The Influence of the Patient-Clinician Relationship on Healthcare Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

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Abstract

Objective

To determine whether the patient-clinician relationship has a beneficial effect on either objective or validated subjective healthcare outcomes.

Design

Systematic review and meta-analysis.

Data Sources

Electronic databases EMBASE and MEDLINE and the reference sections of previous reviews.

Eligibility Criteria for Selecting Studies

Included studies were randomized controlled trials (RCTs) in adult patients in which the patient-clinician relationship was systematically manipulated and healthcare outcomes were either objective (e.g., blood pressure) or validated subjective measures (e.g., pain scores). Studies were excluded if the encounter was a routine physical, or a mental health or substance abuse visit; if the outcome was an intermediate outcome such as patient satisfaction or adherence to treatment; if the patient-clinician relationship was manipulated solely by intervening with patients; or if the duration of the clinical encounter was unequal across conditions.

Results

Thirteen RCTs met eligibility criteria. Observed effect sizes for the individual studies ranged from d = −.23 to .66. Using a random-effects model, the estimate of the overall effect size was small ( d = .11), but statistically significant ( p = .02).

Conclusions

This systematic review and meta-analysis of RCTs suggests that the patient-clinician relationship has a small, but statistically significant effect on healthcare outcomes. Given that relatively few RCTs met our eligibility criteria, and that the majority of these trials were not specifically designed to test the effect of the patient-clinician relationship on healthcare outcomes, we conclude with a call for more research on this important topic.

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Most cited references 22

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Doctor-patient communication: a review of the literature.

L M Ong, J de Haes, A M Hoos … (1995)

Communication can be seen as the main ingredient in medical care. In reviewing doctor-patient communication, the following topics are addressed: (1) different purposes of medical communication; (2) analysis of doctor-patient communication; (3) specific communicative behaviors; (4) the influence of communicative behaviors on patient outcomes; and (5) concluding remarks. Three different purposes of communication are identified, namely: (a) creating a good inter-personal relationship; (b) exchanging information; and (c) making treatment-related decisions. Communication during medical encounters can be analyzed by using different interaction analysis systems (IAS). These systems differ with regard to their clinical relevance, observational strategy, reliability/validity and channels of communicative behavior. Several communicative behaviors that occur in consultations are discussed: instrumental (cure oriented) vs affective (care oriented) behavior, verbal vs non-verbal behavior, privacy behavior, high vs low controlling behavior, and medical vs everyday language vocabularies. Consequences of specific physician behaviors on certain patient outcomes, namely: satisfaction, compliance/adherence to treatment, recall and understanding of information, and health status/psychiatric morbidity are described. Finally, a framework relating background, process and outcome variables is presented.

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Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations.

Jonathan Little, Gina C. Gould, Brook G. Warner … (2001)

To measure patients' perceptions of patient centredness and the relation of these perceptions to outcomes. Observational study using questionnaires. Three general practices. 865 consecutive patients attending the practices. Patients' enablement, satisfaction, and burden of symptoms. Factor analysis identified five components. These were communication and partnership (a sympathetic doctor interested in patients' worries and expectations and who discusses and agrees the problem and treatment, Cronbach's alpha=0.96); personal relationship (a doctor who knows the patient and their emotional needs, alpha=0.89); health promotion (alpha=0.87); positive approach (being definite about the problem and when it would settle, alpha=0.84); and interest in effect on patient's life (alpha=0.89). Satisfaction was related to communication and partnership (adjusted beta=19.1; 95% confidence interval 17.7 to 20.7) and a positive approach (4.28; 2.96 to 5.60). Enablement was greater with interest in the effect on life (0.55; 0.25 to 0.86), health promotion (0.57; 0.30 to 0.85), and a positive approach (0.82; 0.52 to 1.11). A positive approach was also associated with reduced symptom burden at one month (beta=-0.25; -0.41 to -0.10). Referrals were fewer if patients felt they had a personal relationship with their doctor (odds ratio 0.70; 0.54 to 0.90). Components of patients' perceptions can be measured reliably and predict different outcomes. If doctors don't provide a positive, patient centred approach patients will be less satisfied, less enabled, and may have greater symptom burden and higher rates of referral.

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Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials.

Simon Griffin, Ann-Louise Kinmonth, Marijcke Veltman … (2004)

We wanted to identify published randomized trials of interventions to alter the interaction between patients and practitioners, develop taxonomies of the interventions and outcomes, and assess the evidence that such interventions improve patients' health and well-being. Undertaking a systematic review of randomized trials, we sought trials in primary and secondary care with health-related outcomes, which we found by searching MEDLINE, HealthSTAR, and PsycINFO bibliographic databases through 1999. We also completed one round of manual citation searching. Thirty-five trials were included. Most were set in primary care in North America. Trials were heterogeneous in populations, settings, interventions, and measures. Interventions frequently combined several poorly described elements. Explicit theoretical underpinning was rare, and only one study linked intervention through process to outcome measures. Health outcomes were rarely measured objectively (6 of 35), and only 4 trials with health outcomes met predefined quality criteria. Interventions frequently altered the process of interactions (significantly in 73%, 22 of 30 trials). Principal outcomes favored the intervention group in 74% of trials (26 of 35), reaching statistical significance in 14 (40%). Positive effects on health outcomes achieved statistical significance in 44% of trials (11 of 25); negative effects were uncommon (5 of 25, 20%). Simple approaches to increasing the participation of patients in the clinical encounter, such as providing practitioners with a note from patients about their concerns beforehand, showed promise, as did more complex programs providing specific information about disease and attention to emotion. Apparently similar interventions varied in effectiveness across studies. Successful interactions between patients and their practitioners lie at the heart of medicine, yet there are few rigorous trials of well-specified interventions to inform best practice. Trial evidence suggests that a range of approaches can achieve changes in this interaction, and some show promise in improving patients' health. To advance knowledge further, we need to replicate promising studies using rigorous methods. These should include explicit theoretical frameworks designed to link effects on key communication and interaction characteristics through to effects on health outcomes.

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Author and article information

Contributors

Antje Timmer: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2014

Publication date (Electronic): 9 April 2014

Volume: 9

Issue: 4

Electronic Location Identifier: e94207

Affiliations

[1 ]Empathy and Relational Science Program, Psychiatry Department, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America

[2 ]Program in Placebo Studies and the Therapeutic Encounter, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, United States of America

[3 ]Psychology Department, Endicott College, Beverly, Massachusetts, United States of America

[4 ]Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America

[5 ]Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts, United States of America

[6 ]Department of Clinical Psychology & Psychotherapy, University of Basel, Basel, Switzerland

Carl von Ossietzky University of Oldenburg, Germany

Author notes

* E-mail: johnkelley@ 123456post.harvard.edu

Competing Interests: Dr. Riess is a stockholder, Chief Technology Officer, and Chairman of Empathetics, LLP. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.

Conceived and designed the experiments: JMK GKT LS HR. Analyzed the data: JMK GKT LS JK HR. Wrote the paper: JMK GKT LS JK HR.

Article

Publisher ID: PONE-D-13-32724

DOI: 10.1371/journal.pone.0094207

PMC ID: 3981763

PubMed ID: 24718585

SO-VID: b0bf638e-f704-4edf-8ccc-db41a47af9c9

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 8 August 2013

Date accepted : 12 March 2014

Page count

Pages: 7

Funding

This study was made possible with a grant from the Arnold P. Gold Foundation ( www.humanism-in-medicine.org; grant #FI-11-004). Joe Kossowsky's contributions to this study were supported by the Swiss National Science Foundation, grant project (P2BSP1_148628). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The Influence of the Patient-Clinician Relationship on Healthcare Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

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Abstract

Objective

Design

Data Sources

Eligibility Criteria for Selecting Studies

Results

Conclusions

Related collections

PLOS Climate

Most cited references 22

Doctor-patient communication: a review of the literature.

Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations.

Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials.

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