Sicker patients are more dissatisfied; but are their doctors responsible?

Physicians are less sociable, more negative in visits

Sicker patients tend to be unhappy ones. They live with pain, discomfort, and the burden of frequent medical treatments, as well as possible restrictions in their daily living. But recent research indicates that their dissatisfaction with care isn’t just an inevitable by-product of their plights.

The way physicians respond to sicker or chronically ill patients may feed a cycle of negativity that leads to greater patient dissatisfaction, says Judith Hall, PhD, professor of psychology at Northeastern University in Boston.

Physicians respond negatively to patients who are sicker, Hall says. "If you just ask doctors if they like their patients by name, if John Smith is sicker, the doctor likes John Smith less," she says. "If the patient is sicker, the doctor reports less satisfaction after the visit.

"If doctors don’t like sick patients as much, you can imagine what might follow," she says. "There are reams of evidence that the way doctors treat patients affects patient satisfaction."

In fact, some experts recommend risk adjusting patient satisfaction scores to reflect differences in the type of patients surveyed. (See related story, p. 87.)

Physicians may not be able to transform their patients’ bad moods, just as they can’t cure their chronic diseases. But by improving doctors’ communication skills, they can improve the satisfaction of even this hard-to-satisfy consumer group, say Hall and other experts.

Making the effort is important because of another maxim of patient satisfaction: Satisfied patients are more likely to follow physician advice and therefore, have better outcomes, says Gary Rosenthal, MD, associate professor of medicine at Case Western Reserve University and research associate with the Department of Veterans Affairs, both in Cleveland.

Getting down to business

How do physicians usually treat sick patients? They are task focused, asking many biomedical questions and offering little in the way of friendly social conversation. They spend more time with these patients and show emotional concern, especially with patients with a poor mental health status.

At the same time, these visits may elicit more disagreements, criticisms, and patient anxiety.

That is the conclusion of researchers who studied videotapes and audiotapes of 1,300 physician-patient encounters.1 "We think physicians convey quite a bit of negativity to patients who are less healthy, either physically or mentally," says Debra Roter, DrPH, a professor in the department of health policy and management at the Johns Hopkins School of Public Health in Baltimore. "It could be that they’re overwhelmed in some sense with these patients, and they need to step back and think of them as a more integrated person and have an overall greater appreciation for them."

The negativity of the doctor-patient visit often begins with the patient, notes Hall. "If you’re sicker, there are all kinds of things you don’t like," she says. "It’s not just your doctor. [It’s] your community, your job. It’s like there’s a dark cloud over you."

Physicians need to make a conscious effort to break that cycle and improve the tone of visits with sicker patients, she says. "They can work to help build positive relationships with the patient," says Hall.

Hall and others offer the following advice about how to improve physician-patient relationships, particularly with sicker patients:

1. Triage visits to allow more time with sicker patients.

"An important consideration in satisfaction, particularly with primary care providers, is the amount of time the patient feels they’re able to relay their concerns," notes Rosenthal. Setting aside more time for patients with poor health status "may allow more time for patient visits and for them to get everything they want to say on the table," he says.

Feeling pressed for time while trying to address the many concerns of sicker patients can contribute to physician dissatisfaction. And patients who feel they have unmet needs are more likely to rate their physicians lower or even to change physicians, Rosenthal says.

2. Make some social connection, however brief.

It is understandable why physicians make less light talk with patients who have grave health concerns. But they need to realize that making a personal connection with patients, however brief, alters the overall tone of the communication, says Roter.

"They should be well aware that they probably are engaging in a trade-off in which social amenities are giving way to a down-to-business brusqueness. It creates tension in the visit," she says.

In fact, Hall’s research indicates a causal link. "When there’s less social conversation, patients are less satisfied," she says.

Techniques to improve communication may be as simple as maintaining eye contact while talking to patients, shaking their hands when greeting them, and asking how they are dealing with the challenges the disease brings them in their daily lives.

"There are ways to make a patient feel human and valued without spending a long time having idle conversation — the warmth of a greeting, trying to remember something about the patients so they know you know you’ve seen them before," advises Hall.

3. Consider the patients’ perspective of their health status.

Patients’ ratings of their own mental and physical health status differ significantly from the physicians’ ratings of them, Roter says.

"Patients who don’t have much wrong with them but are depressed or anxious downgrade their physical states," she says. "The opposite seems true with doctors. They weigh physical complaints much more heavily than the emotional."

Communication style is more closely linked to physicians’ rating of patient health status, she says. In others words, if the physician considers the patient to be in poor health, he or she will approach the visit in a more businesslike, biomedical, and less sociable manner.

To improve patient satisfaction, physicians should consider how patients are feeling about their health problems, says Roter. In fact, physicians may discover that the patients’ mental health status aren’t as good as they thought.

"They have to ask, ‘What’s going on in your life, and how are you feeling? How are you coping with the day-to-day challenges?’" she says.

4. Address the patients’ expectations of their care.

"These are patients who probably have greater unmet needs, says Rosenthal.

Their health problems are more challenging, and physicians have more opportunities to fail to resolve their concerns, he says.

Asking patients what they expect from the visits and giving them greater choices in their treatment options can enhance satisfaction, communication experts say.


1. Hall et al. Patients’ health as a predictor of physician and patient behavior in medical visits. Medical Care 1996; 34:1,205-1,218.