<figure><img src="image_1.png" /></figure>

ORIGINAL ARTICLE

# How do patients define a good ophthalmologist? A survey from an academic medical center in France

<figure><img src="image_2.png" /></figure>

Qu'est-ce qu'un bon ophtalmologiste selon les patients ? Étude hospitalière française

L. Trouvé<sup>a,*,b</sup>, F. Mouriaux<sup>c,d</sup>, A. Boulogne<sup>e</sup>, A. Lejay<sup>b,f</sup>, L. Dormégny<sup>a,b</sup>, S. Kuntz<sup>b,f</sup>, A. Sauer<sup>a,b</sup>, D. Gaucher<sup>a,b</sup>, N. Chakfé<sup>b,f</sup>, T. Bourcier<sup>a,b</sup>

Reçu le 19 avril 2024 ; accepté le 10 juillet 2024

KEYWORDS

Communication ;
Doctor-patient
relationship ;
Medical education ;
Medical skills ;
Patients' opinion ;
Personality profiles ;
Process-
communication
model

Summary

**Purpose.** — To identify the skills and personality profiles that are most expected by ophthalmology patients and to help ophthalmologists and ophthalmology residents improve their communication with patients and thus their quality of care.

**Methods.** — This prospective, single-center study was carried out from November 2nd, 2020, to April 30th, 2021 in the ophthalmology department of Strasbourg University Hospital (Strasbourg, France). One thousand one hundred and eighty-three volunteer ophthalmology outpatients participated in the study. We created a French-language questionnaire including 16 physician qualities identified in the literature and 18 qualities drawn from Process-Communication© Model profiles.

<footnote><sup>a</sup> Service d'ophtalmologie, nouvel hôpital civil, CHU de Strasbourg, FMTS, université de Strasbourg, BP426, 67091 Strasbourg, France</footnote>

<footnote><sup>b</sup> Gepromed, Strasbourg, France</footnote>

<footnote><sup>c</sup> Service d'ophtalmologie, CHU de Rennes, université de Rennes, Rennes, France</footnote>

<footnote><sup>d</sup> Service d'ophtalmologie, centre universitaire d'ophtalmologie, CHU Laval, université du Québec, Québec, Canada</footnote>

<footnote><sup>e</sup> Faculté des sciences sociales et comportementales, université d'Amsterdam, The Netherlands</footnote>

<footnote><sup>f</sup> Service de chirurgie vasculaire, nouvel Hôpital civil, CHU de Strasbourg, FMTS, université de Strasbourg, Strasbourg, France</footnote>

<footnote>* Auteur correspondant.</footnote>
*Results.* — For the 784 patients meeting inclusion criteria and successfully completing the questionnaire, 60% (n = 470) were female and 40% (n = 314) male, with a mean and median age of 47 years. The most frequently chosen criteria are those relating to communication (mean score 4.45 ± 0.90 out of 5). Organizational qualities were also frequently chosen (3.83 ± 1.23). Respondents somewhat frequently selected both human qualities (3.72 ± 1.55) and theoretical and practical skills (3.71 ± 1.42). Patients preferred a conscientious (n = 611, 13%), responsible (n = 519, 11.05%), and reflective (n = 491, 10.50%) ophthalmologist. The most chosen Process-Communication Model profiles were persisting (n = 737, 94%), thinker (n = 729, 93%) and imaginer (n = 680, 87%).

*Conclusion.* — According to patients, the ideal profile of an ophthalmologist is primarily a good communicator, as well as competent and humble. This study will help physicians to better meet patient demands and might also improve the training of ophthalmologists.

© 2024 Les Auteurs. Published by Elsevier Masson SAS. This article is published Open Access under a Creative Commons Attribution 4.0 License (http://creativecommons.org/licenses/by/4.0/).

## MOTS CLÉS

Communication;
Relation
médecin-patient;
Éducation médicale;
Compétences
médicales;
Avis des patients;
Profils de
personnalité;
Process-
communication

## Résumé

*Objectifs.* — Identifier les compétences et les profils de personnalité les plus attendus par les patients en ophtalmologie et aider les ophtalmologistes et internes en ophtalmologie à améliorer leur communication avec les patients et la qualité des soins.

*Méthodes.* — Cette étude prospective et monocentrique a été réalisée du 2 novembre 2020 au 30 avril 2021 dans le service d'ophtalmologie du CHU de Strasbourg (Strasbourg, France). Mille cent quatre-vingt-trois patients consultant en ophtalmologie ambulatoire ont participé à l'étude. Nous avons créé un questionnaire en français comprenant 16 qualités médicales identifiées dans la littérature et 18 qualités tirées des profils du Modèle de Process-Communication©.

*Résultats.* — Parmi les 784 patients répondant aux critères d'inclusion et ayant répondu avec succès au questionnaire, 60% (n = 470) étaient des femmes et 40% (n = 314) des hommes, avec un âge moyen et médian de 47 ans. Les qualités les plus attendues par les patients sont celles relatives à la communication (score moyen 4,45 ± 0,90 sur 5). Les qualités organisationnelles ont également été fréquemment citées (3,83 ± 1,23). Les répondants sélectionnent assez fréquemment à la fois les qualités humaines (3,72 ± 1,55) et les compétences théoriques et pratiques (3,71 ± 1,42). Les trois critères de personnalité de l'ophtalmologiste les plus attendus par les patients sont: consciencieux (n = 611, 13%), responsable (n = 519, 11,05%) et réfléchi (n = 491, 10,50%). Les profils de personnalité les plus choisis étaient: persistant (n = 737, 94%), penseur (n = 729, 93%) et imaginateur (n = 680, 87%).

*Conclusion.* — Selon les patients, la qualité majeure que doit avoir un ophtalmologiste est une bonne communication; il doit également être compétent et humble. Cette étude aidera les médecins à mieux répondre à la demande des patients et pourrait également améliorer la formation des ophtalmologistes.

© 2024 Les Auteurs. Published by Elsevier Masson SAS. This article is published Open Access under a Creative Commons Attribution 4.0 License (http://creativecommons.org/licenses/by/4.0/).

## Introduction

In the complex field of medicine, certain practitioners are recognized by patients and peers as being outstanding. What skills and characteristics do those identified as "good" doctors have in common? Research indicates that the answer to the question depends on who is responding. Studies that questioned different health care professionals show that their opinions diverge [1-5]. Surgeons and those in other medical professionals ranked effective communication within the medical team highly. For medical students, empathy and the transmission of knowledge were important [1,2]. Across professions, clinical skills and theoretical knowledge were frequently cited. Studies that

investigated patients' opinions and degrees of satisfaction provided complementary results [3-5]. They found that practical skills, patient involvement in treatment decision-making, and doctors' availability were linked to increased satisfaction with the quality of care [4,5]. These studies were carried out across different specialties: psychiatry [6], neurosurgery [7], general surgery and general medicine [2,4-7], but to our knowledge, no studies specifically identify the characteristics of a "good" ophthalmologist. It is possible that patients' expectations differ by specialty. The bottom line is that the overall quality of patient care and patient's safety are intimately linked to the quality of training, acquired competences, amount of practice, experience, and
continuous professional development of the physician who
delivers care.

To develop a relationship of trust between patient and doctor, interpersonal skills such as communication, listening and empathy are as important as theoretical knowledge and practical skills. Several communication models that are beneficial for medical practice exist, such as TIS Methodology [8], DISC [9], MBTI® [10] and PCM [11]. The American psychologist Taibi Kahler developed the Process-Communication Model (PCM) in the 70s [11]. It identifies six distinctive personality profiles and their three corresponding qualities: thinker (logical, organized, responsible), persister (conscientious, observant, dedicated), harmonizer (sensitive, warm, compassionate), imaginer (imaginative, reflective, calm), rebel (spontaneous, creative, playful), promoter (adaptable, persuasive, charming). This scientifically validated method has been used in the medical field to improve communication between caregivers and patients [12]. It may be possible to use the PCM to identify personality profiles shared by "good" doctors.

A better understanding of the factors that have an impact on communication may help doctors improve their interpersonal skills. When speaking of doctor/patient interactions, Ong et al. defined communication as an exchange of ideas, which facilitates the resolution of interpersonal conflicts and the improvement of relationships [13]. It is possible that patients' criteria change based on their sex, age, or their reason for consultation. These questions have yet to be explored.

The aims of this study are to:

* identify the skills and characteristics that are most expected by patients in ophthalmology;

* find out if particular PCM personality profiles are preferred by patients;

* (iii) help ophthalmologists and residents in ophthalmology to improve their communication with patients and subsequently their medical care.

# Material and methods

## Development of the questionnaire

Using the Medline, BDSP, EMBASE and Cochrane Library databases we combined 2 A and B categories using the Boolean operator 'AND'. Category A included the following: good or satisfaction or qualities or Process-Communication. Category B included the following: doctor or surgeon or ophthalmologist or medical specialist, to define the qualities used by patients to identify a 'good doctor' and establish a link with our chosen communication model, PCM. A total of 39 qualities were identified based on the criterion that were cited at least twice in the chosen studies. Three authors (L.T., F.M. and T.B.) analyzed these qualities and 16 were selected to be used in our questionnaire. These 16 qualities were divided into the following subgroups: theoretical knowledge and practical skills (questions 1 to 4), communication skills (questions 5 to 8), human qualities (questions 9 to 12), and organizational qualities (questions 13 to 16). Three versions of the questionnaire were tested on small groups of patients and the Users' Commission of the Rennes University Hospital

(Rennes, France), to make improvements to the initial model. The final questionnaire (Appendix 1) was written in French and was composed of multiple choice questions. The first part of the questionnaire presented the study, its objectives and its anonymous and confidential nature. Patients were first asked socio-demographic questions (age and gender) and then had to choose one or more reasons for consultation among the following: chronic eye disease follow-up, vision control, pre-or post-operation consultation, first-time appointment. In the third part, respondents were asked to evaluate the 16 selected qualities using numerical scales ranging from 0 to 5 (0 being totally disagree and 5 totally agree). The final part asked to patients to select 6 out of the 18 PCM qualities they deemed most important in a "good ophthalmologist".

## Distribution of a patient questionnaire

The study was carried out from November 2nd, 2020, to April 30th, 2021 and began after consulting the ethics committee of the Strasbourg University Hospital (Strasbourg, France). The questionnaire was given to all consenting patients coming for a consultation at the ophthalmology department of the Strasbourg University Hospital. Respondents that met one of the following criteria were excluded from our analysis: younger than 18 years old, blind patients or those having difficulty reading or understanding French. To limit biases, questionnaires were handed out and collected back before the ophthalmologist's examination. Questionnaires were distributed in paper or electronic format. Dragn Survey software was used to hand out the questionnaires electronically. Answers were recorded directly and anonymously in an Excel (Microsoft® Excel, ©2017 Microsoft, Version 15.33) database. A questionnaire was considered properly completed if each item was answered when no additional information was added and, for the paper format, if the questionnaire was legible.

## Statistical analysis

The expected number of patients to include in the study was calculated using the Cochran formula [14]. The desired sample size was 385 patients. By estimating a minimum response rate of 50%, it was therefore necessary to collect a minimum of 770 questionnaires. Statistical analyses were performed using Excel software. We computed means, medians and standard deviations to see the average scores with the corresponding margin of error and the dispersion of the values. The *P*value.io interface, using R software, was used to perform a univariate analysis using Chi-square, Pearson, and Welch tests. Significant *P*-values were < 0.05. We also specify *P*-values < 0.01 and < 0.001. The assessment of patients' favoured PCM personality type was based on the criteria that a quality related to a specific profile was selected at least once.

## Results

We collected 1183 questionnaires over a six-month period, including 497 electronic and 686 paper versions. A total of 399 questionnaires were excluded because they did not
<table><caption>**Table 1** Characteristics of the questionnaire respondents according to the reason for consultation.</caption><thead><tr><td>Reason for consultation</td><td>Male, n (%)</td><td>Female, n (%)</td><td>Mean age (SD)</td></tr></thead><tbody><tr><td>Routine check</td><td>97 (27)</td><td>222 (41)</td><td>43.3 (18.0)</td></tr><tr><td>Chronic disease follow-up</td><td>87 (24)</td><td>120 (22)</td><td>55.0 (18.8)</td></tr><tr><td>Surgery preop., postop.</td><td>88 (24)</td><td>108 (20)</td><td>57.8 (18.6)</td></tr><tr><td>First time at the ophthalmologist</td><td>94 (26)</td><td>89 (17)</td><td>41.4 (17.4)</td></tr><tr><td>Total</td><td>366 (40)</td><td>539 (60)</td><td>47.6 (19.3)</td></tr></tbody></table>

Respondents were 60% (n=470) female and 40% (n=314) male. It was asked to choose one or more reason(s) for consultation. The mean age was 47.6 (± 19.3) year-old (range 18–96). The median age of the respondents (47-year-old) was used to divide respondents into two subgroups: "younger" patients (n=395, under 47 years old), and "less young" patients (n=389, over 47 years old). The main reason for consultation was vision control (41%, n=319). Other patients came for a chronic eye disease follow-up (26%, n=207), ocular surgery programming or early postop follow-up (25%, n=196), whereas 23% (n=183) came for the first time to an ophthalmologist. Most of these patients coming for the first time were males (P<0.001). Reason for consultation "vision control" was mainly chosen by women (P<0.001) and youngest patients (P<0.001). "Chronic ocular disease" and "surgery" were mainly chosen by older patients (P<0.001) whereas youngest patients choose the answer "first time at the ophthalmologist" (P<0.001).

meet the criteria detailed above. The exclusion rate was 33.73%. A total of 784 questionnaires were analyzed in the study. Characteristics of respondents are presented in Table 1.

## Analysis of the qualities and skills questions

We asked patients to rate the importance of 16 criteria using numerical scales (Fig. 1). The most frequently chosen criteria are those relating to communication (mean score 4.45±0.90). Organizational qualities were also frequently chosen (3.83±1.23). Respondents somewhat frequently selected both human qualities (3.72±1.55) and theoretical and practical skills (3.71±1.42).

Patients who only needed vision controls gave less importance to "many diplomas" (3.07±1.30 vs. 3.28±1.30, P<0.01), "commitment to research" (2.54±1.43 vs. 3.31±1.41, P<0.001), "being a good surgeon" (3.76±1.59 vs. 4.29±1.15, P<0.001), "good communication with colleagues" (3.82±1.23 vs. 4.03±1.09, P<0.05), "participation in humanitarian missions" (1.57±1.26 vs. 2.00±1.41, P<0.001), "being computerized" (3.08±1.41 vs. 3.32±1.36, P<0.05) and "accepting emergencies" (4.17±1.09 vs. 3.37±0.89, P<0.01), than other patients. They gave more importance to "being punctual" (3.65±1.25 vs. 3.49±1.22, P<0.05). Patients coming for a follow-up for chronic disease were more concerned with the following qualities: "commitment to research" (3.39±1.44 vs. 2.85±1.45, P<0.001), "being a good surgeon" (4.31±1.12 vs. 3.99±1.45, P<0.05), "participation in humanitarian missions" (2.08±1.39 vs. 1.74±1.34, P<0.01) and "accepting emergencies" (4.43±0.84 vs. 4.24±1.02, P<0.05), but they gave less importance to "punctuality" (3.32±1.35 vs. 3.64±1.19, P<0.01). Patients coming for pre-or post-operation consultations favored the quality "commitment to research" (3.29±1.51 vs. 2.90±1.44, P<0.001) and "being a good surgeon" (4.39±1.14 vs. 3.97±1.43, P<0.001). They were less concerned with whether the practitioner was willing to acknowledge their mistakes (4.45±0.87 vs. 4.59±0.75,

P<0.05) and to take into account patient's preferences (3.67±1.20 vs. 3.84±1.23, P<0.05) (Table 2) shows the scores for the 16 criteria in each group of reason for consultation.

Differences in scores were also found when looking at the respondents' age and sex. For women, the mean score on the 16 questions was 4.00±1.29 and for men, it was 3.82±1.39. The results obtained for 12 out of 16 questions were statistically different according to gender. Women were globally more concerned than men with theoretical and technical knowledge, human, and communication qualities. There were no gender differences in questions about organizational qualities. The mean score for the 16 questions was 3.85±1.36 for young patients as compared to 4.00±1.30 for older patients. The results obtained for 11 out of 16 questions were statistically different according to the age of the respondents.

Patients under 47 years of age preferred the criteria "takes into account my preferences" (3.92±1.13 vs. 3.67±1.30, P<0.01) and "admits possible errors" (4.62±0.70 vs. 4.48±0.86, P<0.05). Older patients were more demanding than young patients regarding the qualities of the ophthalmologist. Among theoretical knowledge and technical skill, compared to young people, they preferred "updating knowledge" (4.65 [± 0.705] vs. 4.53 [± 0.879] for younger, P<0.05), "investment in research" (3.17 [± 1.47] vs. 2.82 [±1.45], P<0.001) and "being a good surgeon" (4.30 [± 1.28] vs. 3.86 [± 1.43], P<0.001). Among the communication qualities, they preferred "good explanation of illness and treatment" (4.78 [± 0.507] vs. 4.69 [±0.627], P<0.05), "take time to listen to me" (4.56 [± 0.725] vs. 4.41 [± 0.889], P<0.05) and "good communication with colleagues" (4.08 [± 1.10] vs. 3.81 [± 1.19], P<0.01). Among the human qualities, they favored "participation to humanitarian missions" (1.95 [± 1.40] vs. 1.71 [± 1.31], P<0.05). Among the organizational qualities, they preferred "being computerized" (3.37 [± 1.41] vs. 3.07 [±1.35], P<0.01), "easily reachable secretary" (4.35 [± 0.892] vs. 4.14 [± 0.910], P<0.001) and "accepting emergencies" (4.45 [± 0.911] vs. 4.14 [± 1.02], P<0.001).
<figure><img src="image_3.png" /><figcaption>**Figure 1.** Overall results of answers to the numeric scale questions. Error bars represent standard deviations. Questions 1 to 4 were related to theoretical knowledge and technical skill of the ophthalmologist, questions 5 to 8 to its communication qualities, questions 9 to 12 to its human qualities and questions 13 to 16 to the organizational aspects of the practice. The questions were scored on a numerical scale from 0 to 5 (0: not at all important, 5: mandatory). The average scores obtained for questions using numeric scale answers were high: 3.93 ± 1.33, with only 4 questions out of 16 with an average score lower than 3.5 (questions 1, 3, 11 and 13). According to the respondents, the 6 most important characteristics, with a result above the score of 4.5/5 were the capacity of good communication with patient: questions 8 (4.73 ± 0.57), 9 (4.64 ± 0.73) and 10 (4.48 ± 0.82), humility with questions 6 (4.55 ± 0.78) and 7 (4.70 ± 0.67) and updating medical knowledge with question 2 (4.59 ± 0.80). The least important qualities were participation in humanitarian missions (1.83 ± 1.36), commitment to research (2.99 ± 1.47), having many medical or scientific degrees (3.20 ± 1.30), being computerized (3.22 ± 1.38) or punctual (3.55 ± 1.24).</figcaption></figure>

## Process-communication model questions

As shown in Fig. 2, the most frequently chosen profiles were persister (n = 737, 94%), thinker (n = 729, 93%) and imaginer (n = 680, 87%). Subgroup analysis revealed that while men favoured imaginative (belonging to imaginer profile, 11% for men vs. 4.7% for women, P < 0.001) and logical qualities (thinker profile, 49% for men vs. 39% for women, P < 0.01), women favoured a warm character (harmonizer profile, 42% for women vs. 32% for men, P < 0.01). Younger patients preferred the promoter personality profile (average age 44.4 ± 18.3, P < 0.001) and the following qualities: playful (average age 40.1 ± 17.3, P < 0.01), adaptable (average age 42.3 ± 17.3, P < 0.001) and charming (average age 36.8 ± 17.8, P < 0.05). Older patients gave more importance to conscientiousness (persister profile, average age 49.2 ± 19.1, P < 0.001), calmness (imaginative profile, average age 50.2 ± 19.4, P < 0.001) and responsible (thinker profile, average age 48.5 ± 19.1, P < 0.05) qualities (Table 3).

Patients that only needed vision control showed more importance to warm (46 vs. 33%, P < 0.001) quality and to harmonizer profile (45 vs. 34%, P < 0.01). Patients coming for pre- or post-operation consultations were more concerned with the calm (62 vs. 50%, P < 0.01) and resourceful (28 vs. 21%, P < 0.05) qualities. Patients coming for a chronic

disease favoured the calm (62 vs. 50%, P < 0.01) and dedicated (32 vs. 22%, P < 0.01) qualities. Patients coming for the first time were more concerned with the reflective quality (69 vs. 61%, P < 0.05).

Some personality profiles correlated with answers given to the numeric scale questions. Indeed, respondents that favoured a persister profile showed higher scores for "good communication with colleagues" (3.97 ± 1.13 vs. 3.49 ± 1.38, P < 0.05). Preference for the rebel profile was associated with high scores for "have an easily reachable secretariat" (4.38 ± 0.79 vs. 4.21 ± 0.93, P < 0.05). Finally, preference for the promoter profile was associated with low scores for "humanitarian missions" (1.71 ± 1.39 vs. 1.91 ± 1.34, P < 0.05) and the imaginer profile was correlated with lower agreement for "accepting emergencies" (4.26 ± 1.01 vs. 4.52 ± 0.67, P < 0.05).

## Discussion

To our knowledge, no study has previously assessed patients' expectations in the field of ophthalmology. The questionnaire that we built allowed for broad, efficient, anonymous, and cost-effective data collection. We obtained a large sample size (n = 784), with statistically significant results. To
<table><caption>**Table 2** Influence of reason for consultation on the choice of medical qualities.</caption><thead><tr><th>Reason for consultation Quality</th><th>Routine check (n = 319)</th><th>Chronic disease follow-up (n = 207)</th><th>Surgery preop., postop. (n = 196)</th><th>First time at the ophthalmologist (n = 183)</th></tr></thead><tbody><tr><td>1. Many diplomas</td><td>3.07 (± 1.30)</td><td>3.28 (± 1.44)</td><td>3.30 (± 1.32)</td><td>3.23 (± 1.13)</td></tr><tr><td>2. Updating knowledge</td><td>4.55 (± 0.909)</td><td>4.67 (± 0.668)</td><td>4.61 (± 0.675)</td><td>4.53 (± 0.783)</td></tr><tr><td>3. Commitment to research</td><td>2.54 (± 1.43)</td><td>3.39 (± 1.44)</td><td>3.29 (± 1.51)</td><td>3.09 (± 1.33)</td></tr><tr><td>4. Good surgeon</td><td>3.76 (± 1.59)</td><td>4.31 (± 1.12)</td><td>4.39 (± 1.14)</td><td>4.16 (± 1.25)</td></tr><tr><td>8. Disease and treatment explanation</td><td>4.72 (± 0.639)</td><td>4.76 (± 0.480)</td><td>4.70 (± 0.540)</td><td>4.73 (± 0.566)</td></tr><tr><td>9. Surgery explanation</td><td>4.63 (± 0.705)</td><td>4.61 (± 0.785)</td><td>4.65 (± 0.739)</td><td>4.63 (± 0.743)</td></tr><tr><td>10. Taking time to listen</td><td>4.50 (± 0.835)</td><td>4.48 (± 0.723)</td><td>4.49 (± 0.807)</td><td>4.45 (± 0.843)</td></tr><tr><td>12. Communication with colleagues</td><td>3.82 (± 1.23)</td><td>4.06 (± 1.02)</td><td>4.01 (± 1.12)</td><td>3.96 (± 1.12)</td></tr><tr><td>5. Take into account my preferences</td><td>3.84 (± 1.30)</td><td>3.77 (± 1.22)</td><td>3.67 (± 1.20)</td><td>3.75 (± 1.17)</td></tr><tr><td>6. Admit possible errors</td><td>4.58 (± 0.777)</td><td>4.51 (± 0.841)</td><td>4.45 (± 0.867)</td><td>4.61 (± 0.686)</td></tr><tr><td>7. Ask suggestions from colleagues</td><td>4.73 (± 0.636)</td><td>4.67 (± 0.716)</td><td>4.68 (± 0.719)</td><td>4.64 (± 0.703)</td></tr><tr><td>11. Humanitarian</td><td>1.57 (± 1.26)</td><td>2.08 (± 1.39)</td><td>1.94 (± 1.41)</td><td>1.86 (± 1.43)</td></tr><tr><td>13. Computerization</td><td>3.08 (± 1.41)</td><td>3.32 (± 1.44)</td><td>3.34 (± 1.41)</td><td>3.16 (± 1.29)</td></tr><tr><td>14. Reachable secretariat</td><td>4.21 (± 0.924)</td><td>4.29 (± 0.890)</td><td>4.32 (± 0.878)</td><td>4.16 (± 0.935)</td></tr><tr><td>15. Accepting emergencies</td><td>4.17 (± 1.09)</td><td>4.43 (± 0.838)</td><td>4.39 (± 0.896)</td><td>4.30 (± 0.926)</td></tr><tr><td>16. Punctuality</td><td>3.65 (± 1.25)</td><td>3.32 (± 1.35)</td><td>3.51 (± 1.21)</td><td>3.51 (± 1.16)</td></tr></tbody></table>

The 16 questions corresponding to the qualities are presented. Questions 1 to 4 were related to theoretical knowledge and technical skill of the ophthalmologist, questions 5 to 8 to its communication qualities, questions 9 to 12 to its human qualities and questions 13 to 16 to the organizational aspects of the practice. The questions were scored on a numerical scale from 0 to 5 (0: not at all important, 5: mandatory). The mean scores ± SD obtained for questions are presented according to the reason for consultation.

decrease comprehension bias, the questionnaire was tested on several groups of patients. We cannot exclude a presentation bias: the order in which questions were presented might have influenced the patient's choice. This study is monocentric, which may reduce its external validity. The median age of the respondents may seem young. Nonetheless, the median age and the average age are equal, revealing a symmetrical distribution. Many respondents came for ophthalmological emergencies, for which the average age is often younger than in scheduled consultations. Finally, we chose not to include blind patients, to avoid influencing patients by helping them orally to complete the questionnaire, which could have generated a bias.

We designed our questionnaire to better know the skills expected by patients in ophthalmology. Without surprise, their expectations are very similar to the professional competences defined by Epstein et al. "the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community

being served" [15]. This being said, there were notable differences between groups when identifying desired skills.

Like Sehiralti et al. [16] and Yoo et al. [17], our findings show that communication skills were scored highest by patients. Indeed, good doctor/patient communication leads to good compliance and better treatment efficacy [18]. The following qualities were the most chosen by older patients: "to listen to me" and "good explanation". These patients may indeed have more difficulty understanding the treatments than younger patients. Older patients were globally more demanding regarding most of the qualities, however younger patients valued the qualities: "take the patient's preferences into account" and "admit mistakes", suggesting that for them, the paternalistic approach gives way to an autonomist approach with shared decision-making and mutual trust. The older participants are more complex cases and there may be a certain nostalgia for the time when GPs were always available and took on a paternalistic role. Devoe et al. [19] found similar results: unlike older patients, younger patients requested more control over their health
<figure><img src="image_4.png" /><figcaption>**Figure 2.** Enneagram representing the overall rate of personality profiles choice according to patients. Respondents were asked to select 6 of the 18 PCM qualities. The numbers from 0 to 800 in the figure correspond to the number of patients who chose the corresponding quality. The three most frequently chosen qualities are as follow: conscientious (n = 611 out of 4704 answers, 13%), responsible (n = 519, 11.05%) and reflective (n = 491, 10.50%). The top 3 chosen PCM profiles were "persister" (n = 737, 94%), "thinker" (n = 729, 93%) and "imaginer" (n = 680, 87%) followed by "harmonizer" (n = 464, 59%) and "promoter" (n = 338, 43%). The "rebel" was the least chosen (n = 154, 20%).</figcaption></figure>

and treatment process. In addition, our findings support Bor-
racci et al. [20] who claimed that female patients preferred
attentive caregivers.

When considering organizational qualities, patients
were most concerned with availability and accepting
emergencies. This can reveal the current difficulties in oph-
thalmology, such as the ease to make appointments, the
availability of ophthalmologists and their ability to have free
slots for emergency consultations. Older patients and those
with chronic conditions were most concerned with accep-
ting emergencies and being computerized. We conclude that
accessibility and availability are most important for patients
that generally require more follow-up appointments.

When analyzing theoretical and practical skills, patients
ranked "updating knowledge" highest compared to other
characteristics. Conversely, patients who had consultations
for chronic eye disease or operative follow-up gave more
importance to "investment in research"; indeed, research
is essential to improve the treatment of chronic diseases
and surgical techniques. Furthermore, patients coming for
pre- or post-operation, older patients and those with chronic
conditions gave more importance to "being a good surgeon"
as they require more surgical care. Patients whose only rea-
son for consultation was vision control were less demanding
and gave lower scores to all skill categories compared to
other patients. We could hypothesize that it is because their
appointment requires less time, less explanation, and less
treatment compared to a patient who has an eye disease.

Amongst the most important human qualities were:
"admitting mistakes" and "ability to address a colleague".
Patients expect their ophthalmologist to be both humble
and honest. As ophthalmologists, we must be good tech-
nicians, but also remain empathetic, highly knowledgeable
and at the same time know our limits tell patients that we
do not know rather than making medical errors. A majority
of patients seek a human-to-human connection with their
ophthalmologist.

As with human qualities, communication skills were given
high importance by patients. Indeed, patients included
in the study favored good communication and human qua-
lities over technical skills. Understanding the relational
mechanisms between people and knowing one's own psycho-
logical profile is likely to promote well-being and effective
communication. For example, in our study, the results of
the subgroup analysis by gender suggest that patients tend
to choose or to prefer a doctor with the same profile as
themselves, which aligns with the results of Boyat's study
[21]. According to Lefeuvre [9], in the general public, 75%
of women qualify as harmonizers and 75% of men as thin-
kers. Our study shows that women favored warmth (quality
corresponding to the harmonizer profile) and men preferred
logic (corresponding to the thinker profile).

In the medical field, it has been shown that problems
amongst professionals or with patients are often due to mis-
communication [8]. The literature review suggested that
very few papers concerning the practical use of PCM in
<table><caption>Table 3 Influence of gender, age and reason for consultation on the choice of qualities and personality profiles.</caption><thead><tr><th></th><th>Male</th><th>Female</th><th>&lt; 47 years</th><th>&gt; 47 years</th><th>Vision control</th><th>Chronic disease</th><th>Pre- or postoperative</th><th>First appointment</th></tr></thead><tbody><tr><td>Qualities</td><td>+++</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Imaginative</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Logical</td><td>++</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Warm</td><td></td><td>++</td><td></td><td></td><td>+++</td><td></td><td></td><td></td></tr><tr><td>Playful</td><td></td><td></td><td>++</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Adaptable</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Charming</td><td></td><td></td><td>+</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Conscious</td><td></td><td></td><td></td><td>+++</td><td></td><td></td><td></td><td></td></tr><tr><td>Tious</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Calm</td><td></td><td></td><td></td><td>+++</td><td></td><td>++</td><td>++</td><td></td></tr><tr><td>Dedicated</td><td></td><td></td><td></td><td></td><td></td><td>++</td><td></td><td></td></tr><tr><td>Resourceful</td><td></td><td></td><td></td><td></td><td></td><td></td><td>+</td><td></td></tr><tr><td>Reflective</td><td></td><td></td><td></td><td>+</td><td></td><td></td><td></td><td>+</td></tr><tr><td>Responsible</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Profiles</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Promoter</td><td></td><td>+++</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Harmonizer</td><td></td><td></td><td></td><td></td><td>++</td><td></td><td></td><td></td></tr></tbody></table>

Only significant results are shown in the table which shows 12 qualities out of 18 and 2 profiles out of 6. The others qualities and profiles were not significant. In the first column are two groups: the first with qualities and the second with profiles. The cross symbols are associated with P-values: (+): P < 0.05, (++) P < 0.01, (+++): P < 0.001.

medicine have been done [12,21] and our study is the first to examine the use of the method in ophthalmology. Other communication models have been described and studied, but we concluded that their inclusion would have made our questionnaire too lengthy and difficult for patients to understand. This study shows the advantage of the PCM model in doctor-patient relationship. Knowing PCM profiles and improving communication skills would therefore be very useful for ophthalmologists and residents. The PCM training allows professionals to deduce patients' personalities, to identify and adapt to patients' preferred channel of communication [21]. However, most ophthalmology residency training solely focuses on transmitting theoretical and practical knowledge at the expense of offering intentional communication training. Residency training curriculum should be designed in such manner that no ophthalmology resident exits with any skill deficit.

to explain the disease and its treatment, to take the time to listen to the patient and their family, to show empathy and personalize information according to the patient's personality. To build a relationship of trust with the patient, communication must be professional and clear. It is therefore necessary for ophthalmologists to acquire the skills that allow them to meet both the physical and psychological needs of their patients. While there is a high degree of confidence in the technical skills of ophthalmologists, our study underlines the importance of interpersonal skills that are largely absent from medical education in our context. We suggest that medical education in communication is fundamental and should be included in courses related to clinical practice during ophthalmology residency. We further suggest that confirmed ophthalmologists be encouraged to maintain their high level of technicity and maintain or acquire interpersonal skills through intentionally crafted continuing education programs.

## Conclusion

Our findings suggest that in addition to being qualified and competent, ophthalmologists should have good human and communication skills to deliver good medical care. Our study underlines that effective communication is the number one priority for our patients. Ophthalmologists must know how

## Ethics approval and consent to participate

Non-interventional study, without modification of practices, approved number: CE-2020-182.
# Availability of data and materials

Data available upon request.

# Funding

The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

# Acknowledgements

Martine Cros, Janel Hooven, Bernard Stoloff.

# Disclosure of interest

The authors declare that they have no competing interest.

# Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jfo.2024.104354.

# Références

[1] Fasce E, Echeverría M, Matus O, et al. Professionalism of physicians from the point of view of physicians and students. Rev Med Chil 2009;137:746-52.

[2] Abu-Hilal M, Morgan CE, Lewis G, et al. What makes a good doctor in the 21st century? A qualitative study. Br J Hosp Med 2006;67:375-7, http://dx.doi.org/10.12968/hmed.2006.67.7.21623.

[3] Banka G, Edgington S, Kyulo N, et al. Improving patient satisfaction through physician education, feedback, and incentives. J Hosp Med 2015;10:497-502, http://dx.doi.org/10.1002/jhm.2373.

[4] Wensing M, Jung HP, Mainz J, et al. A systematic review of the literature on patient priorities for general practice care. Part 1: description of the research domain. Soc Sci Med 1998;47:1573-88, http://dx.doi.org/10.1016/s0277-9536(98)00222-6.

[5] Ibanez G, Cornet P, Minguet C. What is a good physician? Pedagogie Med 2010;11:151-65, http://dx.doi.org/10.1051/pmed/2011002.

[6] Srinivasan N. Who is a good psychiatrist? A collective view. Indian J Psychiatry 2005;47:182-3, http://dx.doi.org/10.4103/0019-5545.55949.

[7] Hénaux PL, Jannin P, Riffaud L. Nontechnical skills in neurosurgery: a systematic review of the literature. World Neurosurg 2019;130:e726-36, http://dx.doi.org/10.1016/j.wneu.2019.06.204.

[8] Grady M, Peacock-Johnson A, Welle MK, The TIS. Methodology: an approach for purposeful, relational communication. Creat Nurs 2020;26:175-81, http://dx.doi.org/10.1891/CRNR-D-20-00019.

[9] Grosbois JM, Valentin ML, Valentin V, et al. L'outil DISC améliore la communication et les résultats de la réhabilitation respiratoire : une approche comportementale adaptée. Rev Mal Respir 2019;36:39-48, http://dx.doi.org/10.1016/j.rmr.2018.10.009.

[10] Talha KA, Hasan MF, Selina F, et al. Myers-Briggs type indicator personality types of female intern doctors and their specialty preference. Mymensingh Med J 2022;31:806-11.

[11] Lefeuvre J. Discover the process communication model. Xlibris; 2017 [p. 1-160].

[12] Andrew MI, Wilkinson S, Wylie N, et al. Evaluation of process communication model training for surgeons and other healthcare professionals: a survey. ANZ J Surg 2021;91:487-8, http://dx.doi.org/10.1111/ans.16351.

[13] Ong LML, de Haes JCJM, Hoos AM, et al. Doctor-patient communication: a review of the literature. Soc Sci Med 1995;40:903-18, http://dx.doi.org/10.1016/0277-9536(94)00155-M.

[14] Charan J, Biswas T. How to calculate sample size for different study designs in medical research? Indian J Psychol Med 2013;35:121-6, http://dx.doi.org/10.4103/0253-7176.116232.

[15] Epstein RM. Defining and assessing professional competence. JAMA 2002;287:226, http://dx.doi.org/10.1001/jama.287.2.226.

[16] Sehiralti M, Akpinar A, Ersoy N. Attributes of a good physician: what are the opinions of first-year medical students? J Med Ethics 2010;36:121-5, http://dx.doi.org/10.1136/jme.2009.032854.

[17] Yoo HH, Lee JK, Kim A. Perceptual comparison of the "good doctor" image between faculty and students in medical school. Korean J Med Educ 2015;27:291-300, http://dx.doi.org/10.3946/kjme.2015.27.4.291.

[18] Suchman AL, Roter D, Green M, et al. Physician satisfaction with primary care office visits. Med Care 1993;31:1083-92, http://dx.doi.org/10.1097/00005650-199312000-00002.

[19] DeVoe JE, Wallace LS, Fryer GE. Patient age influences perceptions about health care communication. Fam Med 2009;41:126-33.

[20] Borracci RA, Álvarez Gallesio JM, Ciambrone G, et al. What patients consider to be a good doctor, and what doctors consider to be a good patient. Rev Med Chil 2020;148:930-8, http://dx.doi.org/10.4067/S0034-98872020000700930.

[21] Boyat M. Process-Communication training in the doctor-patient relationship in general practice. Dijon: UFR of Health Sciences of Dijon; 2021 [p. 1-73].