The Combined Effects of Participatory Styles of Elderly Patients and Their Physicians on Satisfaction

Consumer satisfaction ratings in health care are commonly used indicators of access and outcomes (Kane, Maciejewski, and Finch 1997; Rohrer 1999). An early study found that patients' satisfaction with care was positively associated with their degree of involvement in decision-making during visits (Joos, Hickam, and Borders 1993). In particular, the Medical Outcomes Study demonstrated that patients who rated their physicians as having a low participatory decision-making (PDM) score were more likely to change health care providers (Kaplan et al. 1996). Another study, using a patient sample from a university hospital, revealed that PDM scores were significantly associated with patients' satisfaction with the technical aspects of visits (Lerman et al. 1990). Also, among an asthmatic adult patient sample, higher patient satisfaction was found to be correlated with their physicians' PDM scores (Adams, Smith, and Ruffin 2001). The majority of previous studies, including those cited above, focused on physicians' PDM style. The central question of these studies was whether patients were (more) satisfied if their physicians provided them with sufficient opportunities to participate in decision making. However, not all patients are participatory, regardless of their physicians' PDM style (Waterworth and Luker 1990). For example, one study identified three patterns of participatory style among early-stage breast cancer patients: delayers, deferrers, and deliberators (Pierce 1993). The variation in the level of participation across patients makes it difficult to establish a universal intervention to encourage patient participation (Neufeld, Degner, and Dick 1993). Nonetheless, one study found that interventions that accommodate patients' readiness and willingness to participate yielded improvement in health care outcomes (Prochaska and DiClemente 1983). Moreover, in a randomized trial, patients who were encouraged to use information gained during a 20-minute session prior to their doctor's visit to negotiate with their physician experienced improved treatment effectiveness (Greenfield et al. 1988). Patients' nonparticipation is particularly pronounced among elderly patients. Specifically, older patients were less assertive, asked fewer questions, and provided less information to their physicians (Adelman, Greene, and Charon 1991; Greene et al. 1989). Also, elderly patients were less likely than younger persons to challenge a physician's authority and tended to leave the decision-making authority to physicians (Blanchard et al. 1988; Haug and Lavin 1979). Elderly patients' nonparticipation in care may be explained by their perceptions and expectations of a patient's proper role in medical care (McCormic, Inui, and Roter 1996), but their nonparticipation in health care has not been found to be universal (Hooper et al. 1982). Nevertheless, regardless of their participatory styles, elderly patients did respond to interventions that promoted participation (Rakowski, Hickey, and Dengiz 1987; Tennstedt 2000). Although numerous studies have addressed patient satisfaction, physicians' PDM style, and patients' participation style, little is known about how the concordance between patients' and physicians' participatory styles affects elderly patients' satisfaction with their physicians. Based on the findings from previous studies, one would speculate that the matching of participatory patients with participatory physicians would yield the highest satisfaction due to improved information exchange between physicians and patients. Because elderly patients tend to be nonparticipatory, it is possible that elderly patients could become frustrated and overwhelmed by physicians who are overly enthusiastic about involving patients in decision making, resulting in lower satisfaction. On the other hand, it can be argued that a mismatch between patients' and physicians' participatory styles (e.g., a passive patient with a physician encouraging participation) promotes satisfaction. The reasoning behind this premise is that patients who are passive participants in their own health care do not expect their physicians to encourage them to participate in medical decision-making. As a result, the passive patient might perceive the physician's enthusiasm about patient participation as representing better health care quality. It also follows that patients who are very participatory may be less satisfied than those who are not participatory if they perceive that their physicians do not allow them to participate as much as they would like. That is, patient satisfaction may be affected by discordance, with the mismatch of nonparticipatory patients and participatory physicians producing the highest level of patient satisfaction, and the mismatch of participatory patients and nonparticipatory physicians resulting in the lowest level of patient satisfaction. This might explain the finding from an early study that although most cancer patients in the sample wanted information, nonparticipatory patients were more satisfied (Blanchard et al. 1988). In summary, the arguments for concordance and discordance lead to opposing conclusions regarding how the combination of patients' and physicians' participatory styles is related to patient satisfaction with their physicians. If patient satisfaction with providers is associated with discordance, then interventions that promote physicians' participatory style need to be prioritized. To test whether concordance or discordance is associated with higher satisfaction, this study examined the effect of the interaction of self-reported perceptions of patients' and physicians' participatory styles on patients' satisfaction with their physicians. Using a sample consisting of more than two thousand community-dwelling elderly patients, the study answered the following questions: Do elderly patients' and their physicians' participatory styles, respectively, affect patients' satisfaction with their physicians? Does physicians' participatory style independently affect patients' satisfaction or is its effect dependent on patients' participation? If dependent, what is the direction of the dependency?