This study explored Chinese doctors’ perceptions of the doctor–patient relationship and the significant factors that influenced such perceptions, including sociodemographics, doctor’s work experience, and hospital security measures. We found that doctors had relatively negative perceptions of this relationship (2.9 ± 1.3), compared with patients’ perceptions thereof in similar studies from China.15,16 It is easy to interpret this variance: doctors are engaged in seeing and treating patients in their everyday work, and they easily suffer more from negative comments or even violence from patients. These experiences can make doctors more sensitive to adverse events between doctors and patients.[i]
In multivariable regression, region and hospital type showed significant effects in doctors’ perceptions of the doctor–patient relationship. In China, the eastern region has a higher level of economic development, and so this is where better hospitals with advanced equipment and skilled professionals are concentrated.[ii] This context might exacerbate supply-and-demand imbalance, since more patients with intractable diseases and high expectations are clustered in the eastern region, and therefore there would be more medical disputes in this region. We also found that doctors in TCM and specialist hospitals reported higher perceived doctor–patient relationship scores than those in general hospitals, which has seldom been discussed in other studies. Some analysis has found that medical disputes often occur in emergency and surgery departments.[iii] TCM hospitals offer more-traditional medicine and fewer risky surgeries, which results in fewer adverse events and medical disputes. Furthermore, TCM hospitals are more popular with elders, while specialist hospitals are primarily maternal/child hospitals with mostly women and children as patients. Differences in patient characteristics could have caused the doctors’ differing perceptions because elders, women, and children are more-vulnerable groups less likely to commit violence.
In addition, sex, age, and income influenced perception of the doctor–patient relationship. Although some investigators17,[iv],[v] have thought affective behavior, such as empathy, emotional support, and encouragement, was more pronounced in female doctors and would improve their perception of the doctor–patient relationship, our study found that female doctors were more pessimistic. This outcome might be related to female sensitivity. Previous research showed that female doctors were more likely to become exhausted and to perceive workplace stress than males were, with higher exposure to workplace violence and sexual harassment.[vi],[vii] Additionally, we found that elderly doctors showed a more positive attitude, which was in line with similar research.[viii] The authors of that study considered that elderly doctors had advantages in treating patients: productive communication skills, sophisticated professional ability, and respectable authority. We also found that higher income was a negative influencer, which was inverse to findings of previous studies.[ix],[x] However, Zhao[xi] found that doctors would increase their workloads to obtain higher incomes, which generated greater pressure and influenced their work attitudes.
Our results indicated that doctors’ work experience had an impact on their perceptions of the doctor–patient relationship. Doctors reported that sufficient communication with patients could improve their perceptions, while having had medical disputes in the previous year or a heavy workload did not. Other research has found that information asymmetry is a classic characteristic of the doctor–patient relationship; it can put patients at a disadvantage due to lack of medical knowledge,[xii] but hospitals can benefit from it by providing excessive medical services.[xiii],[xiv] More communication can minimize this limitation and build trust and consensus with doctors.[xv],[xvi] Medical disputes and work pressure were other common factors that damaged doctors’ perceptions of the doctor–patient relationship.10,37 Doctors who had experienced workplace violence had a higher prevalence of depression and anxiety than those who had not.[xvii] Moreover, previous research suggests that defensive behaviors from such doctors, such as acceding to patients’ demands for more medical checks or refraining from expressing their true opinions on clinical decision making, would also increase.[xviii] This suggests that medical disputes, in a long time, could influence doctors who have experienced or witnessed and make them worried, anxious, or even fearful of new doctor–patient relationships. When it came to workload, our data showed that median working time for doctors on a regular day was 10 h, but they would feel their workloads to be excessive after having worked for 7 h. Therefore, most doctors in our sample were under great physical and mental pressure, which worsened their perception of the doctor–patient relationship. Therefore, it would be helpful to create space and methods for doctors to relieve their work pressures, such as stress management workshops. Strengthening the medical hierarchy is also a feasible approach to dispersing patients to family doctors. Furthermore, training in communication skills might be helpful for doctors to effectively gain insight into patients’ emotions and needs.
On the part of hospitals, establishment of security measures played a decisive role in improving doctors’ perceptions of the doctor–patient relationship. Doctors reported positive perceptions if the hospital had effective measures in place to prevent and reduce disputes, if hospital security staff could be present when medical disputes happened, or if hospitals purchased medical-liability insurance for doctors. All of these measures strongly protected the rights of doctors before, during, or after medical disputes, respectively. For doctors, it would be better for the preventive system to be established and maintained by the hospital, such as a dispute mediation department, so that doctors could focus on diagnosis and treatment. Additionally, there is no denying that the presence of security staff is a powerful way to check aggression in patients and control the hospital site, which could increase doctors’ confidence in facing conflicts. Another study concluded that physicians’ job performance could be boosted if hospitals provided them with job security and organizational support, and that physician satisfaction would further impact their behavior and, consequently, the quality of medical care they provide.[xix] Unlike Western medical institutions,[xx] Chinese hospitals can be established and run without purchasing medical-liability insurance for each doctor. Although the government has been pushing this policy since 2000,[xxi] fewer than half the doctors we sampled (46.32%) reported that they had such insurance. But it is unquestionable that insurance companies, as agents, release doctors and hospitals from negotiating compensation with patients or their relatives after a medical dispute, which is beneficial for the doctors. Hence, it is time to improve risk management systems in hospitals, such as patient safety reporting and monitoring measures, adverse-event reporting procedures, and clinical risk management plans. Also, doctors need job security and organizational support. Hospitals could consider measures, such as compulsory purchase of medical-liability insurance, setting up police spots in hospitals, and providing psychological intervention to doctors after medical disputes and workplace violence.
Using a cross-sectional survey of doctors in China, we identified that doctors’ work experience and hospital security measures were strongly associated with the doctors’ perceptions of the doctor–patient relationship, as were hospital type, region, age, sex, and income. In terms of doctors’ work experience, moderate workload, enough communication with patients, and no experience of medical disputes all significantly contributed to positive doctor–patient relationship perceptions. Hospital security measures, effective precautions, in-place security staff, and medical-liability insurance influenced doctor-patient relationship perceptions. Therefore, in order to improve the doctor–patient relationship, it is necessary to reduce doctors’ workload and improve the length and quality of their communication with patients. For hospitals, preventing medical disputes and increasing workplace safety and organizational support are useful ways to improve doctors’ perceptions of the doctor–patient relationship.
4.3 Practice implications
This study provided evidence and advices for Chinese government, as well as Chinese hospitals, to improve doctors’ perceptions by adopting measures to enhance doctors’ work experiences and hospital security. These results may be helpful to raise doctors' confidence to the doctor-patient relationship and ease tense doctor-patient relationship in China.