Interpersonal processes of care and patient satisfaction: do associations differ by race, ethnicity, and language?

Satisfaction with health care and with clinicians is a key quality-of-care indicator (Cleary and McNeil 1988). Numerous studies have explored whether satisfaction with care varies by race/ethnicity. Most have found that one or more minority groups are less satisfied than nonminority groups (Meredith and Siu 1995; Harpole et al. 1996; Cooper-Patrick et al. 1999; Morales et al. 1999; Doescher et al. 2000; Murray-Garcia et al. 2000; Haviland et al. 2003; Saha, Arbelaez, and Cooper 2003; Hunt, Gaba, and Lavizzo-Mourey 2005;). Research consistently finds Spanish-speaking Latinos to be less satisfied than English-speaking Latinos (Hu and Covell 1986; David and Rhee 1998; Carrasquillo et al. 1999; Morales et al. 1999; Mosen et al. 2004;). Research to explore possible mechanisms of these widely observed disparities in satisfaction is needed (Hunt, Gaba, and Lavizzo-Mourey 2005). Cleary and McNeil conceptualize three basic types of determinants of satisfaction: patient characteristics, structure of care, and processes of care (Cleary and McNeil 1988). Establishing links between patient characteristics (e.g., race/ethnicity) and satisfaction helps identify patient groups at risk of poorer satisfaction. The structure of care, such as information management and organizational design, can contribute to improved patient satisfaction (Glickman et al. 2007). Processes of care include technical care and interpersonal aspects of the physician–patient relationship. With respect to interpersonal processes, three broad dimensions have been identified: communication, patient-centered decision making, and interpersonal style (Stewart, Napoles-Springer, and Perez-Stable 1999; Stewart et al. 2007;). Most studies of interpersonal processes and satisfaction have focused on communication. Three literature reviews support the conclusion that the amount and clarity of information provided is a clear correlate of satisfaction (Cleary and McNeil 1988; Hall, Roter, and Katz 1988; Ong et al. 1995;). For example, a meta-analysis concluded that satisfaction was most dramatically predicted by the amount of information imparted by providers (Hall, Roter, and Katz 1988). Regarding interpersonal style, several reviews concluded that patients were more satisfied when physicians were sensitive to their needs and had a supportive, reassuring style (DiMatteo et al. 1985; Buller and Buller 1987; Cleary and McNeil 1988; Greene et al. 1994;). Being treated with respect and dignity also has been independently associated with satisfaction with care among diverse ethnic groups (Beach et al. 2005). Several studies among minority patients found that perceived racism was associated with dissatisfaction with health care (Auslander et al. 1997; LaVeist, Nickerson and Bowie 2000; Hunt, Gaba and Lavizzo-Mourey 2005; Benkert et al. 2006;). In another study, the compassion with which care was provided was the strongest predictor of patients' willingness to recommend care providers (Burroughs et al. 1999). Several aspects of patient-centered decision making also have been associated with patient satisfaction. Patients of physicians who provided a greater opportunity to participate in decision making, negotiation, and other aspects of the medical encounter were more satisfied (Stewart 1984; Brody et al. 1989; Greene et al. 1994; Franciosi et al. 2004;). Reviews suggest that patients are more satisfied when physicians do not have a controlling communication style (Buller and Buller 1987; Hall, Roter, and Katz 1988; Greene et al. 1994;). For example, the more physicians talked relative to patients during visits, the less satisfied the patients (Bertakis, Roter, and Putnam 1991). Finally, being involved in decision making to the extent desired was associated with global satisfaction in four racial/ethnic groups (Beach et al. 2005). Despite the attention to patient satisfaction in the literature, few studies have examined simultaneously a broad range of interpersonal processes; thus, we know little about whether the different domains (e.g., communication, decision making) independently determine satisfaction. Furthermore, many of the studies in diverse populations involve small samples or audiotapes of visits, thus limiting generalization. Finally, we know little about whether the associations between various interpersonal processes and satisfaction differ across racial/ethnic groups. Identifying which interpersonal processes are important to all patients, and those that may be especially important to patients of certain ethnic groups only, can help identify mechanisms to reduce health and health care disparities. The purpose of this study was to explore, in a diverse sample of general medicine patients: (1) whether patient satisfaction differed across racial, ethnic, and language groups; (2) whether reports of several dimensions of interpersonal processes of care (IPC) were independently associated with several measures of satisfaction with care; and (3) whether these associations differed significantly across patient racial, ethnic, and language groups. We hypothesized that good interpersonal processes would be positively associated with satisfaction, but we were uncertain whether the associations would be consistent across racial/ethnic groups. This study extends previous research by studying an ethnically diverse sample that included English- and Spanish-speaking Latinos. Another unique contribution is that the study examined a variety of interpersonal aspects of care provided by physicians and their relative influence on satisfaction using measures that have undergone extensive qualitative and psychometric testing (Napoles-Springer et al. 2006; Stewart et al. 2007;). The measures consisted of patient reports of events rather than ratings, facilitating identification of specific physician behaviors that might be modified to increase patient satisfaction and reduce disparities in care.