Results of the analysis
The analysis showed nearly 200 different themes. Box 1 contains the 15 topics discussed during the interview. After the data was categorised they were grouped into the categories presented below.
Patient’s loyalty is based on trust
The basis for developing and maintaining loyalty is the trust placed in the doctor:
‘A loyal patient, referring to what he feels towards his doctor, is a matter of trust and that’s all.’
(Interview [I]21, male [M], 67 years)
This element of trust could stand on its own or be stabilised by various elements such as availability, a caring attitude, quality of care, and the interest shown to the patient. Trust enabled the patient to confide in the doctor and allowed for more freedom of expression. It improved compliance and acceptance of refusal (such as refusal of treatment, prescriptions, stopping work, referral for imaging examination, or consultation with a specialist):
‘If you trust your doctor, you can tell him anything.’
(I3, female [F], 76 years)
Truth is specific and related to the person. It was a dynamic phenomenon depending on the duration of the doctor–patient relationship. By inciting patients to always consult the same doctor, the reform of the preferred doctor scheme reinforced that bond.
Loyalty and trust were inseparable. There could be no loyalty without trust and in the same way, loyalty strengthened confidence:
‘On the first consultation we meet, then on the second and third one, it becomes normal, confidence settles in and that’s it.’
(I21, M, 67 years)
Loyalty is a dynamic construct: from the first exchange to a final recognition
Recognition here refers to treating the patient with respect and remembering their situation and history. Loyalty would be established with time. Throughout the consultations, it became a source of memory, identification, and knowledge. Mutual knowledge between the patient and the doctor would result in loyalty.
The doctor, over time, would assimilate the medical history and intimate life of the patient. This knowledge was an element of understanding and adaptation that improved the relationship between the doctor and the patient, and helped for better care. It would give the doctor greater analytical and comprehension capabilities. Treatments would be more appropriate and easier to provide:
‘A good doctor is a doctor that can see what is wrong with you because he knows you well.’
(I11, F, 44 years)
The medical record was used as a link and proof of loyalty. Its value depended on personal representations:
‘My entire life is recorded in these files.’
(I1, F, 41 years)
The importance of the medical history and the number of treatments carried out, as well as the length of the period of follow-up reinforced the bond. The record, combined with the assumed integration ability of the data that it contained (that is, adaptation of the care according to the data), increased the patient’s loyalty because of the impact on the care provided by the doctor.
Loyalty improved follow-up, and in the same way, follow-up helped develop loyalty. The importance attached to the follow-up was related to the vulnerability of the patient.
Loyalty is a relational exchange subject to multiple influences
The development of loyalty depended on elements specific to the patient, to the doctor, and also to their relationship. Loyalty was influenced by their personality and habits. For some, it was a high principle of life, and even a universal virtue. It could also be an expression of a reassuring ritualised behaviour:
‘Actually, I am loyal by nature.’
(I27, F, 42 years)
Patients tended to reproduce a relational scheme known since childhood and related to maternal behaviour in terms of care consumption:
‘Oh yes, my mother and I used to see the same doctor.’
(I18, F, 57 years)
Patients’ satisfaction with their GP was a key factor in the doctor–patient relationship and it was critical to maintain it. Loyalty was based on perception of subjective elements and of details the patient felt:
‘Everything is based on whether or not I feel good talking to the person in front of me, and that would make me want to come back.’
(I19, F, 32 years)
That patients persist in going to the same GP introduced the notion of commitment. This could be related to trust and would not necessarily have to do with administrative obligations, or exist as a result of the signing of a preferred doctor declaration form:
‘Trusting him, it is a commitment.’
(I15, F, 47 years)
The preferred doctor declaration generally represented an administrative formality. It could also be seen as a way to create and maintain loyalty:
‘With the paper, it looks as though they are trying to make us come back.’
(I23, M, 75 years)
Nonetheless, the impact of this reform on maintaining loyalty remained negligible:
‘I already had a doctor whom I was seeing and to whom I was loyal. Nothing changed.’
(I24, F, 76 years)
The preferred doctor declaration, although the expression of a pre-existing reality, was a kind of formalisation of the relationship or, even, a pledge of loyalty:
‘It’s a loyalty pledge between us; we think he is our doctor of reference, and we come back to him because that is where we said we would go.’
(I17, F, 37 years)
The possibility to change their practitioner at any time had been clearly identified. For the patient to be loyal, the doctor had to have certain qualities such as kindness and patience. Empathy, an emblematic intrinsic virtue, favoured loyalty. Skill and professionalism were also essential to maintain loyalty. The attitude of the doctor, the consideration given to the patients, and the ability to adapt also helped in the development of the doctor–patient relationship:
‘When you see your GP, it looks like you are the most important person who will be taken care of. That is the feeling I get, and I like it.’
(I27, F, 42 years)
Good social skills are necessary to build loyalty and vice versa. It is based on communication skills, the ability to exchange views, and the attention given to the patients. The lack of any of these qualities would undermine the doctor–patient relationship. Patients want to be able to trust and rely on their doctor. They emphasised the importance of medical assistance in delicate situations:
‘A good doctor–patient relationship helps to get through your problems.’
(I14, F, 66 years)
Patient’s loyalty helps to create contact and access to health care. Patients who were aware of the advantages entailed maintained their loyalty:
‘Going to the same doctor for any medical issue is what loyalty is all about.’
(I15, F, 47 years)
Patients recognise the benefits in being loyal
Maintaining loyalty requires suitable material conditions (closeness of the medical office, availability and punctuality of the GP). Adapting the duration of the consultation according to the patients’ requirements played a part in the development of loyalty. The time spent showed that interest was displayed towards the patient and the doctor was truly involved:
‘She takes her time, she doesn’t throw us out.’
(I2, F, 56 years)
One of the main concerns of the patients was how well they were treated medically. This has an impact on how well things went between the doctor and the patients. Patients thought that the more they consulted the same GP, the better and faster the treatment received. Repeated consultations enabled better knowledge of the patient’s situation and led to better diagnostics:
‘He is going to know everything about my history, which means he will make a better diagnosis.’
(I27, F, 42 years)
Fidelity helped in receiving personalised care. The prescription was considered more appropriate when there was an established medical relationship between patient and doctor:
‘They know our medical history; it allows to be more accurate with prescriptions.’
(I6, F, 31 years)
The doctor’s explanations and advice are important in developing the relationship as well as the care provided, they helped maintain the relationship. The quality of answers provided by the GP with regards to the needs and issues of the patient were equally essential:
‘A loyal patient? That would be someone who gets all the answers when seeing his doctor.’
(I9, M, 68 years)
The ‘family doctor’ has been the archetype of loyalty for generations
The patient’s bond with the doctor is particularly strong. The doctor was allowed within the family unit. Hence, fidelity became implicitly natural:
‘He’s like family to us.’
(I23, M, 75 years)
The family doctor was assumed to have great knowledge of each patient, their medical history, and background. The doctor is also the keeper of the family’s memory. The relation with the family doctor is naturally set in time, over several generations. They became then a reference for the family in terms of health care, implying loyalty over generations.
Several patients felt nostalgia, linked to their childhood, when considering the family doctor. The GP’s presence symbolised stability throughout one’s life.
The inability to meet the patient’s requirements does not necessarily mean breaking their loyalty
Although the patient considered themselves loyal they would sometimes see another GP. In some cases, the patient had their reasons for this (such as urgency felt or travel), whereas in other cases it had to do with the doctor (such as unavailability, refusal of an important demand, or a specific competence required):
‘This is in case I am not here and if there is an emergency.’
(I2, F, 56 years)
These were rare situations that had no impact on the patients’ loyalty. The patients would understand the situation in case of unavailability of the GP:
‘Afterwards, I would see my regular GP anyway.’
(I19, F, 32 years)
The search for a second opinion, a delicate illness or a fear of disappointing their preferred doctor (for example, when discussing difficult subjects such as alcohol consumption) could also explain why patients consulted an alternative GP.
Reasons leading to the loss of loyalty of a patient and to a change of doctor included: retirement of their regular doctor, a change of location, a loss of interest felt by the doctor for his patient, or a medical error:
‘Because my previous doctor moved away.’
(I19, F, 32 years)
‘I was not satisfied. I did not feel comfortable. I felt like I was bothering him.’
(I25, F, 65 years)
