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deals with the extent to which patients did not comply and with the
factors that may be involved in explaining these variations.
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
DOCTOR-PATIENT INTERACTION
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
Study Group
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.
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
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
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
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
Loading
.72
Weight
.58
.66
.50
.52
.36
.36
.11
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
Factor V
Informative Nonevaluativeness
Loading
.99
-.48
Weight
.82
.24
confirms.
280
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
Factor VIII
Entreative Inquiry
Loading
Weight
.69
.77
.51
.52
Loading
Weight
.68
.73
.54
.52
.41
.42
Loading
Weight
.54
.58
.51
.43
DOCTOR-PATIENT INTERACTION
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-
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
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
286
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"
b. Medication
"1.5"
c. Smoking
"4"
d. Alcohol
"0"
Not at all
FEBRUARY. 1968
Weight
score
(1)
(2)
(2)
(1)
14
3
8
0
287
288