Results
The analysis showed two core, conflicting themes that either generated patient satisfaction or patient dissatisfaction. The themes were all about either being taken seriously or not taken seriously. In the beginning of the analysis the themes were more descriptive than theoretical, but by linking to social psychological theories [
18] it became possible to develop a theoretical pattern for the relationship between interpersonal continuity and patient satisfaction. By means of the two social psychological concepts,
recognition and
humiliation, the analysis of the pattern of creation and destruction of satisfaction became clear. Recognition is a relationship concept – an attitude expressed through interaction [
18,
19]. On the one hand, the process of recognition, by respecting and remembering, created and maintained satisfaction while humiliation on the other hand destroyed satisfaction in the relationship. Humiliation is in its everyday sense a strong word and it has to be understood in a theoretical frame of reference, i.e. as the opposite of recognition [
20].
Recognition
All the interviewed patients expressed satisfaction with the interpersonal relationship with the GP in the observed consultation. According to the interviewed patients the crucial points for satisfaction with the relationship were the GP's ability to talk seriously about their problem as well as the fact that the GP 'saw' them;
"He listened to what I was saying, and he took me seriously. So I felt that it was I who was important" (Marianne, 29 years old, first encounter).
'To be taken seriously' is a complex process with constituent parts all forming part of a whole. With a comprehensive term, the process of taking a patient seriously is defined as recognising the patient and his or her application. The term recognising has two different meanings, respecting and remembering, and in this context it means being respected by the GP. The patient experienced that she was taken seriously, if the GP was able to recognise the patient by listening, understanding, confirming and accepting. It satisfied the patient and trust was established;
"I wanted the GP to take it seriously. It is not a serious problem; it is nothing that I will die of or be injured from in any way. It is purely cosmetic, right? But the fact that he understood that it was not something that he should avoid doing something about. It should not just be brushed aside. I realise that it is not important, but it is still important to me. Therefore, I think that it was a good consultation. It was satisfactory" (Ninna, 26 years old, first encounter).
The above patient was seen by a GP she did not know in advance. It was the GP's ability to recognise (respect) her combined with his professional ability that created the immediate satisfaction.
The observations in the consultation confirmed the patients' statements that when the GP, in a non-verbal way, indicated acceptance and understanding by nodding and keeping eye contact, the patient felt recognised (respected). If the GP focused on the patient by for instance turning his body directly towards the patient and not towards the computer, his body language signalled presence. It made the patient feel important;
"I felt that I was in good hands. I had the feeling that I should sit here, and for the next ten minutes, I would be the subject of importance, and indeed, not all GPs are capable of sending that signal. He did this through his behaviour. He signalled that he was interested in what I was saying, and he was calm". (Lene, 56 years old, first encounter)
One patient described his first meeting with the GP this way;
"My impression of him was that he was very obliging. He welcomes you in a pleasant way and says hello and is kind and obliging. So you immediately feel welcome, and I think that he was nice to talk to. He keeps eye contact and is attentive. So my impression is that he is nice to talk to, he seems trustworthy". (Frederik, 39 years old, first encounter)
Satisfaction and trust were constructed contextually in a dynamic process between the GP and the patient, and it did not depend on longitudinal continuity. On the contrary, it depended on the fact that the GP took the patient seriously at the actual encounter.
Humiliation
All of the 22 interviewees could remember an unsatisfactory encounter with a GP. The patients told that they felt humiliated if the GP did not take them seriously. This would happen if the GP ignored, insulted or ridiculed the patient. Therefore all of the negative experiences dealt with the opposite of recognition, i.e. humiliation. The study showed that the first encounter between the GP and the patient was crucial to many of the patients. If the patient felt humiliated, he or she did not want to consult the same GP again;
"I went to see the GP about my knees. The GP's conclusion was that I had to find something else to do, and honestly, I thought that it was a strange thing to say, because if you are told that you cannot work anymore, then what should I do? He cannot just say that I should find something else to do because you can't do that at my age. No, I don't want to consult him again. I do not trust him at all, so I would not like to consult him again".
Interviewer: So the trust is gone?
"Yes, honestly, I think it is. It would be difficult for me to believe what he was saying the next time I consulted him. It would. (Erik, 32 years old, first encounter).
If the GP humiliated the patient by not taking him or his problem seriously, the patient lost confidence in the GP. The overall pattern of recognition versus humiliation was most obvious at the first encounter. It may create the basis for a satisfactory, continuous, trustful relationship, but if the encounter generated distrust, it created no basis to build on.
Association between interpersonal continuity and satisfaction with the relationship
There were ten patients who saw a trainee and all of them were satisfied with the relationship in the consultation. Two of the ten patients did not care who they were to see next time. They were both under the age of 30, and nothing "serious" was wrong with them. For the other eight patients interpersonal continuity was important. Two of the other eight patients would like to continue seeing the trainee because he had started the course and they wanted him to follow up. The other six patients said that they would like to see the trainee again, if they had a minor problem. But they preferred to see their regular GP, if they had a severe problem.
When a good relationship was created with the regular GP, it was valuable for the patients to maintain it. A total of 12 out of 22 interviewees saw their regular GP. They all had a good and trustful relationship with him and preferred to maintain it. They had several reasons for that. It strengthened the feeling of being taken seriously, if the GP remembered the patient;
I think that the better you know your GP, the better you sense that he is taking you seriously. This may be because the GP you consult on a regular basis will of course be better at remembering your situation. The very fact that the GP is able to continue to talk about your disease immediately makes you automatically feel that he is taking you seriously, because he remembers what we talked about the last time I consulted him. (Dennis, 48 years old, 9 years with the same GP)
Another valuable aspect of the continuous relationship was that it provided the patients with a feeling of security. In particular, the patients who were in long-term courses of a disease or who suffered from a chronic disease most clearly expressed their need for security;
I would feel unsecure not consulting a regular GP. I would feel unsecure if one was to continuously meet new faces and inform them. Even though they have our records, you will never have the same contact; and thoroughness, if they have not followed you for many years... and he performs the same examinations every time; and then, it also makes me secure that he knows, and that I know, what is going to happen to me." (Anna, 58 years old, patient with a weak back, 31 years with same GP).
According to the interviewees, it also generated improved coherence in the treatment, and it was a relief not to be forced to tell the medical history over and over again. It made it of special value to sustain the relationship;
I always make an appointment with Peter. I like the continuity. Then I don't have to start with Adam and Eve every time. (Lene, 56 years old, chronically ill, 5 years with same GP)
Many statements described that it was especially satisfying when the patient felt that the GP was interested in the patient as a person, which was possible if the GP knew the patient;
"I seldom associate it with a positive thing to see the GP, but it is a little more comfortable to go there when, at least, you have felt that he is interested in you. I think it is nice when he remembers and recognises you when you go there. This makes you a little more relaxed". (Erik, 32 years old, 32 years with the same GP)
It was therefore very satisfying to be remembered by the GP;
When we consult either Antonsen or Larsen, we are recognised, they know who we are; they may very well skim the records on the computer screen before we enter, but they always ask how things went with this and that. This makes me feel secure. It seems like, well, we are in good hands here, they remember you, they know what it is all about, and that's the way it should be. (Bente, 57 years old, 3 years with same GP).
The GP should respect and remember the patient; as a person as well as in relation to illness. The term recognise has two different meanings, respect and remember, and if the GP did both, interpersonal continuity was especially valuable to the patients. It created a good and trustful relationship to the GP.
Association between interpersonal continuity and dissatisfaction with the relationship
However, the repeated visits made the GP-patient relationship vulnerable. If interpersonal continuity had to be valuable, the meaning of recognition had to include remembering. The patients expected to be remembered as a person, and they became very disappointed if the GP did not remember them;
When we consulted Hansen, it was like we were there for the first time; he hardly knew who you were. I didn't feel that he took me seriously. He did not respect me, and then he talked about his own problems. It is a relationship of trust; it's a question of respect. We need to be secure. (Bente, 57 years old, 20 years with her former GP)
Remembering was a decisive element in being able to maintain satisfaction by interpersonal continuity. If the GP did not remember the patient, then interpersonal continuity lost its value;
I don't think that Sørensen ever got to know me. Well, I was kind of alienated when he saw me. When I was called in from the waiting room, it was almost like he saw me for the first time. I had been attached to this health care centre for six years, so he should know who I am, shouldn't he? I think that he (the new GP) listens more to what I say and is very focused on the fact that we should try to find out what is wrong. Whereas I sensed that Sørensen would not have done that at all". (Katrine, 72 years old, 7 years in same healthcare centre).
Even though the above patient had a continuous relationship with her former GP, she was dissatisfied. She felt objectified. Therefore, she changed after 6 years to one of the other GPs in the same health centre whom she had seen by chance. The new GP 'outmatched' the continuous relationship because he remembered her, "listened more", and focused on taking her inquiry seriously as opposed to the former GP.
All of the negative experiences dealt with the opposite of recognition (remembering and respecting), i.e. humiliation. Humiliation was an overall term for the negative experiences. There were numerous examples of the relationship never becoming satisfactory if the patient felt objectified, insulted, ignored or ridiculed even though the patient continued with the same GP;
"I had actually suffered from a bad leg for years, but I damn well did not mention it to Hansen anymore. He had laughed at me once, and he should not be allowed to do that again, should he? There have been a lot of such examples; that he almost laughed and started talking about the birds in the garden, how many different kinds he had and that he could hardly manage to take care of the garden." (Bente, 57 years old, 20 years with her former GP).
The above patient felt exposed to ridicule. She had seen this GP for 20 years, even though she was dissatisfied. This applied to some of the other patients. They told about long-term relationships where they had been dissatisfied without changing GPs. However, the patient could feel so offended in a specific consultation that there was no other solution than to change;
"I changed because he said that I was hysterical. I had a problem of sweating a lot and he examined me, but ended up telling me that I was hysterical. There are certain things you do not want to hear when you go to the GP. It is something you want him to take seriously". (Pernille, 29 years old, 8 years with former GP).
For a long time, the above patient had been dissatisfied. But it was not until she felt that the GP offended her specifically that she changed. Another patient felt insulted in a specific consultation because the GP did not take his suggestion seriously, and afterwards he changed GP;
"I went to my former GP, and asked if it could be this disease, my mother had. He said; no, it is not, I guarantee. Then I asked for some tests and he just said; if you insist! But I was right. Then the trust was gone." (Søren, 72 years old, 15 years with former GP).
Even though the GP-patient relationship was characterised by dissatisfaction, the relationship could still be a long-lasting one.
Authors' contributions
HBF carried out the design of the study, collected the data, performed the data analysis and drafted the manuscript. JK and GDL participated in the design of the study and the data analysis. All authors read and approved the final manuscript.