The analysis of the included studies identified two overarching themes, each with several elements: the development and maintenance of patient–doctor relationships, and the ongoing depth of the patient–doctor relationship.
Development and maintenance of patient–doctor relationships
The processes by which patient–doctor relationships appear to be developed and maintained can be described in terms of longitudinal care and consultation experiences.
Longitudinal care
Seeing the same doctor, or longitudinal care, was identified as a key process in developing and maintaining patient–doctor relationships.16–21,23–25 Longitudinal care was central to many accounts of personal care experienced by patients in Tarrant et al's study.19 Roberge et al suggested that regularity, rather than frequency, of contact is of greater importance.24
It is important that patients are able to retain some choice regarding who they see, because longitudinal care on its own does not guarantee a depth of relationship.19,20,24,25 It is the quality of patient–doctor encounters that has a major bearing on how the patient–doctor relationship is both developed and maintained.
Consultation experiences
The focus of the majority of studies was patients' personal experience with doctors during consultations, for themselves or family members.16,17,19–21,23–26 Patients seem most likely to form a relationship with a doctor who meets their expectations or needs. Although some patients' initial expectations may be met by virtue of the doctor's sex or age,16,21,26 the key means by which this occurs are the doctor's consultation skills.
Patients want doctors who appear interested, listen well, explain clearly, are open to discussion, and involve the patient in decision making, if it is desired.16,17,19–26 Patients cited actions – for example, the way in which the doctor questioned or examined them – that suggested thoroughness and a caring attitude. ‘Human communication’ may include social talk or ‘chit chat’, and appropriate use of humour.18,19,21 Lings et al's idea of ‘asymmetry of perception’ seems to recognise that patients and doctors have different roles and responsibilities within a relationship.17,23 Some patients may choose to test these and other patient–professional boundaries.16 Although it may be important that the patient communicates as well as they are able,24 from the patient's perspective the emphasis is always on the doctor to facilitate this process.
A closely related element that contributes to the development and maintenance of patient–doctor relationships is time.17–21,23 The studies highlighted the importance patients placed on not feeling hurried, and their appreciation of doctors who ‘had time’.19 Lings et al reported that listening was characterised by the sense of being able to talk things over without feeling that time was a critical issue.17
Another aspect of patients' views on how their relationships with doctors develop or are maintained concerns indirect experience: the outcome of problems shared and the opinions of friends or family. A patient–doctor relationship may be deepened or destroyed by good or bad clinical outcomes respectively.16,21,23–26 Word of mouth, positive or negative, about a doctor's behaviour or practice may reinforce or challenge a patient's opinion of a doctor.16,23
Patient–doctor encounters may also be affected by factors at the practice level. For example, being met by friendly reception staff may mean the patient goes into the consultation in a more positive frame of mind.19,21,26 Wiles and Higgins noted how the congenial surroundings and ‘positive atmosphere’ of private hospitals may enhance a patient's communication with their doctor.18
Depth of patient–doctor relationship
In addition to the processes by which patient–doctor relationships are developed and maintained, the studies suggested that depth of relationship, as a product of longitudinal care and consultation experiences, was important. This encompassed four main elements: knowledge, trust, loyalty, and regard. These elements reflect patients' enduring views about their relationship with the doctor outside of consultations. They appear to be the ongoing product of the dynamic aspects of the relationship.
Knowledge
Knowledge emerged as a dominant aspect contributing to depth of relationship.16,17,19–23,25,26 Studies described both patients' knowledge of the doctor, and doctors' knowledge and understanding of the patient.
Many patients like ‘knowing’ the doctor.16,20,23,25 This might start with a simple familiarity with what they look like, but may develop into more personal knowledge, for example, concerning the doctor's personality. Of particular importance is the idea that the patient knows or anticipates how the doctor will behave or react.20,23
Similarly, with respect to the doctor's knowledge of the patient, the starting point is basic physical familiarity (putting a name to a face), but also knowledge of the patient's medical history.19–23,25 Patients value these aspects for two reasons – because the doctor is able to see changes in their appearance and hence possibly their health, and because there is a sense of shared history. Patients dislike having to repeat information: they may find it difficult, or feel they do not have enough time to put everything into words every time they see a new doctor.
At a deeper level, the doctor accumulates personal knowledge about the patient, such as their background (including family and social circumstances) and their expectations.17,19–23,25,26 This contributes to a patient feeling understood and treated as an individual in the context of their life and illness, rather than just the presenting problem. Patients perceive that the doctor has achieved a deeper understanding of them at an emotional or personal level. Some studies referred to patients within ‘good’ patient–doctor relationships as experiencing empathy and holistic care.19–22
Holistic care was more commonly described as occurring in longer-term relationships.20,22 However, von Bultzingslowen et al identified several patients who felt understood in single consultations or short-term relationships, and one patient who complained about a lack of empathy with their ‘personal doctor’ who had been known for some time.20
Trust
Patients' trust in the doctor was another prominent aspect of the depth of patient–doctor relationships.16,17,19–26 Unlike knowledge, however, trust may start at a generic level of ‘trust in doctors in general’, which may be refined (usually deepened), in terms of a personal ‘trust in my doctor’; that is, in the absence of bad experience, patients usually assume that doctors are trustworthy.20,25
Goold and Klipp reported how patients' comments about doctors in general were more abstract than their comments concerning a specific doctor.25 For some patients, trust in their doctor may remain ‘blind’,25 but for the majority, trust in a specific doctor was rooted in experience.16,19,20,21 Patients used words such as ‘confidence’, ‘faith’, ‘security’, and ‘competence’. Patients' trust was based at least partly on their views of doctors' openness and honesty, including doctors recognising the boundaries of their own abilities, and their readiness to refer on to others.22,23
Patients' perceptions of their doctor's trust in them were associated with feelings of being believed;20 they may feel mistrusted if their symptoms are minimised or not taken seriously.
Loyalty
Roberge et al's study of loyalty defined it in terms of a contract or agreement between the patient and the doctor.24 Loyalty is closely associated with, yet distinct from, longitudinal care.20,22,24 For a given doctor, longitudinal care describes a patient's pattern of visits over time, whereas the loyalty aspect of the depth of the patient–doctor relationship describes the patient's preference for seeing that particular doctor.
Patients' preferences may be shaped by their past experiences and their presenting problem. Discontinuity of a physician may be less of an issue for patients who are used to it; this is suggested by Brown et al's study, whose participants differed from those in other studies because they regularly saw new doctors rotating through their health centre as part of their training programme.22 In addition, patients' preferences regarding who they see may depend on the problem with which they are presenting.19–21,24 Patients generally preferred to see the same doctor when dealing with long-term, complex, or emotional problems.19 However, they may be happy to see any doctor for minor problems, ‘any doctor but my usual doctor’ for embarrassing problems, and a specific doctor for a specific problem.16,19,25,27
Patient loyalty is also measured in terms of their tolerance of unsatisfactory aspects of care.16,17,21 Lings et al called this a satisfaction paradox, a ‘seemingly contradictory phenomenon, whereby patients express dissatisfaction with certain procedures or events but still maintain a positive relationship’.17 Examples of such dissatisfaction relate to characteristics of the practice (distant location, problems with the appointment system) and the doctor (running late, poor availability, unsatisfactory consultations, failing to return phone messages).16,21,23 Patients who have developed a relationship with a doctor ‘appear able to accept and tolerate less than optimum care if the usual care is good and satisfactory – that is, they seem to ‘forgive’ the doctor an occasional lapse’.17
In turn, a doctor's actions may be perceived by patients as a marker of their loyalty to them.16,17,22 Gore and Ogden gave an example of how a doctor remained committed to a patient despite their obviously deceitful behaviour.16
Regard
This final aspect of the depth of patient–doctor relationships is a primarily affective attribute. It comprises comfort17,21 and liking,16,17,23 which reflect perceived care from the doctor and respect in the relationship.20–22,24,25 As a consequence of doctors appearing interested and ‘on side’ with patients, patients feel that they matter to the doctor.
On the basis of their data, Lings et al defined liking as ‘having an easy and comfortable relationship with the doctor’.17 Some patients likened a good patient–doctor relationship to a friendship.18,23 Gabel, et al reported: ‘For some, friendship was a reciprocal relationship with both parties perceived to feel the same bond. The relationship was characterised as warm, caring, or comfortable. There was a feeling of closeness that was a result of knowing each other for a long period of time’.23
Relationships between longitudinal care, consultation experiences, and depth of relationship
The relationships between, and distinctiveness of, the different elements of longitudinal care, consultation experiences, and depth of relationship may vary. Some patients may decide in a single consultation (during or after a positive consultation experience), that they like (regard) that doctor, and cite this as a reason to seek longitudinal care with them in the future.19,21 However, because patients have different needs – they interact with the doctor within the context of their unique problem, expectations, and so on – depth of relationship may develop by different routes. For instance, the relationship may deepen more rapidly during a crisis in the patient's life, especially if the doctor demonstrates advocacy or makes an extra effort to help them through a problem.16,22,25
Some aspects of the depth of patient–doctor relationships may be more closely related to either longitudinal care or consultation experiences, yet it is likely that longitudinal care and consultation experiences have synergistic effects. For example, although longitudinal care may facilitate the doctor's accumulation of medical knowledge about a patient, without satisfactory patient–doctor communication, personal knowledge is unlikely to grow.
The distinctiveness of some of the elements identified in this study may be blurred at the margins. For instance, the literature highlights how longitudinal care is the product of a complex interaction between access to a given doctor and the patient's preferences for seeing him or her. Patient loyalty may, therefore, be both the product of, and the driver for, seeing the same doctor.21 Clearly, longitudinal care is affected by a doctor's availability, whatever its determinants,20,23,24,26 and some patients may struggle to maintain a good relationship with their doctor because of lack of availability and appointments.16 Perhaps paradoxically, when physicians acknowledge that patients have consulted other doctors, this may actually build trust.21