Abstract
OBJECTIVE
To investigate patients' preferences for care by general internists and specialists for common medical conditions.
DESIGN
Telephone interview.
SETTING
A convenience sample of general internal medicine practices at 10 eastern academic medical centers.
PATIENT/PARTICIPANTS
A probability sample of 314 participants who had at least one visit with their primary care physician during the preceding 2 years.
MEASUREMENTS AND MAIN RESULTS
Items addressed patients' attitudes concerning continuity of care, preferences for care by general internists or specialists for common medical problems, and perceptions about the competency of general internists and specialists to manage these problems. Continuity was important to participants, with 63% reporting they preferred having one doctor. Respondents were willing to wait 3 or 4 days to see their regular doctor (85%) and wanted their doctor to see them in the emergency department (77%) and monitor their care while in the hospital (94%). A majority (>60%) preferred care from their regular doctor for a variety of new conditions. Though respondents valued continuity, 84% felt it was important to be able to seek medical care from any type of physician without a referral, and 74% responded that if they needed to see a specialist, they were willing to pay out-of-pocket to do so. Although most participants (98%) thought their regular doctor was able to take care of usual medical problems, the majority thought that specialists were better able to care for allergies (79%) and better able to prescribe medications for depression (65%) and low-back pain (72%).
CONCLUSIONS
Participants preferred to see their general internist despite their perceptions that specialists were more competent in caring for the conditions we examined. However, they wanted unrestricted access to specialists to supplement care provided by general internists.
Keywords: decision making, patient participation, referral, consultation
The patient's role in health care has evolved from passive recipient to autonomous consumer.1–4 During this evolution, interest in the patients' perspective has increased5–8 to the point that patients often evaluate physician performance.9 Simultaneously, generalist physicians have been encouraged to hold down costs by restricting patient access to specialists. However, recent surveys indicate that managed care patients are dissatisfied with access to specialty care.10,11 This “gatekeeping” role may put generalists at odds with patient expectations for specialty care.
As the debate about how to hold down medical costs and provide quality care continues, information comparing the cost and quality of care provided by generalists and specialists proliferates.12,13 Associations between patient characteristics and care from specialists and generalists have been demonstrated.14 However, information about patients' preferences for care provided by generalists versus care provided by specialists is limited.15,16
This kind of information is valuable in the current health care market. Patient satisfaction is associated with fulfillment of expectations,7,17 and it may be improved if expectations for specialty care are known. For example, patients who prefer to see a specialist may be dissatisfied with care by a general internist even though the care was appropriate. Conversely, patients who value continuity may be dissatisfied if they are referred from specialist to specialist rather than having one physician coordinate their care. Understanding when patients prefer to see a generalist or under what circumstances they prefer to see a specialist could allow targeted access to specialists.18 Moreover, if patient preferences for specialty care are found to be unrealistic in the face of limited resources, efforts to educate patients about specialists' roles in providing care may be appropriate.6
In this study, we conducted structured patient interviews to investigate patient preferences for care by general internists and specialists in the outpatient setting. We addressed patient attitudes and preferences for care by general internists and specialists in several situations: general medical care, care for newly developed conditions, and care for three common medical conditions. To explore factors that may influence these preferences, we examined patients' knowledge of physician training and practice, and their perceptions of general internists' and specialists' competency in managing selected conditions.
METHODS
Participants
Participants were selected from patient panels of faculty general internal medicine practices at 10 eastern academic medical centers. We obtained lists of eligible patients from clinic records and generated a random sample of 120 names at each site. Only English-speaking patients over the age of 18 years who had seen their primary care provider within the last 2 years were eligible. We obtained institutional review board approval at each institution, and providers at these institutions consented to having their patients contacted. Before initiating telephone contact, a letter of recruitment signed by their provider was sent to assure potential participants that their answers would be confidential and not seen by their providers. Several sites were required by their institutional review board to have patients return postcards agreeing to participate before they could be contacted. We interviewed participants until each site obtained 40 participants or the end of the study time frame was reached. Recruitment began in February 1996 and continued until July 1996.
Questionnaire Design
We developed the instrument based on a literature review of patient expectations for care in the ambulatory setting.5,8,17,19–22 Questions required short answers or Likert response scales of : 1 = strongly disagree, 2 = disagree, 3 = agree, and4 = strongly agree. If respondents were not able to commit to one of the four Likert responses, the item was coded as 2.5. The instrument consisted of three sections.
In the first section, we asked participants about their “regular doctor,” defined as “a doctor whom you would see for usual health problems and for preventive care.” Items addressed continuity of care, freedom to choose a physician, and respondents' knowledge about physician training, scope of practice, and perceived competency of their regular doctor. In the second section, we listed 15 common medical conditions and asked respondents to indicate their preferences regarding care if they developed the condition during regular office hours. Response options were regular doctor, specialist, emergency department, or no preference. In the third section, we asked about continuity of care, physician choice, and perceived competencies of physicians in caring for three specific medical conditions: seasonal allergies, depression, and low-back pain. These conditions were chosen because they are common outpatient conditions managed by both generalists and specialists.
Data Analysis
We reported descriptive data as means and proportions, and we analyzed Likert scales as continuous variables. Stratified comparisons among subgroups were performed using t tests, one-way analysis of variance (ANOVA), and Wilcoxon ranked sum tests. If the statistical significance did not differ between the t tests and the Wilcoxon ranked sum tests, we reported the t test results only. All reported p values were 2-sided; a p value ≤ .05 was considered statistically significant. We analyzed the data using STATA statistical software package version 5.0 (College Station, Tex).
RESULTS
We completed 314 telephone interviews with patients from 10 internal medicine sites. The number of completed interviews varied by site (range, 5–41; mean, 31). Participant characteristics are shown in Table 1. In general, respondents were well-educated, middle-class, white women. About 40% reported very good to excellent health, yet within the previous year, many reported frequent physician visits and hospitalizations.
Table 1.
Respondent Characteristics (N = 314)
| Characteristic | Value |
|---|---|
| Mean age, y (range) | 55 (22–83) |
| Women, % | 71 |
| Race, % | |
| White | 80 |
| Black | 14 |
| Other | 6 |
| Marital status, % | |
| Married or living with significant other | 69 |
| Divorced, widowed, or never married | 28 |
| Other | 3 |
| Education, % | |
| Less than 12 y of school | 11 |
| Completed 12 y of school | 27 |
| Some college/college graduates | 40 |
| Graduate school | 22 |
| Household income, % | |
| < $20,000 | 20 |
| $20,000–$50,000 | 41 |
| >$50,000 | 33 |
| No response | 6 |
| Self-reported health status, % | |
| Excellent | 14 |
| Very good | 29 |
| Good | 34 |
| Fair | 18 |
| Poor | 5 |
| Employed, % | 53 |
| Insured, % | 92 |
| Belongs to HMO, % | 25 |
| Has a regular doctor, % | 96 |
| Number of times saw regular doctor in the past 12 mo, mean (range) | 6.5 (0–40) |
| Number of other doctors seen in the past 12 mo, mean (range) | 2.5 (1–14) |
| Hospitalized this year, % | 30 |
Selection and Preferences for Primary Care Physicians
Nearly all respondents identified a primary care physician (reflecting our sampling technique). Table 2 shows how participants selected their primary care physician and their preferences for gender and practice duration. Most participants selected their physicians based on recommendations from another physician or friend. Although most respondents expressed a preference for practice duration and preferred a doctor who had been in practice more than 5 years, a minority expressed a gender preference.
Table 2.
Selection and Preferences for Primary Care Physicians
| Selection/Preference | % |
|---|---|
| How did you select your regular doctor? | — |
| Referred by another doctor | 33 |
| Recommended by a friend | 27 |
| Chose from a medical insurance list | 12 |
| Assigned when called for an appointment | 9 |
| Other | 19 |
| I prefer a doctor who has | |
| Just completed training and opened a new office | 2 |
| Been in practice more than 5 y | 59 |
| Been in practice more than 15 y | 22 |
| No preference | 17 |
| Would you prefer your regular doctor be a man or woman? | |
| Strongly prefer woman | 10 |
| Prefer woman | 8 |
| Prefer man | 12 |
| Strongly prefer man | 11 |
| No preference | 59 |
Preferences and Attitudes Regarding General Medical Care
Table 3 shows respondents' preferences for general medical care. Most participants valued continuity with their generalists. Almost two thirds preferred to have one doctor take care of their medical problems. Furthermore, respondents reported a willingness to wait 3 or 4 days to see their regular doctor and a desire for their doctor to see them in the emergency department and monitor their care while in the hospital. Although respondents reported a desire for continuity, over half noted that for a new problem they preferred to see a doctor who specializes in that problem.
Table 3.
Patient Preferences and Attitudes Regarding General Medical Care
| Preference/Attitude | Strongly Disagree, % 1 | Disagree*, % 2 | Agree*, % 3 | Strongly Agree, % 4 | NP†, % 2.5 |
|---|---|---|---|---|---|
| Continuity | |||||
| I prefer having one doctor take care of my medical problems. | 12 | 22 (34) | 22 (63) | 40 | 3 |
| I prefer my regular doctor handle any new health concerns that come up because she/he already knows my health history. | 1 | 1 (2) | 12 (97) | 85 | 1 |
| I prefer my doctor see me in the emergency room. | 3 | 13 (16) | 38 (77) | 39 | 7 |
| I would rather wait 3–4 d to see my doctor instead of seeing a different doctor immediately. | 5 | 10 (15) | 22 (85) | 63 | 0 |
| I would prefer that my doctor monitor my care in the hospital. | 1 | 4 (5) | 20 (94) | 74 | 1 |
| I am willing to see a nurse practitioner/physician assistant for my regular care. | 30 | 36 (66) | 24 (34) | 10 | 0 |
| At the start of a new problem, I prefer to see a doctor who specializes in that particular problem. | 14 | 25 (39) | 28 (57) | 29 | 4 |
| Choice | |||||
| It is important to me to be able to seek medical care from any type of doctor without a referral. | 5 | 11 (16) | 23 (84) | 61 | 0 |
| I would avoid an insurance plan that will not allow me to choose the regular doctor I want. | 5 | 6 (11) | 18 (89) | 71 | 0 |
| I would avoid an insurance plan that will not allow me to choose the specialist I want. | 6 | 7 (13) | 19 (87) | 68 | 0 |
| If I think I need to see a specialist, I am willing to pay extra out of my own pocket. | 12 | 15 (27) | 34 (73) | 40 | 0 |
| Competency | |||||
| It is important to me that my doctor be trained in the U.S. | 12 | 17 (29) | 27 (69) | 42 | 2 |
| It is very important to me that my doctor receives continued medical education. | 1 | 1 (2) | 7 (98) | 91 | 0 |
| In choosing a regular doctor, it is important to me to review my doctor's credentials. | 6 | 18 (24) | 39 (76) | 37 | 0 |
| I believe my regular doctor is able to take care of the usual problems that people are likely to have. | 1 | 1 (2) | 13 (98) | 85 | 0 |
Responses of strongly agree and agree/strongly disagree and disagree are collapsed and shown in parentheses.
Respondents offered no preference.
Participants also valued the freedom to choose their doctors and to have unencumbered access to specialists. For instance, they reported a desire to seek care from any type of physician without a referral, and almost 90% of participants would avoid insurance plans that limited their choice of generalists or specialists. Moreover, almost three quarters reported a willingness to pay out-of-pocket to see a specialist if they thought it was necessary.
Patients' Knowledge and Attitudes Regarding Physician Training and Practice
Not surprisingly, respondents believed that their doctor's training and credentials were important. Most respondents preferred a doctor trained in the United States, and almost all respondents thought that their doctor should receive continuing medical education. Seventy-six percent agreed that it is important to review their doctors' credentials, yet only 13% reported having done so. Almost all agreed that their regular doctor is “able to take care of the usual problems that people are likely to have.”
Table 4 shows participants' knowledge and understanding about physicians' training and scope of practice. Almost half of respondents thought that it took 3 to 4 years of training to become a regular doctor, and a majority thought it took 7 to 9 years to become a specialist. However, a significant number of respondents did not know the duration of training for generalists or specialists. Participants thought internists provided a broader scope of practice than most are trained to provide, with over half indicating that internists care for children and about a quarter indicating that internists deliver babies. About three fourths of those surveyed reported knowing the meaning of board certification.
Table 4.
Knowledge About Physician Training and Practice
| Patient Perception | Regular Doctor, % | Specialist, % | |
|---|---|---|---|
| Years of training required after medical school | |||
| 0–2 | 14 | 3 | |
| 3–4 | 46 | 16 | |
| 5–6 | 17 | 33 | |
| 7–9 | 5 | 23 | |
| >9 | 3 | 11 | |
| Don't know | 15 | 14 | |
| An internist | Agree, % | Disagree, % | Don't Know, % |
| Takes care of children | 51 | 43 | 6 |
| Takes care of adults | 96 | 2 | 2 |
| Delivers babies | 22 | 71 | 7 |
| Does minor surgery (e.g., removal of a mole) | 51 | 42 | 7 |
| Does major surgery (e.g., taking out an appendix) | 11 | 83 | 6 |
Preferences for Care of New Medical Conditions
Table 5 shows respondents' preferences for care of 15 medical conditions that hypothetically developed during regular office hours. The item was worded: “Next I am going to read you a list of medical conditions. Imagine that you have just developed that condition and it is during regular doctor's hours. I want you to tell me if you would prefer to go to your regular doctor, a doctor who specializes in that particular condition, or the emergency room. If you don't care what kind of doctor you see for that particular problem, then tell me.”
Table 5.
Patient Preferences for Care of a New Condition During Office Hours
| New Condition | Regular Doctor, % | Specialist, % | Emergency Dept., % | NP*, % |
|---|---|---|---|---|
| High blood pressure | 97 | 3 | < 1 | 0 |
| High cholesterol | 96 | 3 | 0 | 1 |
| Hemorrhoids | 91 | 8 | 0 | 2 |
| Sinus infection | 90 | 8 | 1 | 1 |
| Stomach ulcer oracid indigestion | 87 | 11 | < 1 | 2 |
| Diabetes or highblood sugar | 86 | 13 | 1 | 0 |
| Blood in your stool | 85 | 11 | 3 | 1 |
| Urinary tractinfection | 85 | 14 | 1 | 0 |
| A very painfulheadache | 82 | 11 | 5 | 2 |
| Anxiety | 79 | 14 | 2 | 5 |
| Prostate problem† | 72 | 28 | 0 | 0 |
| Ingrown toenail | 71 | 23 | 1 | 5 |
| Stitches for aminor cut | 68 | 2 | 27 | 3 |
| Changes in a mole | 62 | 37 | < 1 | < 1 |
| Initiation of birthcontrol‡ | 62 | 35 | 0 | 3 |
Respondents offered no preference.
Men respondents only (n = 90).
Women respondents only (n = 224).
Most respondents expressed a strong desire to seek care from their regular doctor for these 15 conditions. For example, more than 85% of participants indicated they would see their doctor for high blood pressure, high cholesterol level, hemorrhoids, sinus infection, ulcer disease, and diabetes. There were only four conditions for which a fifth or more of respondents indicated a preference to receive care from a specialist: prostate problem, initiation of birth control, changes in a mole, and ingrown toenail. A minor cut requiring stitches was the only condition for which a significant number of patients preferred to seek care in the emergency department (27%).
Preferences for Care of Specific Medical Conditions
Table 6 shows respondents' preferences for care of three common conditions: seasonal allergies, depression, and low-back pain. Most participants indicated that they preferred to see their regular doctor for these conditions because their physician was familiar with their other medical problems. However, respondents thought that specialists were better able to treat allergies and low-back pain, prescribe medications for depression and low-back pain, and counsel them about treatments for low-back pain. In addition, more than 80% believed that they should be able to see a specialist for these conditions without a referral.
Table 6.
Preferences for Care and Attitudes About Specific Medical Conditions
| Preference | Strongly Disagree, % 1 | Disagree*, % 2 | Agree*, % 3 | Strongly Agree, % 4 | NP†, % 2.5 | Have Condition Agree/Strongly Agree, % 3/4 | Do Not Have Condition Agree/Strongly Agree, % 3/4 |
|---|---|---|---|---|---|---|---|
| Allergy | |||||||
| I prefer to see my regular doctor for my allergies because she/he knows about my other medical problems. | 3 | 14 (17) | 38 (79) | 41 | 4 | 79 | 79 |
| It is important to see the same doctor for my allergies that I see for my other medical problems. | 17 | 40 (57) | 29 (43) | 14 | 0 | 41 | 45 |
| I believe that specialists know how to take care of allergies better than regular doctors. | 3 | 18 (21) | 40 (79) | 39 | 0 | 75 | 82 |
| Only a specialist is familiar with the medicines that may be necessary for allergies. | 18 | 42 (60) | 27 (40) | 13 | 0 | 33 | 49 |
| It is important to be evaluated by an allergy specialist for my allergies. | 6 | 22 (28) | 33 (71) | 38 | 1 | 70 | 74 |
| It is important that I am able to choose the type of doctor I want to see for my allergies. | 1 | 6 (7) | 28 (93) | 65 | 0 | 90 | 95 |
| I should be able to choose the doctor I want to treat my allergies without a referral from my regular doctor. | 6 | 13 (19) | 29 (81) | 52 | 0 | 70 | 84 |
| Depression | |||||||
| I prefer to see my regular doctor for my depression because she/he knows about my other medical problems. | 5 | 13 (18) | 35 (78) | 43 | 4 | 70 | 81 |
| It is important to me to see the same doctor for my depression that I see for my other medical problems. | 16 | 35 (51) | 27 (48) | 21 | 1 | 47 | 48 |
| The first doctor I think of to see for depression would be my regular doctor. | 6 | 6 (12) | 15 (88) | 73 | 0 | 80 | 91 |
| If medication were needed for my depression I would prefer to see a mental health specialist. | 11 | 22 (33) | 35 (60) | 25 | 7 | 58 | 60 |
| Only a mental health specialist would know how to counsel me about my depression. | 16 | 44 (60) | 26 (39) | 13 | 1 | 37 | 39 |
| A mental health specialist would know how to prescribe medications that may be necessary for my depression better than a regular doctor. | 7 | 28 (35) | 40 (65) | 25 | 0 | 50 | 72 |
| I would want to see a mental health specialist for this problem from the start. | 36 | 40 (76) | 13 (24) | 11 | 0 | 34 | 19 |
| It is important to be able to pick the type of doctor I want to treat my depression. | 2 | 4 (6) | 25 (94) | 69 | 0 | 94 | 92 |
| I should be able to choose the doctor I want to treat my depression without a referral from my regular doctor. | 8 | 11 (19) | 27 (81) | 54 | 0 | 85 | 80 |
| Low-back pain | |||||||
| I prefer to see my regular doctor for back pain because she/he knows about my other medical problems. | 6 | 21 (27) | 33 (68) | 35 | 5 | 65 | 72 |
| It is important to me to see the same doctor for my back pain that I see for my other medical problems. | 14 | 23 (37) | 29 (63) | 34 | 0 | 58 | 72 |
| I believe that a specialist knows how to take care of back pain better than a regular doctor. | 4 | 21 (25) | 47 (74) | 27 | 1 | 75 | 72 |
| I believe that a specialist knows how to counsel me about treatments available for back pain better than a regular doctor. | 4 | 17 (21) | 43 (78) | 35 | 1 | 78 | 80 |
| I believe a specialist would know how to prescribe medications needed to relieve my back pain better than a regular doctor. | 7 | 21 (28) | 46 (72) | 26 | 0 | 74 | 71 |
| I should be able to choose the doctor I want to treat my back pain without a referral from my regular doctor. | 5 | 13 (18) | 26 (81) | 55 | 1 | 82 | 80 |
Responses of strongly agree and agree/strongly disagree and disagree are collapsed and shown in parentheses.
Respondents offered no preference.
We performed subgroup analyses comparing respondents with the condition and those without the condition. Table 6 shows the percentage with and the percentage without the condition who agreed or strongly agreed with the statements. Of those who suffered from allergies (n = 148), 43% reported having seen a specialist for treatment. Respondents with allergies more strongly endorsed the following statement: “Only a specialist is familiar with the medicines that may be necessary for allergies” (mean Likert, 2.54 vs 2.16, p < .001).
Subgroup analysis of participants reporting a history of depression (n = 98) revealed that 70% had been cared for by a specialist. Participants with depression more frequently endorsed a preference to see a mental health specialist from the start (mean Likert, 2.17 vs 1.90; p = .02) and more strongly agreed that mental health specialists would know how to prescribe medications necessary for depression better than their regular doctor (mean Likert, 2.93 vs 2.59; p = .007).
Among those who reported having low-back pain (n = 187), for an acute episode of low-back pain, 53% would see their regular doctor, 12% would see an orthopedist, 6% would see a chiropractor, 6% would go to the emergency room, 2% would see a neurosurgeon, 2% would see a physical therapist, and 17% would see other providers. Respondents with low-back pain believed, however, that it was less important to be followed by their regular doctor for this problem than those who reported no back pain (mean Likert, 2.71 vs 3.03; p = .007).
DISCUSSION
Respondents in this survey reported that general internists were able to care for most common conditions and preferred that their general internist provide care for ongoing medical conditions and most new ones. However, when generalists were compared with specialists, respondents thought specialists were better able to care for the conditions examined. Moreover, they wanted to have the freedom to seek care from specialists without referrals from their regular doctors. Only about half of the respondents were knowledgeable about the duration of physician training, and many indicated that general internists provide a broader spectrum of care than most internists commonly provide.
Some have theorized that patients, acting as consumers, would choose to see specialists to obtain the highest-quality care available.23 However, this study demonstrated that the choice of physician type involved other factors. Although respondents perceived specialists as more competent, they reported wanting to see their regular doctor initially for most of the conditions that we examined.
This indicates that respondents highly valued continuity of care. Studies prior to the advent of managed care also demonstrated that continuity of care with one physician was important to patients.2,24,25 More recently, it has been shown that having a physician who had “knowledge of the patient” was associated with better adherence to treatment recommendations.26 This study affirmed the importance of continuity to patients in the context of specific medical conditions. Furthermore, it demonstrated that patients still value an ongoing relationship with a general internist in the managed care era.
Respondents who had personal experience with allergies, low-back pain, and depression were less enthusiastic about seeing their regular doctor for these conditions. One explanation could be that those with the target condition had already established a relationship with a specialist and wanted to continue this relationship. Or, perhaps, they had received treatment by a general internist previously and perceived it as ineffective.
Although a majority of respondents reported that they preferred to see their regular doctor for most new conditions, a majority also reported wanting to see a specialist “at the start of a new problem.” This inconsistency may be due to the way respondents interpreted the items, perhaps perceiving a “problem” as more serious than a “medical condition” and deserving of specialty care. The Medical Outcomes Study showed that patients with more severe disease were seen by specialists more frequently than generalists,14 but whether patient preference played a role in this is not known. This inconsistency could also be indicative of two important and seemingly contradictory themes that emerged from this study: patients' desire for both continuity of care with one provider and unrestricted access to specialty care.
Almost all respondents in this study wanted access to specialists without a referral from their regular doctor. This finding may be in part due to the way the questions were asked. Previous work has shown that asking what patients prefer instead of what they expect may result in unrealistic expectations.27 However, our findings may also suggest that respondents have unrealistic expectations about health care in the face of limited resources.28
Finally, respondents did not know the scope of care provided by general internists even though they were patients in internal medical practices. The scope of care perceived by respondents is that provided by family physicians; therefore, internists' efforts to educate patients about their expertise seem warranted.29
This study has several important implications. First, because patients value continuity of care, general internal medicine practices should be organized to maximize continuity with primary care physicians. This may not be practical for hospitalized patients given the need to shorten length of stay. However, in the outpatient setting, a scheduling strategy for acute visits that allows for physician continuity even if it requires a delay of several days is a reasonable goal. Second, because patients want free access to specialists, general internists should openly discuss patients' expectations for specialty care. This study demonstrated that respondents' preferences for specialty care were dependent on the medical condition and prior experience with the condition. An open discussion could serve to educate patients about the role of specialty care. It also may decrease the number of unnecessary referrals made when physicians feel unspoken pressure to refer because they think that is what the patient wants.30 Furthermore, explicit discussion of patients' expectations for referrals may improve patient satisfaction with care by having these expectations addressed. These discussions may also allow patients to voice concerns about possible financial incentives for general internists related to nonreferral.31
Several limitations of this study should be mentioned. Although our participants came from 10 different internal medicine practices in the eastern United States, they were cared for in academic institutions (hospital-based clinics), and these results may not be generalizable to other populations. Furthermore, because we contacted participants by telephone, our sample was most likely biased toward those who had telephones, were home, and were available for interview. Because our analysis was exploratory, we performed multiple statistical tests, and some of the statistically significant findings could have occurred by chance. The data presented were self-reported, and no attempt was made to confirm the information by review of the medical record.
In summary, participants preferred to see their general internist despite their perception that specialists were more competent in caring for the conditions we examined. However, respondents who had a target condition were more likely to want to see a specialist for this condition. Respondents valued the continuity of care provided by their general internist, but also wanted free access to specialists. Discussions about specialty care may serve to educate patients about the role of specialists and improve patient satisfaction with care provided by general internists.
Acknowledgments
The authors are grateful to the following persons for their contributions to the research effort, data analysis, and manuscript preparation: Teresa Partin and Robert F. DeVellis, PhD, at the University of North Carolina at Chapel Hill; and Alicia Williams at West Virginia University.
This work was supported in part by grant 2D28PE54004 from the Bureau of Health Professions, Health Resources and Services Administration, to the Faculty Development Program for General Internal Medicine, University of North Carolina at Chapel Hill, and by grant 52285 from the Summa Health System, Akron, Ohio.
REFERENCES
- 1. How is your doctor treating you? Consumer Rep. February 1995:81–8.
- 2.Lupton D, Donaldson C, Lloyd P. Caveat emptor or blissful ignorance? Patients and the consumerist ethos. Soc Sci Med. 1991;33(5):559–68. doi: 10.1016/0277-9536(91)90213-v. [DOI] [PubMed] [Google Scholar]
- 3.Lazare A, Eisenthal S, Wasserman L. The customer approach to patienthood. Arch Gen Psychiatry. 1975;32:553–8. doi: 10.1001/archpsyc.1975.01760230019001. [DOI] [PubMed] [Google Scholar]
- 4.Wang VL, Reiter H, Lentz GA, Whaples GC. An approach to consumer-patient activation in health maintenance. Public Health Rep. 1975;90(5):449–54. [PMC free article] [PubMed] [Google Scholar]
- 5.Sanchez-Menegay C, Hudes ES, Cummings SR. Patient expectations and satisfaction with medical care for upper respiratory infections. J Gen Intern Med. 1992;7:432–4. doi: 10.1007/BF02599162. [DOI] [PubMed] [Google Scholar]
- 6.Kravitz RL. Patients' expectations for medical care: an expanded formulation based on review of the literature. Med Care Res Rev. 1996;53:3–27. doi: 10.1177/107755879605300101. [DOI] [PubMed] [Google Scholar]
- 7.Kravitz RL. Internal medicine patients' expectations for care during office visits. J Gen Intern Med. 1994;9:75–81. doi: 10.1007/BF02600205. [DOI] [PubMed] [Google Scholar]
- 8.Joos SK, Hickam DH, Borders LM. Patients' desires and satisfaction in general medicine clinics. Public Health Rep. 1993;108(6):751–9. [PMC free article] [PubMed] [Google Scholar]
- 9.Weingarten SR, Stone E, Green A, et al. A study of patient satisfaction and adherence to preventive care practice guidelines. Am J Med. 1995;99:590–6. doi: 10.1016/s0002-9343(99)80243-5. [DOI] [PubMed] [Google Scholar]
- 10.Franks P, Clancy CM. Referrals of adult patients from primary care: demographic disparities and their relationship to HMO insurance. J Fam Pract. 1997;45(1):45–53. [PubMed] [Google Scholar]
- 11. Donelan K. What patients really think of managed care. Managed Care. February 1996:17–24. [PubMed]
- 12.Gabriel SE. Primary care: specialists or generalists. Mayo Clin Proc. 1996;71:415–9. doi: 10.4065/71.4.415. [DOI] [PubMed] [Google Scholar]
- 13.Cram P, Ettinger WH. Generalists or specialists: who does it better? Physician Exec. 1998;24(1):40–6. [PubMed] [Google Scholar]
- 14.Kravitz RL, Greenfield S, Rogers W, et al. Differences in the mix of patients among medical specialties and systems of care. JAMA. 1992;267(2):1617–23. [PubMed] [Google Scholar]
- 15.Alexander GC, Sehgal AR. Dialysis patient ratings of the quality of medical care. Am J Kidney Dis. 1998;32(2):284–9. doi: 10.1053/ajkd.1998.v32.pm9708614. [DOI] [PubMed] [Google Scholar]
- 16.Owen SA, Maeyens E, Jr, Weary PE. Patients' opinions regarding direct access to dermatologic specialty care. J Am Acad Dermatol. 1997;36:250–6. doi: 10.1016/s0190-9622(97)70290-1. [DOI] [PubMed] [Google Scholar]
- 17.Uhlmann RF, Carter WB, Inui TS. Fulfillment of patient requests in a general medicine clinic. Am J Public Health. 1984;74(3):257–8. doi: 10.2105/ajph.74.3.257. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Blecher MB. The gate swings wider. Hosp Health Netw. 1997;7(2):65–6. [PubMed] [Google Scholar]
- 19.Lerman CE, Brody DS, Caputo C, Smith DG, Lazaro CG, Wolfson HG. Patients' perceived involvement in care scale: relationship to attitudes about illness and medical care. J Gen Intern Med. 1990;5:29–33. doi: 10.1007/BF02602306. [DOI] [PubMed] [Google Scholar]
- 20.Brody DS, Miller SM, Lerman CE, Smith DG, Lazaro CG, Blum MJ. The relationship between patients' satisfaction with their physicians and perceptions about interventions they desired and received. Med Care. 1989;27(11):1027–35. doi: 10.1097/00005650-198911000-00004. [DOI] [PubMed] [Google Scholar]
- 21.Brody DS, Miller SM, Lerman CE, Smith DG, Caputo GC. Patient perception of involvement in medical care: relationship to illness attitudes and outcomes. J Gen Intern Med. 1989;4:506–11. doi: 10.1007/BF02599549. [DOI] [PubMed] [Google Scholar]
- 22.Frowick B, Shank JC, Doherty WJ, Powell TA. What do patients really want? redefining a behavioral science curriculum for family physicians. J Fam Pract. 1986;23(2):141–6. [PubMed] [Google Scholar]
- 23.Cooper PF, Nichols LM, Taylor AK. Patient choice of physician: do health insurance and physician characteristics matter? Inquiry. 1996;33:237–46. [PubMed] [Google Scholar]
- 24.Fletcher RH, O'malley MS, Earp JA, et al. Patients' priorities for medical care. Med Care. 1983;21(2):234–42. doi: 10.1097/00005650-198302000-00010. [DOI] [PubMed] [Google Scholar]
- 25.Hulka BS, Kupper LL, Daly MB, Cassel JC, Schoen F. Correlates of satisfaction and dissatisfaction with medical care: a community perspective. Med Care. 1975;13(8):648–58. doi: 10.1097/00005650-197508000-00004. [DOI] [PubMed] [Google Scholar]
- 26.Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47(3):213–20. [PubMed] [Google Scholar]
- 27.Davis EL, Albino JE, Tedesco LA, Portenoy BS, Ortman LF. Expectations and satisfaction of denture patients in a university clinic. J Prosthet Dent. 1986;55(1):59–63. doi: 10.1016/0022-3913(86)90074-0. [DOI] [PubMed] [Google Scholar]
- 28. Samuelson RJ. Having it all. Newsweek. September 1998:71–72.
- 29. ACP-ASIM. Doctors for adults campaign. Available at: www.acponline.org/public/docs4adults.
- 30.Walker JD, Griffiths ID, Leon CM. Referrals to a rheumatology unit: an evaluation of the views of patients, general practitioners, and consultants. Ann Rheum Dis. 1991;50:926–30. doi: 10.1136/ard.50.12.926. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Levinson DF. Toward full disclosure of referral restrictions and financial incentives by prepaid health plans. N Engl J Med. 1987;317(27):1729–31. doi: 10.1056/NEJM198712313172708. [DOI] [PubMed] [Google Scholar]