it can be indicated that a positive interaction will correlate with a positive care outcome for patient. Similarly in 2 cases, it can be indicated that a negative interaction will correlate with negative patient care. This indication is due to the data in which the interactions as perceived by the patient (good or bad) also had a relationship to good or bad care. However, due to the 22 cases in which the interaction and care were varied, and no correlation could be identified with 100% certainty, the findings from the Empathetic Engagement and Enhanced Care and Dismissive Encounters and Detrimental Care categories can only be defined as indicators of a potential correlation. It is important to note, however, that within the Varied Interaction and Ambiguous Outcome category, many participants followed the themes above, with positive interactions and positive care or negative interactions with negative care, however, they were not clearly defined enough to identify in full. It is also important to consider the implications to care that were not defined by the thematic analysis. The interaction held between the patient and doctor proved to impact 20 participants willingness to see a doctor in the future, and in 15 of these cases, participants who had a positive interaction were more inclined to see a doctor, but 4 participants with a negative interaction were less inclined to see a doctor, as shown in table 11. This confounding aspect shows that the care received goes beyond the visit, and in some cases, participants’ willingness to see a doctor in the future, this is to say their future care was directly impacted by the one visit recalled. Table 10 demonstrates the impacts of chronic illness on the interaction, which allows for an understanding of potential interruptions to the visit for participants specifically suffering from a chronic illness. 

DISCUSSION:

The study was designed to examine the potential implications that the doctor patient interaction could have on the care that was received.

Fulfillment of Gap: 

Within then initial dive into previous scholarly work, an understanding was formed on the potential interruptions to the interaction, such as voice, status, and communication style. It was also understood that, individually, hypotheses were formed about what indicates patient health outcomes and patient satisfaction. These two ideas were formed, yet isolated, and there was not a clear correlation between how interaction implemented care. In this research, participants were asked about several aspects of the interaction held, as well as the care received, and it was found that a positive interaction indicated positive care, and a negative interaction indicated negative care. For the more varied and undefined responses, similar themes were followed that shows indications that the doctor-patient interaction directly implements patient care. The gap became the foundation of my research design and process. 

CONCLUSION:

Implications:

Previous research indicates the significance of the DPI to the process of medicine. The results of this study can be used to educate medical professionals going forward. The comparisons made between qualitative and quantitative data in the mixed method comparative analysis allowed me to formulate a thematic analysis. The 3 main categories of thematic analysis can be used to educate professionals going forward on significance the interaction holds on care. More specifically, the subcategories can be used to understand what aspects of the interaction most are looked at, to improve communication and patient voice. Understanding the aspects of interaction and their relation to care can help doctors become more familiar and empathetic of patients. As participant 14 states, “Doctor was nice, but I felt like another number,” the results of this study can be used to address feelings like these to promote better interaction and overall care. 

Limitations:

In several questions, clarification could have been used. Two questions regarding the cost of care and time spent with doctors were included, however, results from these questions had to be dismissed, as a lack of clarification created uncertain results. In a future scenario, the time could be more specified to be with doctor only- not the whole visit, and the cost could be more defined by the price if no insurance was used. In some cases, participants recalled a visit where no concerns were brought up and consequently no care was received. While this data was still viable, going forward the specification of the type of visit may allow for more relevant data. Beyond clarification, there was some bias and inaccurate reporting. In some cases, participants explained a good interaction with the doctor and care, however, reported an overall low rating of the visit due to a rude receptionist or long wait time to get in. These separate variables created a negative atmosphere that carried into the data, causing inaccuracy. Additionally, participants were asked to rate how well they remembered the visit on a 10-point Likert scale (0= not accurate, 10= very accurate). Although no participants fell below a 5 in their choice, several fell between a 5 and 7, which could be a reason for more inaccurate data, as the number for how well recalled is at the lower end of the range chosen by all participants. Although the data was not dismissed, it could have implications, and going forward the time of the visit could be lessened to be from no longer than 6 months ago. Finally, on the question asking if participants had a chronic illness, despite understanding a chronic illness’ as defined by the World Health Organization, a clear and full definition was not provided as a part of the question (only part of the definition was utilized) causing potential confusion on the reporting of their chronic illnesses impact on the interaction and care received. 

Areas for future research:

The studies confounding variables are catalysts for future research. The understanding of chronic illnesses potential impacts on interaction and care can be a cause for further research, addressing how chronic illness plays a role in this model. Similarly, interactions impact on willingness to see a doctor could be further studied to understand how the DPI implicates care beyond the visit held the day of the interaction. 

Appendix A

Figure 1- Survey question and Response Options 

Appendix B

Figure 1- Participants in thematic analysis categories

Figure 2- Thematic Subcategory: Empathetic Engagement and Enhanced Care

Figure 3- Thematic Subcategory: Dismissive Encounters and Detrimental Care

Figure 4- Thematic Subcategory: Variable Interactions and Ambiguous Outcomes

Figure 5- Chronic illness impact on interaction and care

Figure 6- Interaction and future care

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