Patient–physician concordance and discordance in gynecology: Do physicians identify patients’ reasons for visit and do patients understand physicians’ actions?

Abstract

Objective

To assess physician–patient concordance on reasons for consultation and actions taken during consultation in five different gynecological practices, and to investigate patient and physician factors influencing discordance in reporting.

Methods

1667 post-encounter questionnaires completed by patients and physicians were compared in terms of reasons for consultation and actions taken during consultation. Patient–physician concordance was assessed using kappa statistics. Multivariable regression analyses served to identify determinants of discordance.

Results

A moderate to high level of patient–physician concordance on reasons for consultation and actions taken during the consultation was found. Discordance regarding reasons for consultation was associated with patient and practice characteristics, discordance regarding actions taken during the consultation only with practice characteristics. Counseling emerged as a particular source of patient–physician discordance.

Conclusion

In gynecological practices, discordance depends on the reason or action assessed, but is particularly pronounced when it comes to counseling. The influence of physician characteristics on patient–physician concordance needs more attention in research.

Practice implications

Gynecologists need to establish a mutual understanding with their patients about the reason of the consultation and the actions taken in the consultation, in particular with regard to counseling.

Introduction

Concordance is an important feature of the patient–physician interaction. Not surprisingly, a considerable body of literature has investigated patient–physician concordance with regard to symptom etiology [1], [2], [3], patients’ health status [4], [5], [6], physicians’ understanding of their patients’ expectations and treatment goals [7], [8], [9], [10]. Studies from different medical fields provide evidence that patient satisfaction, adherence to treatment and outcomes of care are higher when physicians and patients agree with each other [7], [10], [11], [12], [13]. Moreover, better understanding between patients and physicians is also related to a reduced need for further consultations [1] and better patient self-management of care [7], thereby decreasing health care costs.

Less is known on the degree of agreement between patients and physicians on why the patient consults the doctor and on what happens during the consultation itself. Studies showed that doctors and patients do not always agree with each other regarding the reasons for a specific consultation [14], [15], [16] and actions taken therein [15], [17], [18]. Using post-consultation questionnaires, Boland et al. [14] observed that although physicians were generally able to identify patients’ reasons for seeking a general medical examination, in 20% of the visits agreement was low or absent. Family physicians and patients frequently gave discrepant reports of what had happened during the consultation [18]. As reported by Street and Haidet [19] physicians may misperceive how their patients understand clinical actions even for relatively common medical issues, such as blood pressure control.

So far, physician–patient concordance in gynecological care has hardly been addressed apart from studies which examined the validity of patient reports regarding preventive clinical interventions such as mammography and Pap screening in comparison to medical record data which were considered as gold standard [20], [21], [22]. However, in basic gynecological care, the ability to establish a mutual understanding regarding reasons and content of consultation may be of particular importance because, besides treatment, information giving, counseling and decision making involving patient preferences constitute a considerable part of a consultation, e.g. for contraception, pregnancy, or menopause.

Factors influencing patient–physician concordance are still not fully understood [5]. Several studies have examined how patients’ socio-demographic characteristics such as socio-economic status, education, or ethnicity influenced patient–physician concordance. Results of these studies have been mixed. While some suggested that concordance might be negatively effected by lower socio-economic status [17] or ethnicity [18] through less effective patient–physician communication, others found no effect for patient education, income or race/ethnicity [5]. Again other studies showed that agreement rather depends on patients’ health status [5], [6], their active participation [7] or the continuity of the patient–doctor relationship [24]. Yet, few studies have investigated the influence of physician characteristics on patient–physician concordance [10]. According to an early study by Sawyer et al. [20], women who had been seen by nurse practitioners were more likely to report their last Pap smear more accurately than women seen by an internist or family practitioner. Rohrbaugh and Rogers [18] reported that discrepant physician and patient perceptions on what happened in routine family clinic visits could not be explained by patients’ demographic characteristics but varied by visited physicians and were more pronounced if physicians minimized attention to psychosocial issues and/or felt confident about understanding the patient's problem.

In order to address the above mentioned lack of research with regard to patient–physician concordance on reasons and content of gynecological consultations, the aims of the study are, first, to compare patients’ and gynecologists’ reports of reasons for a particular consultation and actions taken during this consultation based on post-encounter questionnaires across five different gynecological practices, and to assess physician–patient concordance in these reports. Second, we sought for a better understanding of the factors influencing discordance in reporting. Based on the insights from other studies, we hypothesized, that discordance would not only vary by patient characteristics but also differ between the practices due to different working approaches. We also expected that physicians will have a better concordance with long-term patients than with patients with whom they have had only few or no previous visits.