Doctor-patient relationship improved during COVID-19 pandemic, but weakness remains

The doctor-patient relationship (DPR) plays a crucial role in health care, as it is closely associated with treatment adherence, patient satisfaction, and treatment outcome [1‐4]. A good DPR is a determinant for patient satisfaction and a better clinical outcome, which affects the management of both chronic and acute disease, regardless of sociocultural factors [5].

It is believed that DPR can be restricted or promoted in different dimensions, i.e., the quality and type, which might affect how both the medical staff and patients view a given medical event [6]. As a special type of social interpersonal relationship shaped and evolved by the environment, DPR is dynamic, and depends on the social and medical situations [7].

During the past year, with the outbreak and protracted course of the COVID-19 pandemic, the healthcare industry has experienced unprecedented challenges. The disease caused by SARS CoV2 soon spread across many countries [8] and caused over-whelming challenges in healthcare service delivery globally in many ways [9‐13], including limited resources, appropriate priority setting, availability of medical care, isolation of doctors and patients, information sharing, etc., resulting in disproportional psychological [14] and well-being concerns [15] on both medical staff and patients. Although the pandemic has posed much pressure on the Chinese healthcare system, it also affected how society views medical workers, with many reports referring to medical workers as heroes or “white angels” [16, 17]. Hence, we may infer that the DPR during the pandemic might have been altered accordingly.

Since the outbreak of COVID-19, the DPR has attracted the public attention in China, which was reflected by increased searches of “COVID-19” and “DPR” in Baidu, a leading search engine in China [18]. Yet, it is unclear what impact the pandemic has on DPR in this country. In clinical practice, DPR is usually measured by patients’ perception [19], which was regarded as the feedback of medical service quality [20]. Based on the advantages of comparability and external validity of results, quantitative assessment using a validated scale is the most common method to measure doctor-patient interaction [21]. However, to date, there has been few studies using validated scales to assess DPR during the pandemic in China.

Therefore, in the present study, we aim to investigate the impact of COVID-19 pandemic on DPR. We compared patient’ perceptions of DPR before COVID-19 and during COVID-19 by using the patient-doctor relationship questionnaire (PDRQ-9), an instrument for evaluating DPR from patients’ perspective [22] with excellent reliability and internal consistency [19]. We also aim to examine how patient perceptions of DPR was impacted by multiple contextual factors, such as patient demographic data and changes in healthcare system in response to the pandemic, as well as to identify the key points for improving DPR. Findings of this study may help us to better understand the relationship between doctors and patients, as well as provide suggestions for future medical practice and healthcare policy.

In this study, we compared the quality of DPR before and during the pandemic and explored possible influencing factors that affect DPR during COVID-19 from the perspective of patients. Our findings revealed that respondents were optimistic about the DPR in China and reported an improved DPR during the pandemic. We also found that positive media reports, telemedicine, and medical policies significantly and positively affected the DPR during the pandemic. Furthermore, it was also found that doctor-patient communication, patient satisfaction, consultation time, doctor’s attitude and medical knowledge were specific aspects that needed to be prioritized to improve DPR in the future.

Respondents reported a better DPR in the present study, which was consistent with mainstream media coverage during the outbreak. According to our results, the improvement of DPR is mainly attributed to three factors, i.e., medical policies, positive media reports, and telemedicine. To respond to the COVID-19 pandemic, the Chinese government has taken nationwide and comprehensive measures [35]. One of the main actions taken by the government was free medical observation and treatment for confirmed cases, suspected cases, and close contacts [36]. This action helped form a firm doctor-patient relationship and reduce suspicion and mistrust between both sides. The media also played an important role at different levels in mobilizing public participation, shaping public sentiment, and improving awareness [37]. In the fight against the pandemic, many reports referred to Chinese medical staff as heroes and praised their hard work through media [16, 17]. This enhanced public understanding and support of medical staff, which in turn improved the DPR. Moreover, in the face of COVID-19, telemedicine demonstrated substantial benefits by providing effective consultations, remote patient monitoring, and prevention and treatment guidance for both the public and medical staff without transferring to physical location [38, 39]. During the pandemic in China, a multimodal telemedicine network combing smartphone APPs, 5G services, and existing telemedicine systems was activated immediately [40], and several types of online health services have been provided for people in need [41, 42]. The above measures were proved acceptable, feasible, and effective to improve health care outcomes and DPR in China. In line with our findings, Xu et al. claimed that free medical care, treatment equality, mutual understanding and cooperation, effective and informative communication, positive media reports lead to a harmonious DPR in mobile cabin hospitals during the COVID-19 in China [43]. However, according to a survey of DXY forum, only 13.94% of people believe that the COVID-19 situation could improve the DPR in China [18], which was inconsistent with our findings. A possible explanation for this discrepancy might be differences in participants, methods, and tools. DXY is a medical website with most users being young medical staff, while the participants of our study are patients. In addition, we used PDRQ-9 scale to quantitatively evaluate DPR while the DXY survey used only one question.

In Western studies, there are some different voices in the assessment of DPR during the pandemic. Similar to our study, general practitioners in Italy experienced an improvement of DPR during the early stage of the COVID-19 pandemic in terms of patient understanding, compliance, and solidarity [44]. In the US, many patients expressed positive feelings towards medical service providers and had a better understanding of the evolving field of healthcare facing the challenges [45]. However, Roubille et al. claimed that confidence vanished or impaired with accumulated distrust due to COVID-19 [46]. A possible reason for the inconsistencies is a combination of economic, political, social, and cultural differences. There is a need for cross-cultural and cross-setting studies to explore this complex topic.

Another strength of this study was that the IPA analysis revealed specific priorities for improving the DPR, which were mainly items fell in Quadrant III and Quadrant IV. Items regarding communication and patient satisfaction fell in Quadrant IV (“concentrate here”), indicating that these aspects were in urgent need for improvement and needed attention and intervention from clinicians and policymakers. Effective communication is essential for medical practice and DPR [47], and patient satisfaction may influence treatment compliance, continuity, and communication between doctors and patients [48]. During the pandemic, strict preventive measures such as lock-down, face mask and personal protective equipment were used, which created obstacles for effective doctor-patient communication [49, 50] and posed direct impact on both patients and doctors [50, 51]. Hence, when speaking to patients, doctors need to use patient-centered strategy with clear language [52], as well as eye contact, body gestures and movements [53], to improve patients’ confidence and build a doctor-patient rapport.

Three items fell into Quadrant III (“low priority”). Among them, consultation time ranked last both before and during the pandemic, indicating that the current consultation time was inadequate from the patient’s perspective. Qiao et al. found that shorter consultation time could negatively affect the DPR [24]. Cape and Mohd also found that shorter communication with doctor is a common cause of patient dissatisfaction [54, 55]. In China, the bed-to-nurse ratio is far below the level set by the Ministry of Health, and the workload of medical staff is so heavy that the time allotted to each patient is significantly reduced. Previous study showed that the consultation time in Chinese provincial hospital is only about 3–5 min [24]. Therefore, trying to reduce the workload of doctors and ensure adequate time for consultation will be effective to improve DPR. The doctor’s attitude is also an important factor for DPR. According to some patients, an open and friendly attitude of the doctor makes them feel respected and valued; they also expect close attention and enough time from their doctors [56]. This suggests that doctor’s understanding of doctor-patient communication should not be limited to the length of time but also the attitude and overall quality. It is worth noting that the item 6 (medical knowledge) showed low scores both before and during the pandemic. This might be related to the information asymmetry, which led to misunderstandings and disharmony between doctors and patients [57]. From this perspective, approaches such as medical education [58] and shared decision-making [59] are required to narrow the information gap between doctors and patients.

The present study has important implications for the future of medical services in China. For example, better medical education for both patients and medical professionals can help improve medical services delivery to patients [60], as well as promote public awareness of the current crisis. This may help stabilize public sentiment in the face of uncertainty and maintain social trust [61]. Regular updates of information about COVID-19 and latest policies and services can also promote trust between patients, doctors, and healthcare administrators. Media portrayal of doctors during the pandemic are crucial for the public perception of doctors, which may affect DPR directly. Moreover, DPR can also be affected by other factors such as healthcare system and administration, culture, and financial management medical sectors [62]. With all the above measures, medical services will be improved nationally during the pandemic and the public better prepared for the crises [63].

There are some limitations that should be mentioned. First, due to the nature of the questionnaire and the sampling method, selection bias cannot be ignored. With the use of the convenient online sampling strategy, the population included in this study might not be able to reflect the general population. Second, the measurement of DPR before and during the COVID-19 pandemic were evaluated with the same questionnaire and was based on patients’ self-reports, which may lead to a recall bias. Third, the data disclosed in a previous article might induce over representatives [34]. Four, due to the cultural circle and the specificity of the social relationship between doctors and patients in China, the results of this study cannot be extrapolated to other parts of the world. Therefore, further studies are needed to confirm the impact of COVID-19 on DPR in cross-cultural contexts. As the impacts of medical policies and media on social attitudes still remain unknown, these results should be interpreted with caution. In addition, there are some other factors (such as equal health services and social discrimination) that may affect DPR and need to be verified in follow-up studies.

In conclusion, this study investigated and compared the doctor-patient relationship before and during COVID-19 from the patient’s perspective. We have identified the main factors leading to better DPR during the pandemic and key points that need to be prioritized for improvement. Our findings may help us better understand the doctor-patient relationship and provide a reference for building a harmonious doctor-patient relationship in the future.