In the present study, data saturation was achieved after 31 F2F interviews; three FGDs with faculty members, interns and residents; and 21 sessions of field observation. Participants consisted of 13 patients, 32 faculty members, 27medical interns and 21 residents, as key informants. Participants’ baseline characteristics are revealed in Table 1.
All our findings were confirmed by participants’ feedback and their member checking. Data analysis resulted in the emergence of three categories: 1- physician-related factors, 2- patient-related factors and 3- health system-related factors. The emergent categories, Semantic labels to define factors influencing PPRs and tips for improving PPRs based on supporting condensed meaning units are summarized in Table 2. Factors in each group are listed according to the frequency of repetition by participants. The most frequently cited factors by the participants are listed upper in the list.
1- Physician-related factors
Physician-related factors were divided into five sub-categories including personal characteristics; communication competencies; patient-centered practice; professional collaboration and time allotted for a visit.
All participants stated that spending enough time on the consultation process by physicians had been the main factor affecting the EPPR. A participant said that “a hasty examination of patients not only can induce stress but also may lead to a feeling of not understanding in patients” (Faculty member. 8). A patient said that “when I feel to have enough time, I do trust my physician and I disclose my history of disease completely” (Patient .3). According to a participating resident, other factors such as resident’s rational working hours and the not being fatigued; not being forced to visit a high number of patients in each working shift; and not using medical terms unknown for patients, could significantly affect the physician-patient relationship (Resident.5).
Communicating effectively with other team members in care provision, i.e. optimal physician-physician, physician-nurse, and physician- medical staff communications was described as another important factor affecting the EPPR by a participating faculty member (Faculty member .21). A resident believed that “When a treating physician forces a patient to go to a specific center that he or she recommends for taking paraclinical tests, the patient usually thinks that the treating physician has conflict of interest and only pays attention to the financial benefits of his colleagues”(Resident. 5). The majority of participating physicians in this study believed that requests for only necessary consultations and paraclinical tests, not only could cease any delay in fulfilling the diagnostic processes but also could prohibit wasting energy and decrease the workload of the consulting physicians, which ultimately could result in patient satisfaction and affect the EPPR (Faculty members .11, 12,21,26,28 and residents. 1, 5, 10, 15, 18, 20).
Coordination between a physician and a nurse could decrease delays or errors in the execution of physician orders. In one case which was mentioned by a faculty member, “failure to inject the prescribed anticoagulant to the patient prior to his surgery had resulted in deep vein thrombosis”. He declared that “the head nurse was present when ordering the injection of the anticoagulant but my order had been missed” (Faculty member.17).
According to many participants, pre-coordinated and supervised collaboration of the medical team has been crucial for engaging patients in an interactive relationship (Faculty member.4, residents 6, 12, 21, interns.1, 2,9,14 and patient.7, 11, 13). The positive outcome of such proper coordination could be realized when patients were needed to be physically examined by medical students, interns, residents, and faculty members at different stages. When this intended coordination was performed, it could decrease fatigue and dissatisfaction among patients (Patients. 1, 5, 8, 10, interns 3, 4, 6). From the participating patients' and faculty members’ viewpoints, hierarchical supervision of residents’, interns’ and medical students’ performance could inhibit repetitive physical examinations and consequently could increase patients’ satisfaction and cooperation ( Faculty members 1,7,10, patients 5,10,12).
Many patients believed that feeling a mutual respect and being in an environment supportive for constructive criticism made them satisfied and ultimately increased their trust to physicians (Patients. 1, 2, 8, 9, and 10). The punctuality of physicians was stated as one of the main factors by a few patients that could cause a sense of respect (Patients.3, 8). Many participating patients stated that paying attention to their requests and their feelings and concerns while they had been able to protest could have been easily overshadowed by the EPPR (Patients 1, 2, 4, 7, 8, 10, 13). According to both patients and faculty members as the emotional understanding was another reinforcer of making an EPPR, physicians should be trained about empathy and should apply it in their daily visits (Faculty members.7, 15, patients.3, 10). In addition, a patient believed that physicians’ confidence and charisma could easily affect the EPPR (Patient.4). According to the participating patients, doubts and hesitations of physicians could be reflected in their tone of voice and even in their gazes (Patients 4, 13). Patients often could understand such hints and were very sensitive to even a minor reaction which may not be taken seriously by physicians (Faculty member.3).
Patients stated that they had increasingly wanted physicians to consider their role in making treatment decisions, while to show authority. According to those patients, when physicians had not prevented them from being involved in decision making; and had respected their rights in this regard; and had not considered their involvement as interference with their own scientific position and capability to treat, they had enjoyed their relationship and were open to provide any details about their history of disease (Patients. 6, 9, 11). Another reinforcing factor of the EPPR, emphasized by most faculty members, were training medical students to be capable in initiating communication; in interviewing with patients; and in breaking bad news while being supervised (Faculty members. 4,9,14,18,22,25,30). In this regard, most interns and residents believed that communication skills of faculty members should be sharpened too (Interns.5, 8, residents.2, 19).
2- Patient-related factors
Patient- related factors were divided into two sub-categories including personal attributes and trust-supported attitude.
Patients' levels of education and health literacy were stated to be important factors in reinforcing patient-physician relationship from the viewpoint of many physicians and some patients. Patients' readiness to establish participatory communication was dependent on their levels of education and health literacy for the most part. Three of the patients participating in the study stated that when they sought, studied and understood useful and credible information about their medical problems before being visited by a physician and tried to use that information in practice, they adhered more to medical instructions because they trusted more in the abilities of their physicians in such conditions (Patients.5, 8, 11). In this regard, many faculty members believed that establishing relationships with patients with high health literacy, who did not attribute the reasons for the failure of the physicians' diagnostic and treatment plan to the poor competencies of their physicians, was easier. Those faculty members declared that they were willing to spend more time with patients with higher health literacy because communicating with those patients did not waste their energy and interest (Faculty members. 2, 6, 13, 24, 31).
Patients stated that when they had been visited by the physicians with the same gender and age group, they had shared more information with their physician. Gender difference was stated as an important factor influencing the physician-patient relationship. This factor was stated to be even more prominent in Iranian society. Gender- appropriateness was even more important in the case of female patients during urology and gynecology appointments. In this study, the need for patient-physician gender matching was raised by participating patients, interns and residents.
According to the participants, gender matching was true to the situations in which the treating physicians with the same gender had communicated with patients' own language and had paid attention to the patients' culture (Patients.7, 10, interns 2, 5, 6, 14, residents. 19). Some participating patients stated that they had not known how to describe some of their problems in a language other than their mother tongue. Therefore, when the treating physician had not spoken to them in their mother tongue, they had preferred to refrain from reporting some of their problems (Patients. 3, 9, 10). According to a participating faculty member, the familiarity of a physician with patient's language was more important when patients were not able to communicate with the national spoken language in the country (Faculty member.7).
A faculty member believed that in the setting of this study, a range of physicians and patients from Fars, Turkish, Kurdish and other ethnicities had to communicate with each other. In this regard, that faculty member said that he always had advised his students to spend enough time studying the cultural characteristics of patients and their team members. Otherwise, some of their advice in the absence of respect for beliefs and cultural values of the patients and other members of the medical team might cause serious problems in their relationships (Faculty member.26). One participating intern who lived in the university dormitory believed that she was able to communicate more well with patients than her other friends because she was roommate with students from different cultures and was familiar with different cultural values (Intern.19)
The age difference between the physician and patients could affect their relationship. Elderly patients, in particular, found it easier to communicate with physicians in the same age group (Patients.2, 10).
In addition to gender and age appropriateness and taking into account patients' culture and language, acceptable status of the patients' health and not having stress induced by the presence in a medical environment could affect the EPPR too (Patients. 7,11 intern 2). This outcome could be obvious in critically ill patients and traumatic cases that were in stressful situations. In such circumstances, the ability to manage such challenging conditions and paying attention to the reactions of patients and companions to even minor issues had resulted in an EPPR (Interns 2, 15). In this regard, one of the participating interns stated that in order to decrease his patients and their companions’ concerns and stress about the hours and days the patients would be hospitalized, he had routinely asked his patients and their companions about their concerns and had tried to clearly explain hospitalization- related processes to them. He believed that when he had assured his patients and companions that he would always be there to hear their concerns and provide necessary information, they had reported less stress during hospitalization (Intern.15).
Moreover, according to participants, putting aside previous unpleasant experiences by the patients and not involving them in accepting the diagnosis and treatment of the treating physicians could significantly decrease the denial of diagnoses and refusal of medical treatments by patients. One participating patient in this study noted that after his father died, he was visited by the same physician as his father when he was hospitalized. He said he was very happy that he ignored the unpleasant memories of his father's hospitalization and also the doubts of his family members about that doctor's abilities, and trusted that doctor and his abilities, and got a very good result from his treatment (Patient.4).
3- The health system-related factors
Health system related factors were divided into three sub-categories including context-related, socio-cultural and organizational factors.
Participating residents highlighted the role of allocating sufficient time to consult with each patient in the success of a communication. According to them, not being forced to perform time-consuming administrative bureaucracies such as "getting patients' lab-tests results by interns and attaching them to the patients' files or taking the radiology reports to other wards to show the faculty members", which could be easily completed by staff of the wards, could be of great help in this regard (Residents.9, 17).
Most interns stated that communicating with patients in an environment away from the hustle and bustle, where patients' companions and other patients were absent during the visit helped patients communicate more openly and with more trust (Interns. 5, 7, 10, 14, 20, 21, 25). Most of the participating patients believed that respecting their privacy, while they were consulted in a convenient and supportive environment had increased their motivation to provide a more complete history to physicians (Patients.1, 3, 4, 7, 9, 10, 12, 13).
According to the participants, if the process of stress management in urgent decision making conditions were defined and educated, working in stressful environments such as an emergency department would not induce stress and the PPR would not be easily impaired. In this regard, many interns stated that physicians visiting in the emergency department should have been aware of the specific needs of the patients who were directly discharged from the emergency department and not hospitalized later, because experiencing good communication and the needs being addressed would reinforce patients' later PPRs (Interns.3, 6, 7, 11, 15, 20, 21). In all, faculty members mentioned that they have had more effective relationships with patients in inpatient wards, compared to the patients in emergency or outpatient wards (Faculty members.3. 7, 24).
Another context-related reinforcing factor raised in the present study by faculty members was the power of the working environment to motivate the health care providers to analyze the existing strengths and weaknesses, to analyze the previously defined working processes or hidden patterns and bureaucracies in the working context; to find problems around; and to plan solutions to them. Indeed, planning for resolving the problems such as delayed admission; poor medical filings; errors in submitting documents for health insurance coverage, etc would decrease waste of patients’ time and energy, their exhaustion and dissatisfaction, which would consequently affect their future relationships with physicians (Faculty members.1, 8, 20).
In this study, working or living in a context with appropriate social propaganda and favorable beliefs about physicians in which there are no provocations against the health system was stated as one of the most important socio-cultural factors influencing the PPR. Some participating patients in this study believed that physicians were affluent people who usually could not understand many of patients' socioeconomic problems. They clarified that they usually preferred not to talk to doctors about many of these problems (Patients. 4, 5, 9). Two participating faculty members defined this issue as a social propaganda about physicians in Iran. They attributed this propaganda to the differences in physicians' income levels and marked differences in their lifestyles with other people in Iranian society (Faculty members.5, 19).
Paying attention to specific religious do's and don'ts about illness and health in society was introduced as another reinforcing factor of the PPR (Patient.10, Faculty member.30).
Participants declared that reputation of a medical center of being a good caring center, not as a slaughterhouse, could significantly affect patients' and their companions' trust in the physicians' capability in improving their health status; otherwise, social misbeliefs would gradually grow and breaking them would be more difficult and their pertinent unpredictable consequences would be experienced. Some inpatients in this study believed that some hospitals had a bad reputation for being a place for certain death. Those patients thought that if they were admitted to those hospitals, they would surely die. For this reason, some patients believed that inpatients did not trust the treatment team in those hospitals and would not be motivated to communicate effectively with their physicians (Patients.1, 6, 11). A participating faculty member also referred to the notion of reputation of some hospitals as a slaughterhouse among people. He believed that those hospitals were mainly referral hospitals and mostly complicated cases were admitted in those hospitals (Faculty member.3).
All participating faculty members noted that not forcing physicians to visit a large number of patients per shift was a key to their EPPR. Some interns and residents emphasized the need to change the regulations regarding the visit of the high number of patients per shift (Interns.3. 8.19, residents.2, 17, 19). One of the participating residents stated that in a few departments, rules had been set so that junior residents were not forced to do all the work of the wards alone. He added that in those settings, one of the faculty members had supervised adherence to the rules and collaboration of the junior and senior residents in performing the ward works. He believed that in such wards he had more easily and effectively communicated with patients (Resident.21).
Many interns believed that if they had been supervised by well-trained supportive mentors and had received constructive feedback on their communication content and process, they would have been made more effective relationships with patients (Interns. 4, 7, 10, 15, 17, 18, 20, 24). In this regard, the role of supportiveness and flexibility of the working context against physicians' risk-takings was highlighted. In this regard, one of the interns mentioned that with the encouragement of one of the faculty members, he had volunteered to do an abdominal tapping for an inpatient as the first person in their group. He said he had not changed his mind about volunteering because he had been sure he would not have been held accountable for any possible errors due to his teacher's presence. In addition, due to the successful completion of the procedure under the auspices of that teacher, the next day he had communicated with his patient with more confidence (Intern.15).
Participating residents believed that paying special attention to the quality communications of health care providers and encouraging high quality communications could motivate all members of a treatment team to establish more interactive relationships with patients (Residents.1, 8, 15). According to them, in this regard, priorities should be given to building effective relationships, not earning just more money, by authorities in medical centers. Defining criteria for effective communication with patients in physicians' work evaluation checklists in order to distinguish between quality and non-quality communications of physicians in annual evaluations should be considered as a very important reinforcing factor of the PRR too.