In this study, doctors were recruited to evaluate inpatients from a general hospital in China to explore the reliability, validity and psychometric characteristics of DDPRQ-10 Chinese as an instrument measuring DPR in Chinese hospitals. The findings indicated that the Chinese version of the DDPRQ-10 was consistent with a modified two-factor model of positive and negative feelings, demonstrating satisfactory internal consistency, discrimination, reliability, and validity. The questionnaire was found to be useful in identifying and screening DPRs that were more challenging or conflicted, making it a viable option for evaluating DPRs in Chinese culture. Besides its psychometric properties, the research also revealed some findings that have not been reported previously and require further investigation in cross-culture circumstances.
Firstly, this study confirmed that the Chinese version of the DDPRQ-10 questionnaire conformed to the adjusted two-factor structure model, which included two factors of negative feelings and positive feelings. These factors respectively represented the negative emotions that doctors felt in the DPR, such as difficulties, frustration, and avoidance, as well as positive emotions such as relaxation, enthusiasm, and anticipation. In Hahn's original study of the DDPRQ-10(5, 6, 33), the questionnaire could be divided into subscales including subjective experiences of doctors, objective evaluations of patient behavior, and symptoms. Another study on the DPR divided the DPPRQ-10 questionnaire into three dimensions: negative personality traits of patients, communication difficulties, and negative emotional responses of doctors(7). These studies had similar dimensions, all of which reflected the importance of patient traits, doctors' subjective experiences, and effective communication in the DPR. However, the two dimensions reflected in this study mainly revolved around the subjective experiences of doctors in the diagnosis and treatment process. This difference may be related to different cultures and medical backgrounds. Due to the insufficient medical resources in China, the DPR is mostly dominated by doctors to increase efficiency, so doctors' experiences and coping strategies play a major role in the DPR.
Secondly, the study used statistical methods based on item response theory to assess the psychometric properties of DDPRQ-10 for the first time. The results indicated that each item had satisfactory discrimination in both the multidimensional IRT model of the full scale and unidimensional IRT models of the two subscales. The item information curves showed that DDPRQ-10 was more effective in providing information for difficult DPRs, but not for patients with good DPRs. Therefore, DDPRQ-10 is more suitable for screening and risk assessment of difficult DPRs, and can provide sensitive indicators for intervention studies on such relationships. Future research should investigate whether this information function model is consistent in other cultural environments and explore ways to improve the measurement performance of DDPRQ-10 in measuring good DPRs.
Thirdly, the convergent validity of the DDPRQ-10 Chinese scale has been examined with correlation to PHQ-9, and MBI scale. This study proved a correlation between the difficulty of DPRs and the level of depression in patients through correlation analysis with the PHQ-9 scale, which was consistent with previous study. Hahn et al conducted the original study on the DDRPQ-10(6), showing that patients with physical symptoms and psychological disorders were more likely to be identified as having difficult DPRs. In addition, the study by Jackson et al(34) also confirmed that mental illnesses such as depression, anxiety, or personality disorders usually indicate poor DPRs, especially for patients diagnosed with more than four mental illnesses, with a 100% identification rate for difficult DPRs. Furthermore, the main predictive factors for poor DPRs include the presence of five or more physical symptoms, poor functional status, threatening and aggressive personality, failure to meet expectations, and high frequency of medical visits(34). This result once again demonstrated the importance of identifying patients with serious mental and psychological comorbid such as depression, and incorporating this factor into the DPR for establishing a good DPR among non-psychiatric physicians.
In addition, this study also found a significant correlation between difficult DPRs and physician burnout. A large body of researches have similarly shown a bidirectional relationship between burnout and difficult DPRs, with physician burnout being one of the contributing factors to poor DPRs(35), while difficult DPRs can also exacerbate physician burnout(36, 37). Therefore, in clinical practice, taking measures to alleviate physician burnout is crucial for shaping good DPRs.
There are also some limitations in this study. Firstly, due to the limited number of validated and widely used tools for evaluating DPRs and patient treatment satisfaction in Chinese, this study used the validated Chinese version of the PHQ-9 as the evaluation tool for the DDPRQ-10 convergent validity. In the future, more validated scales can be included in the patient’s evaluation to comprehensively assess the mental and personality traits of patients from the perspective of patient factors in DPRs. Secondly, the doctors included in this study were non-psychiatric specialists in general hospitals, and the sample size was relatively small, which may lead to selection bias. In the future, a larger sample of doctors from different departments, including surgical and non-surgical departments, can be included for scale measurement and analysis to further validate the robustness of its psychological measurement properties.