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As part of a study of compliance by patients with doctors' orders, this paper

deals with the extent to which patients did not comply and with the
factors that may be involved in explaining these variations.

VARIATIONS IN PATIENTS' COMPLIANCE WITH DOCTORS'


ADVICE: AN EMPIRICAL ANALYSIS OF PATTERNS
OF COMMUNICATION
Milton S. Davis, Ph.D., F.A.P.H.A.

Introduction
T HIS paper stems from a larger study
of the major social, psychological,
and physical factors that account for
variations in patients' compliance with
doctors' orders. The investigation considered (1) the extent of patient noncompliance, and (2) the range and nature of factors that may lead to or help
explain these variations. The factors reported in this paper represent a continuation of the analysis of dimensions
that characterize doctor-patient interaction.1
In principle, the range of factors that
may account for variations in patients'
compliance is immense. The following
set of assumptions, however, guided the
larger investigation from which this report stems.
a. Individuals who go to a doctor
have in common the fact that something
is troubling them, but differ more or less
in their personal characteristics.
b. In some measure, these personal
characteristics are taken into account by
the doctor so that variations occur in the
nature of the regimen prescribed for
each patient.
c. After being told their regimens,
patients may discuss and assess the doctors' advice with paramedical and
274

other influential persons, i.e., relatives,


friends, and associates, whose opinions
on the matter they value.
d. Such influences interact with the
personal characteristics a patient brings
to the situation, the nature of the regimen, and the nature of the doctor-patient relationship, to produce patterns of
compliance with the doctor's orders.
Patterns of Compliance
To label patients compliant or noncompliant without elaboration is misleading. The medical regimen is ordinarily a composite of recommendations,
and a patient may comply with all,
some, or none of the advice. Different
degrees of compliance also characterize
each regimen, and assuming that the patient complies at all, it is clear that
he may do so consistently or intermittently through time. A review of the
literature demonstrates a range from 15
to 93 per cent of patients reportedly
noncompliant.2 This wide range is not
surprising when the variety of populations, the various methods of data collection, and the different medical problems investigated are considered. Nevertheless, a pattern emerges when these
studies are examined as a whole. Regardless of the differences, at least a
VOL. 58, NO. 2. A.J.P.H.

DOCTOR-PATIENT INTERACTION

third of the patients in most studies


failed to comply with doctors' orders.
Patient Characteristics

A review of the literature on noncompliance evidences conflicting conclusions


regarding what demographic attributes
characterize a noncompliant patient. Although many factors have been investigated, they are not dealt with consistently in each study and the results are
inconclusive. Therefore, it is only possible to cull some impressions about
what patient characteristics influence
noncompliant behavior. It seems that females are somewhat more likely to default than males3; that older people,4
patients in lower socioeconomic status
groups,5 and patients with little education6 are least likely to follow doctors'
orders.
One might expect that physical characteristics of patients would affect variations in patient compliance. Most studies,
however, focus on a population with a
particular diagnosis, and comparative
findings are few. Patients with long-term
illnesses are reportedly more compliant
if they are given careful instruction,7
and the urgency of an acute illness has
been related to compliance.8
Studies concerned with psychological
characteristics of patients have shown
that noncompliant patients can be identified by examining coping mechanisms,9
dependency,'0 and defensiveness and externalization.1" One author suggests that
fear arousal is necessary for acceptance
of medical advice.'2
Regimen

A suggested medical regimen usually


combines prescriptions (behavior to be
initiated) and proscriptions (behavior
to be prohibited).13 Most patients, however, choose to comply with two out of
three regimens and select those which
are the least difficult.'4 Restrictions
which necessitate relinquishing personal
habits are the most difficult to followFEBRUARY, 1968

unlike medications which are the easiest.


Compliance with one specific regimen
appears to affect adherence with others.15
However, no relationship was found between follow-through with regimens
which require patient self-care and compliance with advice involving the patient in clinic procedures.'6 The former,
regimens which require patient judgment, are more closely associated with
noncompliance. There is also agreement
that the more complex regimens affect
increased noncompliance.17 These findings evidence a need for more explanation and presentation of advice in the
least complex manner.
Personal Influence

It is possible that influence from family members, friends, and associates


may conflict with the medical advice
and counteract the doctor's potential
authority. But there is also the possibility that these extra-medical influences
will reinforce the doctors' recommendations. Family discord is closely associated with noncompliance,18 while
availability of local help and family
cohesiveness during crises are associated
with increased levels of compliance.19
The more stable home situation is perhaps associated with positive reinforcement of medical advice.20 Such positive
reinforcement is particularly functional
when one considers that the patient is
not able to relate to his doctor with the
same frequency and intensity as he does
with family, friends, and co-workers.
Doctor-Patient Relationship

Few empirical investigations have


dealt with the way in which interaction
between patient and doctor influences
patient compliance. Those who have
studied this factor empirically have been
concerned with perceptions of doctors
and patients and have not considered
objective measurement of the doctor-patient interaction or how this might influence the patient's decision regarding
275

compliance.21 This may account for incongruent findings. For example, in one
report, barriers in doctor-patient communication could not account for patient
noncompliance.22 Another study shows
that communication between doctor and
patient is less important than the psychological readiness of the patient.23
However, when doctors fail to clearly
convey the significance of a regimen
to the patient, there is a reciprocal failure on the part of the patient to comply.24 Reciprocity seems to affect compliance, whether between a very docile
approval-seeking patient and a nurturant
doctor, or a psuedo-independent patient
and an aloof doctor.25 While there is not
complete agreement on exactly how the
doctor-patient relationship affects compliance, most investigations do recognize the importance of communication
and explanation.26

from the sample who: (a) had a chief


complaint which indicated that they
would probably be sent to another clinic
after one visit; (b) came regularly to
one or more other hospital clinics (although they were considered new to the
general medical clinic) ; (c) sought
follow-up care of a condition already
diagnosed and well known to the patient; or (d) had a language or hearing problem.27
Survey data were collected on a random sample of clinic patients prior to
this investigation to describe and characterize patient experiences in the general medical clinic. The composition of
the present study population compares
favorably with the estimated clinic population based on that survey.28
Data Collection and Analysis
Prior to the initiation of the present

Hypothesis and Design of the Study

study, exploratory data were collected


from doctors and patients over succes-

While a full range of factors affecting


compliance is recognized and was investigated in the larger study, this paper
is particularly concerned with the ways
in which dimensions of doctor-patient
interaction relate to patient compliance.
It is hypothesized that patterns of communication which deviate from the
normative doctor-patient relationship
will be associated with patients' failure
to comply with the doctors' advice.

sive patient visits to the general medical


clinic to evaluate the relative merits of
various technics for studying doctor-patient interaction.29 On the basis of this
exploratory work, it was decided that
data could most feasibly be collected by
a combination of (a) tape recordings,
(b) survey methods-including interviews and questionnaires, and (c) a
content analysis of patients' medical
records.

Study Group

Tape Recording of Interaction

The study group consists of 154 new


patients seen by 76 junior physicians
(fourth-year medical students) who
regularly care for patients in the clinics,
and 78 senior (attending) physicians assigned to the general medical clinic of
a large general voluntary teaching hospital. A new patient had either never
been to the general medical clinic before, or had not attended the clinic for
at least one year. Patients were excluded
276

A method developed by Robert F.


Bales, Interaction Process Analysis, was
adapted for this research.30 With this
method, all doctors' and patients' verbal
communication is coded into 12 categories of action (see Table 1). Scores
representing the amount of activity devoted to each of the 12 categories were
computed separately for each doctor and
patient and transferred onto code sheets
from which IBM cards were punched.
Data analysis involved correlating an
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DOCTOR-PATIENT INTERACTION
Table 1-Bales' categories for interaction
process analysis
1. Showvs solidarity, raises other's status, gives
help, rewvard.
2. Showvs tension release, jokes, laughs, shows
satisfaction.
3. Agrees, shows passive acceptance, understands, concurs, complies.
4. Gives suggestion, direction, implying autonomy for others.
5. Gives opinion, evaluation, analysis, expresses feeling, wish.
6. Gives orientation, information, repeats,
clarifies, confirms.
7. Asks for orientation, information, repetition, confirmation.
8. Asks for opinion. evaluation, analysis, expression of feeling.
9. Asks for suggestion, direction, possible
ways of action.
10. Disagrees, shows passive rejection, formality, withholds help.
11. Shows tension, asks for help, withdraws
ouit of the field.
12. Showvs antagonism, deflates other's status,
defends or asserts self.

independent measure of patient compliance with four types of data derived


from the interaction process analysis.
First. the relative volume of participation by doctor and patient was determined; second, communication profiles for doctor and patient were compared; third, by manipulating category
scores, indexes of difficulties encountered in the interaction were measured;
and fourth, a factor analysis was performed. Although the latter analysis was
not in Bales' original formulation, it was
employed here to discover what additional dimensions in the doctor-patient
relationship might account for variations
in patients' compliance. This paper is
primarily concerned with the factor
analysis data.
Interaction Process Analysis is an expensive method requiring extensive
time for tape recording, transcribing,
coding, and analyzing data.31 ConseFEBRUARY, 1968

quently, only two crucial periods of interaction were recorded: first, the doctor's formulation (presentation of medical regimen and diagnosis to the patient) during the primary visit; and
second, the entire interaction between
doctor and patient at the time of the
patient's revisit. The latter was recorded
to examine changes in the doctor-patient relationship.
A total of 223 doctor-patient interactions were subsequently coded. Of the
154 doctor-patient pairs in the study
group, 80 had both visits taped, 39 had
only the first visit, 24 only had the second, and 11 had no tapes at all. Reliability in coding averaged 85 per cent,
rather good considering the subjective
nature of the material.32
Survey Methods

Personal interviews and a self-administered questionnaire were used to study


the perceptions of doctors and patients
with reference to their own specific role
obligations and the role expectations of
the other.
During the exploratory phase of the
study, a series of questionnaires and
interview schedules was developed and
pretested. Data were subsequently collected from the patient study, group by
means of four interviews: one before
the primary visit, one after that visit,
and one after the second and third
clinic visits. However, because of variations in patients' illnesses. the number
of appointments, and the formulation of
medical regimens on any specific visit,
it was necessary to allow the interviewers a certain amount of leeway in the
administration of the various interview
schedules. In addition, a self-administered questionnaire was completed by
each physician treating a study patient.
Content Analysis of Patients' Medical Records

Some months after the survey data


were collected, a chart review was designed to collect demographic data, a
277

listing of all regimens recorded by the


doctor, and a record of the proportion
of broken appointments during a sixmonth period.

Index of Compliance
A variety of indexes have been employed in other studies to measure compliance, some based on subjective reports, others on objective physical measurements.33 In this study, the composite
index of compliance includes patients'
perceptions of their compliant behavior,
doctors' perceptions of the patients' compliant behavior, and an independent review of patients' medical records. The
inclusion of these three types of data to
measure noncompliant behavior overcomes many of the difficulties inherent
in accepting the patients' word, the doctors' word, or the medical records as the
sole source of information.
The compliance score is a weighted
average of patient follow-through with
two types of recommendations ordered
by the doctor. First, recommendations
may involve patient initiative at home
or at work. This category includes prescription and nonprescription medications, recommended diets, changes in
rest habits and worrying, limitation of
smoking and alcoholic consumption, and
changes in work activities. Second, recommendations may also require patient
participation in the hospital organization. Here we examined diagnostic procedures, specific treatments, referrals to
specialty clinics, and revisits to the
clinic. Medical records were used to ascertain a list of specific regimens. In
addition, patients were asked if any
other regimens were recommended by
the doctor. Some patients reported advice which the doctor did not list in
the medical record.34
After it was discovered which orders
were recalled, the patient was asked how
closely he followed these recommendations. The responses were coded for
278

each regimen as follows: (0) none of


the time, (1) very seldom, (2) less than
half the time, (3) compliant most of the
time, and (4) all of the time. The physicians were also asked how closely the
patient followed the advice and these responses were coded similarly. When the
responses of the physician and the patient
were not in agreement, an average was
taken of the two. A patient was categorized as not at all compliant with regard to those regimens reported by the
physician but not recalled by the patient.
We assumed that patients who did not
recall a recommendation when asked
were not following the advice. The proportions of broken appointments for revisits and referrals and diagnostic tests
were also coded according to congruent
categories and included in the composite
index. For each type of recommendation, a weight was assigned indicating
the relative importance of the regimen.35

Results
Extent of Noncompliance and Demographic Differences
In this study group, 37 per cent of the
patients were classified as noncompliant
and 63 per cent were classified as compliant. This rate of compliance, in accordance with the findings of the literature review, indicates that while the majority of patients follow their doctors'
advice, over one-third of the patients
simply do not do what they are told.
The data from the present study show,
contradictory to many reports, that there
is no significant relationship between
compliance and any of the demographic
characteristics investigated. This finding is, nevertheless, noteworthy. No variations in patient compliance can be attributed to demographic characteristics
peculiar to the patient, i.e., age, sex,
marital status, religion, education, or occupation. This supports the contention
that dimensions in the doctor-patient relationship are more fruitful avenues for
VOL. 58. NO. 2, A.J.P.H.

DOCTOR-PATIENT INTERACTION

explaining variations in patient compliance.36

Interaction Between Doctor and Patient


Presumably, all doctors and patients
have certain ideas about the kind of relationship they should have, and the kind
of roles they are expected to play.37 The
way in which doctors and patients initially behaved and whether or not they
continued to conform to expected ways
of behavior was examined in an earlier
paper.38 Failure to adhere to medical
advice after the doctor visit was related
to deviant communication in the doctorpatient relationship. There was a reversal in roles over successive doctor
visits. While the doctor was directive
and emotionally neutral in the primary
visit and the patient passively conformed
with his role, data from the revisit suggest that this conformity was only momentary. In the second visit, many doctors passively accepted the patient whose
participation was increasingly active.
Noncompliant behavior was further explained by increased difficulty of communication, and attempts by doctors and
patients to control each other.39

Factor-Analyzed Dimensions of DoctorPatient Interaction


The 12 categories of interaction
(Table 1), in and of themselves, have a
theoretical significance which describes
the structure and process of group interaction.40 The doctor-patient profiles and
the indexes suggested by Bales represent
only a few ways of combining the 12
categories. Furthermore, they did not
account for much noncompliance. In
order to discover some other dimensions,
a factor analysis on the interaction categories was completed. The method of
factor analysis was selected for its advantage in permitting the grouping of
interaction categories in a way which is
independent of any a priori thought. It
FEBRUARY. 1968

was expected that discovery of such factors would further our knowledge of dimensions of doctor-patient interaction
which ultimately could be related to variations in patient compliance.
The rates for the 12 interaction categories for doctor and patient were correlated to form a 24 x 24 product moment correlation matrix. Principle factors were extracted with unity as the
diagonal value. Ten factors, judged
salient on the basis of the magnitude of
factor loadings, were rotated to oblique
simple structure by the Promax procedure.41 Each of the ten factors is defined
by a particular group of categories. A
list of the factors with the loadings and
weights for each category appears in
Table 2.
Seven of the 24 categories were heavily
loaded on more than one factor and
consequently were differentially weighted
for each dimension. To compute scores,
the weight of the factor loading was
multiplied times the rate of doctor-patient
activity which fell into the categories.
The ten factors represent empirically
determined dimensions of doctor-patient
communication. The label for each factor is an arbitrary name intended to
summarize the interaction categories defining that dimension.
Factor I, malintegrative behavior,
characterizes the type of doctor-patient
communication which exhibits negative
social-emotional interaction. Both participants appear to be formal, show passive rejection, and withhold help from
the other. The patient shows antagonism
toward the doctor and simultaneously
withdraws from the situation. What we
find here is a dimension measuring deviant interaction.
Factor II, active patient-permissive
doctor, represents a pattern of communication between an authoritative patient
and a doctor who passivTely accepts the
authoritative position taken by the patient. The patient is likely to present
his own evaluation and analysis of the
279

Table 2-Primary loadings and weights for categories defining factors in


doctor-patient interaction (N= 152)
Factor I
Malintegrative Behavior

Loading
.72

Weight
.58

.66

.50

.52

.36

.36

.11

Patient: Shows antagonism, deflates other's status, defends or asserts self.


Doctor: Disagrees, shows passive rejection, formality,
withholds help.
Patient: Disagrees, shows passive rejection, formality,
withholds help.
Patient: Shows tension, asks for help, withdraws out
of field.
Factor II
Active Patient-Permissive Doctor

Loading
.80

Weight
.37

-.72

.39

.63

.36

.46

.23

Loading
.95

Weight
.79

.53

.28

.36

.11

Loading

Weight

.84

.65

.52

.28

-.49

.40

Doctor: Agrees, shows passive acceptance, understands,


concurs, complies.
Patient: Agrees, shows passive acceptance, understands,
concurs, complies.
Patient: Gives orientation, information, repetition, confirmation.
Patient: Gives opinion, evaluation, analysis, expresses
feeling, wish.
Factor III
Solidary Relationship

Patient: Shows solidarity, raises other's status, gives


help, reward.
Patient: Shows tension release, jokes, laughs, shows
satisfaction.
Doctor: Shows solidarity, raises other's status, gives
help, reward.
Factor IV
Nondirective Antagonism
Doctor: Gives opinion, evaluation, analysis, expresses
feeling, wish.
Doctor: Shows antagonism, deflates other's status, defends or asserts self.
Doctor: Gives orientation, information, repetition, confirms, clarifies.

Factor V
Informative Nonevaluativeness
Loading
.99

-.48

Weight
.82
.24

Doctor: Gives suggestion, direction, implying autonomy


for others.
Doctor: Gives orientation, information, repeats, clarifies,

confirms.

280

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DOCTOR-PATIENT INTERACTION
Table 2- (Continued)

Loading
.85

Weight
.68

-.63

.49

.36

.12

Loading
.49

Weight
.59

-.45

.46

.41

.42

-.35

.34

Factor VI
Nonreciprocal Informativeness

Doctor: Asks for orientation, information, repetition,


confirmation.
Doctor: Gives orientation, information, repeats, clarifies, confirms.
Patient: Gives orientation, information, repeats, clarifies, confirms.
Factor VII
Evaluative Congruence

Patient: Agrees, shows passive acceptance, understands,


concurs, complies.
Patient: Asks for opinion, evaluation, analysis, expression of feeling.
Doctor: Agrees, shows passive acceptance, understands,
concurs, complies.
Doctor: Asks for opinion, evaluation, analysis, expression of feeling.

Factor VIII
Entreative Inquiry

Loading

Weight

.69

.77

.51

.52

Loading

Weight

.68

.73

.54

.52

.41

.42

Patient: Asks for orientation, information, repetition,


confirmation.
Patient: Asks for suggestion, direction, possible ways
of action.
Factor IX
Tension Build-up

Doctor: Shows solidarity, raises other's status, gives


help, reward.
Patient: Shows tension, asks for help, withdraws out
of the field.
Doctor: Shows tension, asks for help, withdraws out
of the field.
Factor X
Tension Release

Loading

Weight

.54

.58

.51

.43

Doctor: Shows tension release, jokes, laughs, shows


satisfaction.
Patient: Shows tension release, jokes, laughs, shows
satisfaction.

situation and shows little acceptance of


what the doctor says. It is assumed that
a doctor-patient relationship which exhibits a high score on this factor is deviFEBRUARY, 1968

ant from the normative doctor-patient


interaction.
Factor III, solidary relationship, is indicative of communication characterized
281

by friendly behavior on the part of both


doctor and patient. Positive social-emotional interaction reckons high in this
factor. The patient is able to show satisfaction with the interaction and release
much of the tension which arises from
the situation.
The communication in which Factor
IV, nondirective antagonism, is high,
suggests an antagonistic doctor who neglects to give the patient information,
explanation, or orientation. He confines
his activity to expressing opinions and
feelings about the situation.
Factor V, informative nonevaluativeness, typifies the doctor who gives a great
deal of direction to the patient but does
not present any diagnosis or evaluation.
Items defining Factor VI, nonreciprocal-informativeness, reflect the way in
which doctors collect information in
order to make a diagnosis. The doctor
asks for information from the patient
and the patient cooperatively orients the
doctor. In this case, however, the doctor
also withholds information from the patient. There is no feedback.
Factor VII, evaluative congruence,
measures the successful solution of the
problems introduced by lack of agreement on values and expectations The
doctor and patient agree on what they
consider important and beneficial for
their relationship.
An encounter scoring high on entreative inquiry, Factor VIII, illustrates how
a patient who desires information communicates in order to determine what
the problem is and how he can resolve
it. This type of patient does not wish
the doctor to withhold any information.
He asks for orientation, information, and
analysis.
Factor IX presents one way doctors
manage interaction saturated with tension. High scores on the factor tension
build-up indicate that both doctor and
patient show a great deal of tension regardless of the doctor's attempts to
282

achieve reintegration by communicating


in a friendly manner.
Factor X, tension release, is a corollary
of Factor IX. Here the doctor and patient exhibit tension release through
joking, laughing, and showing some satisfaction with the relationship.

Compliance and Factors of Doctor-Patient Communication


It was hypothesized that those patterns
of communication deviant from prescribed institutional doctor-patient relationships will result in patients' failure to
comply with doctors' advice. Scores for
the ten factors for each doctor-patient
pair were computed for the first visit
and the revisit, and subsequently correlated with patients' compliance.
First, there is very little association
between what occurs in the primary visit
and later compliance. In the first visit,
not one of the factors was significantly
associated with later patient compliance.
In the revisit, however, five of the ten
factors were associated with patients'
compliance. Table 3 shows a significant
correlation between compliance and
malintegrative behavior (Factor I). The
greater the malintegrative behavior in
the interaction, the less likely the patient
will follow the doctor's orders after he
leaves the doctor's office.
There is also a negative correlation
between compliance and Factor II, active
patient-permissive doctor. When a patient acts in an authoritative manner with
a permissive doctor, the doctor's position
is threatened and the patient is unlikely
to comply. Similarly Factor IV, measuring the extent to which a doctor is nondirective in an antagonistic way, is also
negatively correlated with compliance.
When a doctor confines his activity to
analysis of the situation and the expression of his opinions, he is likely to promote noncompliance. The opposite type
of behavior, however, does not insure
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58, NO. 2, A.J.P.H.

DOCTOR-PATIENT INTERACTION

compliance. Factor V, indicative of a


minimum of analysis and evaluation and
a maximum of direction on the doctor's
part, is not significantly related to compliance. These data suggest that compliance is a function of a delicate balance
of direction and evaluation presented in
a manner which is acceptable to the
patient.
Compliance is also a function of reciprocal interaction.42 Noncompliance
was significantly associated with Factor
VI, nonreciprocal-informativeness. Apparently it makes little difference how
much information the patient requests
(Factor VIII), but when the doctor
takes time to collect information without giving any feedback, the patient will
probably react in a reciprocal deviant
or noncompliant way.
It is interesting to note that only three
of the ten dimensions iterated in the
factor analysis measure positive rapport
in the interaction (solidary relationship,
evaluative congruence, and tension release), and only one of these, tension release, is significantly related to patient
compliance. When tension is built up,
it effects malintegration, but if released

through joking or laughing, the possibility of patient adherence to the medical regimen is increased.
Factor III, measuring the amount of
friendly rapport in the relationship, is
not significantly correlated with patient
compliance. As the relationship between
the doctor and patient becomes friendly,
strains are created which interfere with
their role functions. It may be easier
then for a patient to ignore the advice
of a friendly physician than one who is
formal and authoritative. If the friendly
doctor's authority is undermined, the
patient may be as likely to accept the
advice of a friend as that of the doctor.
This is also evident when Factor VII,
evaluative congruence, is examined.
Doctors and patients who are on the
same wave lengths, who agree on what
they consider desirable, right, and
proper, may communicate more effectively, but this activity is unrelated to
the patient's later compliance.
In sum, the hypothesis relating patient noncompliance and deviant patterns of communication is supported by
these data. Caution, however, is recommended when interpreting the find-

Table 3-Product moment correlations and levels of significance for


doctor-patient interaction factors and compliance behavior

Interaction factors

I. Malintegrative behavior
II. Active patient-permissive
doctor
III. Solidary relationship
IV. Nondirective antagonism
V. Informative nonevaluativeness
VI. Nonreciprocal informativeness
VII. Evaluative congruence
VIII. Entreative inquiry
IX. Tension build-up
X. Tension release

FEBRUARY, 1968

Primary visit
(N =119)
r
p

Revisit
(N =104)
r

-.141

>.05

-.260

<.01

-.132
.072
-.040
-.070
-.029
.102
-.031
-.081

>.05
>.05
>.05
>.05
>.05
>.05
>.05
>.05
>.05

-.304
.173
-.236
.040
-.315
.123
-.053
-.060
.223

<.01
>.05
<.01
>.05
<.01
>.05
>.05
>.05
<.05

.108

283

ings. The nature of each factor is such


that a negative correlation between
compliance and any factor does not
imply that the absence or reverse of
that factor is positively correlated with
compliance. For example, while malintegrative behavior is negatively correlated with compliance, the absence of
such behavior does not necessarily affect compliance. As indicated above,
compliance is not affected by the extent
to which the intereaction is characterized as a solidary relationship. One
should also note that while these data
evidence some statistically significant
correlations, the associations are relatively small. Furthermore, the factors
iterated in this particular investigation
have not been standardized. Consequently, they are descriptive characteristics of this particular population of
doctor-patient relationships. The significance of this research would be increased greatly if, in further studies,
these factors are employed as independent variables to investigate compliance in medical as well as other settings.

Summary and Discussion


Communication between doctor and
patient ideally necessitates a certain degree of reciprocity. Each person has
certain rights and obligations. When the
doctor performs a service, the patient is
obligated to reciprocate: first, by cooperating with the doctor in their interaction; and second, by complying with
the medical recommendations once he
leaves the doctor's office. We have seen,
however, that there are deviations from
these norms. The data reported in this
study, collected by means of tape recordings of doctor-patient interaction and
supplemented with a series of patient
interviews, a self-administered questionnaire completed by physicians, and
a content analysis of patients' medical
records, were analyzed to determine the
284

extent of deviant patient behavior within


and outside the doctor-patient relation-

ship.
Thirty-seven per cent of the patient
group disregarded what their doctors
advised. A factor analysis suggested
some patterns of

communication which

help explain noncompliance. While interaction in the primary doctor visit was
compliance, the
data suggest that revisits between an
authoritative patient and a physician
who passively accepts such patient participation may promote patient noncompliance. Effective communication is impeded when doctors and patients evidence tension in their relationship. Unless this tension is released, noncompliance may result, regardless of the
doctor's efforts to achieve solidarity.
And when doctors seek information
from patients without giving them any
feedback, the patient is unlikely to follow the doctor's orders once they are
formulated.
Implicit in this discussion of noncompliance is the problem of controlling patient behavior. In the doctor-patient relationship, whether in private practice,
hospital clinic, or oIn a ward, the doctor
must rely on his ability to establish good
rapport in order to inculcate in his patient a positive orientation and commitment to the relationship so that ultimately the patient will follow his advice.
In order to do this, it becomes necessary
for the doctor continually to explore
and diagnose the social and psychological facets of his interaction with his
patients as well as the manifest medical problem.
not associated with later

ACKNOWLEDGMENT-For criticismii and suggestions in the research plan and in preparing this paper the author is grateful to Mary
E. W. Goss. Thanks also to Joan Z. Cohen
and Jean Como, whose work as assistants on
this project has benefited it greatly. The
author would also like to acknowledge the help
of Jane Germer, Herman Freeman, and Joseph Reed in programing and statistical analysis of the data.
VOL. 58. NO. 2. A.J.P.H.

DOCTOR-PATIENT INTERACTION
FOOTNOTES
1. In another paper, preliminary findings
relating compliance to dimensions of doctorpatient interaction were reported. Davis, M. S.
Deviant Interaction in an Institutionalized Relationship: Variation in Patients' Compliance
with Doctors' Orders. Paper presented before
the Medical Sociology Session, Sixth World
Congress of Sociology, Evian, France (Sept.),
1966.
2. A systematic review of compliance literature may be found in Davis, M. S. Variations in Patients' Compliance with Doctors'
Orders: Analysis of Congruence Between Survey Responses and Results of Empirical Investigations. J. Med. Educ. 41,11:1037-1048,
Pt. 1 (Nov.), 1966.
3. Dixon, W. M.; Stradling, P.; and Wooton, I. Outpatient PAS Therapy. Lancet
273:871-873, 1957. Luntz, G. R., and Austin,
R. New Stick Test for PAS in Urine. Brit.
J. Med. 1:1679-1683, 1960. Morrow, R., and
Rabin, D. L. Reliability in Self-Medication
with Isoniazid. Clin. Research XIV,2 :362
(Apr.), 1966. Wynn-Williams, N., and Arris,
M. On Omitting PAS. Tubercle 39:138-142,
1958.
4. Cobb, B.; Clark, R. L.; McGuire, C.;
and Howve, C. D. Patient-Responsible Delay
of Treatment in Cancer. Cancer 7:920-925,
1954. Davis, M. S., and Eichhorn, R. L. Compliance with Medical Regimens: A Panel
Study. J. Health & Human Behavior 4:240249, 1963. Schwartz, D.; Wong, M.; Zeitz,
L.; and Goss, M. E. W. Medication Errors
Made by Elderly, Chronically Ill Patients.
A.J.P.H. 52,12:2018-2029, 1962.
5. Cobb, B. et al., op. cit. Donabedian, A.
and Rosenfeld, L. S. A Follow-up Study of
Chronically Ill Patients Discharged From Hospital. Pub. Health Rep. 79:228, 1964. Hardy,
M. C. Psychologic Aspects of Pediatrics:
Parenit Resistance to Need for Remedial and
Preventive Services. J. Pediat. 48:104-114,
1956. Johannsen, W. J.; Hellmuth, G. A.;
and Sorauf, T. On Accepting Medical Recommendations. Arch. Environ. Health 12:6369, 1966. MacDonald, M. E.; Hagverg, K. L.;
and Grossman, B. J. Social Factors in Relation to Participation in Follow-up Care of
Rheumlnatic Fever. J. Pediat. 62:503-513, 1963.
Mather, W. Social and Economic Factors
Related to Correction of School Discovered
Medical and Dental Defects. Pennsylvania
M. J. 62:983-988, 1954. Pragoff, H. Adjuistment of Tuberctilosis Patients One Year
After Hospital Discharge. Pub. Health Rep.
77:671-679, 1962. Watts, D. D. Factors Related to the Acceptance of Modern Medicine.
A.J.P.H. 56,8:1205-1212, 1966.
6. Bates, F. E., and Ariel, I. M. Delay in
Treatment of Cancer. Illinois 1I. J. 49:361365 (Dec.), 1948. Davis, M. S., and Eichhorn, R. L., op. cit. Johnson, W. L. Conformity to Medical Recommendations in Coronary Heart Disease. Paper presented at the
annual meeting of the American Sociological

FEBRUARY, 1968

Association, Chicago (Sept.), 1965. Pragoff,


H., op. cit.
7. Abramson, J. H.; Mayet, F. G.; and
Majola, C. C. What Is Wrong with Me?
A Study of the Views of African and Indian
Patients in a Durban Hospital. South African M. J. 35:690-694 (Aug. 19), 1961.
8. Ambuel, J. P.; Cebulla, J.; Watt, N.;
and Crowne, D. Doctor-Mother Communications. Midwest Society Pediat. Res. 65:113114, 1964.
9. Cobb, B., et al., op. cit.
10. Ellis, R. The Relationship Between
Psychological Factors and Remission of Duodenal Ulcer. Unpublished doctoral dissertation, University of Chicago, 1964.
11. Hellmuth, G. A.; Johannsen, W. J.;
and Sorauf, T. Psychological Factors in Cardiac Patients. Arch. Environ. Health 12:
771-780 (June), 1966.
12. Leventhal, H. Fear Communications in
the Acceptance of Preventive Health Practices. Bull. New York Acad. Med. 41,11:
1144-1168 (Nov.), 1965.
13. For a discussion of the content of
normative prescriptions and proscriptions, see
Mizruchi, E., and Perrucci, R. Norm Qualities and Differential Effects of Deviant Behavior: An Exploratory Analysis. Am. Sociol.
Rev. 27:391-399, 1962. See also, Hollander,
M. The Psychology of Medical Practice.
Philadelphia: W. B. Saunders, 1958.
14. Davis, M. S., and Eichhorn, R. L., op.
cit.
15. Davis, M. S. Predicting Non-Compliant Behavior. J. Health & Social Behavior
8:265-271, 1967. Johannsen, W. J., et al.,
op. cit.
16. Berkowitz, N. H.; Malone, M. F.; Klein.
M. W.; and Eaton, A. Patient Followthrough in the Out-Patient Department. Nursing Res. 12:16-22, 1963; and Patient Care
as a Criterion Problem. J. Health & Human
Behavior 3:171-176, 1962.
17. Davis, M. S. J. M. Educ., op. cit. Ley.
P., and Spelman, M. S. Communications in
an Out-Patient Setting. Brit. J. Social and
Clinical Psychol. 4:114-116, 1965. Riley, C. S.
Patients' Understanding of Doctors' Instructions. M. Care 4,1:34-37 (Jan.-Mar.), 1966.
18. Elling, R.; Whittemore, R.; and Green,
M. Patient Participation in a Pediatric Program. J. Health & Human Behavior 1:183191, 1960. Ku, R., and Jordan, G. A Study
of Self-Administration of Isoniazid in Children. Health Research Training Program,
New York City Department of Health, 1964,
pp. 1-11. Wallace, H. M., et al. Study of
Follow-up of Children Recommended for
Rheumatic Fever Prophylaxis. A.J.P.H. 46,12:
1563-1570, 1956.
19. Eichhorn, R. L.; Riedel, D. C.; and
Morris, W. H. M. Compliance to Perceived
Therapeutic Advice. Proceedings of the Purdue Farm Cardiac Seminar. W. H. M. Morris (ed.). Lafayette, Ind.: Agricultural Experiment Station (Sept.), 1958, pp. 65-68.
Pragoff, H., op. cit.
285

20. Abramson, J. H., et al., op. cit. Davis,


M. S., and Eichhorn, R. L., op. cit. Watts,
D. D., op. cit.
21. The single exception here is the doctoral dissertation by Ellis, R., op. cit.
22. Berkowitz, N. H., et al., op. cit. Johnson, W. L., op. cit.
23. Johannsen, W. J., et al., op. cit.
24. Davis, M. S., and von der Lippe, R. P.
Discharge from Hospital Against Medical Advice: A Study of Reciprocity in the DoctorPatient Relationship. Social Science & Med.
1:336-342, 1968. Hoffman, R. The Doctor's
Role: A Study of Consensus, Congruence
and Change. Doctoral dissertation, University of Nebraska, 1958. Sapolsky, A. Relationship between Doctor-Patient Compatability, Mutual Perception and Outcome of
Treatment. J. Abnorm. Psychol. 70,1:70-76,
1965. Sobel, R., and Igalls, A. Resistance
to Treatment, Explorations of the Patient's
Sick Role. Am. J. Psychotherapy 18:562-573,
1964.
25. Ellis, R., op. cit.
26. Abramson, J. H., et al., op. cit. Ambuel,
J. P., et al., op. cit. Cobb, B., et al., op. cit.
Davis, M. S., and Eichhorn, R. L., op. cit.
Elling, R., et al., op. cit. Leventhal, H., op.
cit. Ley, P. and Spelman, M. S., op. cit.
Mohler, D. N.; Wallin, D. G.; and Dreyfus,
E. G. Studies in the Home Treatment of
Streptococcal Disease. New England J. Med.
252:1116-1118, 1955. Riley, C. S., op. cit.
Robbins, G. F.; Conte, A. J.; Leach, J. E.;
and MacDonald, M. Delay in Diagnosis and
Treatment of Cancer. J.A.M.A. 143:346-348,
1950. Ullmann, A., and Davis, M. S. Assessing the Medical Patient's Motivation and
Ability to Work. Social Casework XLVI, pp.
195-202, 1965. Watts, D., op. cit.
27. Interviewers were instructed to drop patients judged to be noninterviewable. Because of insufficient numbers of suitable new
patients coming to the clinic at certain times,
an interviewer occasionally attempted to administer the first interview schedule to someone he hoped would be suitable but who, in
fact, was not. Ten such patients were eliminated because of language barriers, hearing
difficulties, and inappropriate medical problems. Another five patients were dropped
from the study at the request of the physician, two because of the sensitive nature of
their problems, and one because her doctor
felt that the study was too distracting for
her. (He insisted that she had been so fascinated by the tape recorder that she had
ignored him completely.) A number of doctors and patients expressed reservations about
the tape recorders but only one patient and
one doctor refused to be taped. Three others
were dropped from the study because they refused to be interviewed. Finally, ten patients were eliminated from the study group
because the interviewer assigned to the case
either failed to or was unable to follow them
properly.
Altogether, 32 patients were
dropped from the study population.

286

28. Turgeon, L., and Long, D. A Study of


New Patients in the General Medical Clinic.
Research Memorandum, Comprehensive Care
and Teaching Program, New York HospitalCornell University Medical Center (Feb.),
1965 (mimeo.). The sample included patients seen in October, 1962; the present report is based on a sample of patients seen
between November, 1964 and June, 1965. Data
comparing demographic characteristics of the
study population with the estimated composition of the clinic population based on the
1962 survey are available upon request.
29. The exploratory phase of the research
was supported by United States Public Health
Service Grant (MH08458-01), and was entitled "Dimensions of Compliant Doctor-Patient Relationships."
30. Bales, R. F. Interaction Process Analysis. Cambridge, Mass.: Addison-Wesley Press,
1951. While interaction process analysis has
been employed experimentally and to study
the interaction between doctor and patient in
a psychotherapeutic situation, it has not been
used in an investigation of interaction in a
medical situation.
For the reader who wishes to examine other
methods of recording interaction see: Adler,
L. Mc. A Scale to Measure Psychotherapy
Interactions. University of Southern California School of Medicine. Los Angeles, 1964.
(Mimeo.). Carter, L. F. Recording and Evaluating the Performance of Individuals as Members of Small Groups. Personnel Psychology
7:477-484, 1954. Carter, L.; Haythorn, W.;
Meirowitz, B.; and Lanzetta, J. A Note on
a New Technique of Interaction. J. Abnorm.
& Social Psychol. 46:258-260, 1951. Chapple,
E. D. The Interaction Chronograph: Its Evolution and Present Application. Personnel 25:
295-307, 1949. Dittman, A. T. The Interpersonal Process in Psychotherapy: Development of a Research Method. J. Abnorm. &
Social Psychol. 47:236-244, 1952. Dollard,
J. A Method of Measuring Tension in Written Documents. Ibid. XLII, pp. 3-32, 1947.
Freedman, M. B.; Leary, T. F.; Ossonio, A.
G.; and Coffey, H. S. The Interpersonal Dimension of Personality. J. Personality 20:143161, 1951. Guetzkow, H. Unitizing and Categorizing Problems in Coding Qualitative Data.
J. Clin. Psychol. 6:47-58, 1950. Heyns,
R. W., and Lippitt, R. Systematic Observational Techniques. The Handbook of Social
Psychology. Lindzey, G. (ed.). Reading, Mass.:
Addison-Wesley Publishing, 1954, pp. 370-404.
Lennard, H. L., and Bernstein, A. The Anatomy of Psychotherapy. Chapter II, Methodology. New York: Columbia University Press,
1960. Matarazzo, J. D.; Saslow, G.; and Matarazzo, R. G. The Interaction Chronograph as
an Instrument for Objective Measurement of
Interaction Patterns During Interviews. J. Psychol. 41:347-367, 1956. Melbin, M. Field
Methods and Techniques: The Action-Interaction Chart. Human Organization 12 :3435, 1953. Murray, H. A Content Analysis
Method for Studying Psychotherapy. Psychol.

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DOCTOR-PATIENT INTERACTION
Monogr. LXX :13, 1956. Psathas, G. Problems and Prospects in the Use of a Computer System of Content Analysis. Sociol.
Quart. (forthcoming). Ruesch, J.; Block, J.;
and Bennett, L. The Assessment of Communication: I. A Method for the Analysis of
Social Interaction. J. Psychiat. 35:59-80,
1953. Stenzar, B. The Development and
Evaluation of a Measure of Social Interaction. Am. Psychol. 3:266, 1948. Stone, P. J.;
Dunphy, D. C.; Smith, M. S.; and Ogilire,
D. M. The General Inquirer: A Computer
Approach to Content Analysis. Cambridge,
Mass.: Massachusetts Institute of Technology
Press, 1966.
31. Four coders worked in pairs, each pair
coding together for a week. Every week partners were changed to produce the greatest
uniformity in coding and to minimize the
chance of developing rigid coding idiosyncracies. The coders listened to each recording unitizing the dialogue on transcripts and
indicating statements of affect. This was done
individually and then pairs were compared.
Any disagreements were resolved through
discussion, or if necessary by relistening to
the tape. Coding was then done individually
and the two code sheets compared. Again
differences were resolved through discussion
and relistening to the interaction. Any disagreements which could not be resolved were
referred to the other two coders during the
period set aside for that purpose each day.
When the coding was completed there was
some concern that increased familiarity with
the code might cause some significant differences in coding between tapes done at the
beginning and at the end of the coding period. A random sample of visits from the
early tapes was recoded and 4 per cent of the
answers were changed. However, when a random sample from all the other tapes was
taken and recoded, 3 per cent of the codes
were changed from one category to another.
It was concluded, therefore, that a certain
insignificant percentage of codes would be
changed regardless of how many times the
interactions were recoded.
32. Bales, R. F., op cit., Chapter 4. By
coding after the observation of doctor-patient
interaction, many of the difficulties of reliability of categorizing were eliminated. The

problem of reliability of attribution and unitizing was nonexistent because the transcription was utilized and interaction was unitized and attributed to doctor or patient prior
to the coding process.
33. For a comparison of indexes of compliance, see Davis, M. S., and Eichhorn, R. L.,
op. cit; and Davis, M. S. J. Health & Social
Behavior, op. cit.
34. Several patients were administered specific regimen and compliance sections of the
interview when regimens were not recorded
by the doctor either in the patient's medical
record or the doctor's questionnaire. Occasionally, the physician made a suggestion,
e.g., "Don't worry about yourself," "Maybe
you should lose some weight," and so on,
which was not meant as a specific recommendation.
35. For example, consider a patient who
(a) was advised to make six clinic visits
during the period he received medical care,
(b) received a prescription for a single
medication, (c) was told to cut down on his
smoking, and (d) was advised to eliminate
alcoholic beverages.
According to the chart review, the patient
kept only three of his appointments (50 per
cent broken appointment rate). The patient
reported that he had cut down on his smoking as recommended and took the medication
most of the time. He did not recall the doctor
telling him anything about alcoholic beverages. The doctor reported, in the questionnaire, that the patient did not take his medications at all, but had cut down on his
smoking. According to the doctor, the patient had not curbed his drinking habits at all.
With regard to the clinic visits, the patient
was given a score of "3," compliant most
of the time (each patient was allowed a proportion of broken appointments before he
was considered deviant). For the medication
regimen, he was given a score of "1.5," the
average of the disagreement "3+0." The doctor agreed that the patient had indeed complied with the smoking regimen and the patient was given a score of "4," compliant
all of the time. With regard to the alcohol
regimen, the patient was scored as "0," not at
all compliant. Accordingly, the compliant profile for the patient is as follows:

Weighted
Compliance score

Regimen
a. Clinic visits

"3"

Most of the time

b. Medication

"1.5"

Less than half the time

c. Smoking

"4"

All of the time

d. Alcohol

"0"

Not at all

FEBRUARY. 1968

Weight

score

(1)
(2)
(2)
(1)

14

3
8
0

287

The composite index of compliance is the


sum of the weighted scores divided by the
sum of the weights. In this case, the index
is equal to 14/6 or 2.3, compliant less than
half the time.
36. More detailed data relating extent of
compliance and demographic variables can
be found -in an earlier paper: Davis, M. S.
Sixth World Congress of Sociology, Evian,
France, op. cit.
37. Coser, R. L. Life on the Ward. East
Lansing: Michigan State University Press,
1962. Kasl, S. V., and Cobb, S. Health Behavior, Illness Behavior and Sick Role Behavior. Arch. Environ. Health 12:246-266
(Feb.), 1966. Mauksch, H. O., and Tagliacozzo, D. M. The Patient's View of the Patient Role. Department of Patient Care Research, Presbyterian-St. Luke's Hospital. Publication 2, Chicago, Ill. (Mar.), 1962. Mechanic, D., and Volkart, E. H. Illness Behavior and Medical Diagnoses. J. Health &
Human Behavior 1:86-94, 1960. Parsons, T.

The Social System. Glencoe, Ill.: The Free


Press, 1951, Chapter X.
38. Davis, M. S. Sixth World Congress of
Sociology, Evian, France, op. cit.
39. Ibid.
40. Bales, R. F. Theoretical Framework.
Chapter 2, op. cit.
41. Hendrickson, A. E., and White, D. 0.
Promax: A Quick Method for Rotation to
Oblique Simple Structure. Brit. J. Statist. Psychol. 17:65 (May), 1964. The relations among the factors of the oblique solution range from .22 to -.29. Most of the
items have a high factor loading on one factor and a low loading on the remaining factors. Only items with a factor loading of .30
or greater were used to define a factor.
42. Gouldner, A. W. The Norm of Reciprocity: A Preliminary Statement. Am. Sociol.
Rev. 25:161-178 (Apr.), 1960. A paradigm
of types of doctor-patient reciprocity can be
found in Davis, M. S., and von der Lippe,
R. P., op. cit.

Dr. Davis is associate professor of Community Medicine and Public Health


(Medical Sociology), University of Southern California School of Medicine (2025
Zonal Ave.), Los Angeles, Calif. 90033.
This paper was presented before the Medical Care Section of the American
Public Health Association at the 94th Annual Meeting in San Francisco, Calif.,
November 3, 1966.
The research reported here is part of a larger investigation of variations in
patients' compliance with doctors' orders carried out as part of a program in
patient care research at Cornell University Medical College, Comprehensive
Care and Teaching Program, George G. Reader, director, with the support of
U. S. Public Health Service Program Grant (CH00103 01).

288

VOL. 58. NO. 2, A.J.P.H.