Judith Belle Brown, PhD

Family physicians are in an optimal position to identify women who are victims of abuse, because they are often the first point of contact in the medical arena. However, recent studies indicate that family physicians continue to be reticent in accepting this responsibility, thus contributing to the underdetection of woman abuse.^1,2 For almost 2 decades family medicine educators and researchers have made a concerted effort to understand and increase identification and treatment of woman abuse by family physicians.^1-17 As part of this initiative, our focus has been on the development of a screening tool for family physicians to use in the context of a routine office visit or a well-woman examination to identify and assess women who are experiencing emotional, physical, or sexual abuse by their partners.^8,18

The Woman Abuse Screening Tool (WAST), which consists of 7 questions, was developed and pilot tested using purposive samples of abused and nonabused women.¹⁸ It was found to have high internal consistency among this sample ({a} =0.95). It also demonstrated construct validity, with total scores correlating highly (r=0.96) with scores on the Abuse Risk Inventory (ARI).¹⁸ The validation study also provided evidence of discriminant validity, finding significant differences in the scores of abused and nonabused women both on individual items and on the overall scores.¹⁸

The first 2 questions of the WAST (“In general, how would you describe your relationship: a lot of tension, some tension, no tension?” and “Do you and your partner work out arguments: with great difficulty, some difficulty, no difficulty?” constitute the WAST-Short, which has been an effective tool for initially screening for the presence of abuse.¹⁸ The screening tool correctly classified 91.7% of the abused women and 100% of the nonabused women in the validation study.¹⁸ These 2 questions were also identified by the abused women in the validation study as those with which they would be most comfortable if asked by their family physicians. The remaining questions on the WAST were used to gain a more complete assessment of the abuse. In the validation study there were significant differences found between the abused and nonabused women on the mean overall WAST scores (18 vs 8.8, respectively; P <.001).

To establish the generalizability of the WAST, we field-tested it by having family physicians ask the questions of adult women in the general population who were presenting for routine visits (complete physical examination or prenatal care) as well as acute complaints.¹⁹ Although reported interest of family physicians in having a brief screening tool had been the genesis of this program of study, their comfort in using the WAST during a clinical encounter had not been assessed.⁸ Also, determining the level of comfort of women patients being asked the WAST questions by a family physician during an actual office visit versus a hypothetical encounter (as was the case in the validation study) was viewed as important.¹⁸

Inquiring about abuse has been found to cause discomfort for both physicians and women patients. It has been noted previously that family physicians remain reluctant to delve into the issue of woman abuse in spite of the fact that educating physicians about this abuse (including the use of a screening protocol) has been shown to significantly increase the detection rates of abused women in emergency departments.^20,21 Also, both patients and physicians have indicated that the discomfort of physicians with issues of abuse may deter them from inquiring about this topic.^7,8,22,23 Data from previous studies showing a decline in detection once a formal assessment protocol is discontinued emphasize the importance of maintaining a continuous screening approach if woman abuse is to be detected.²¹ Thus knowledge of the level of comfort physicians have in using the WAST and whether it aided in their identification of woman abuse and determining their ongoing commitment to use it required investigation.

Women are often reluctant to disclose abuse to their family physicians for numerous reasons, including shame, denial, fear of reprisal by their partner, a tendency to minimize or normalize the abuse, fear of a negative or punitive response by their physician, or assignment of power and control to the physician.^6,24-26 However, studies have shown that when women feel understood, listened to, and validated by their physicians they are more inclined to discuss the abuse.^27-29 Also, previous studies with abused women^22,23,27-29 have found that they want their physicians to take responsibility for asking questions about abuse and to do so in a manner that is caring, respectful, and supportive. Thus, determining the comfort of women being asked the WAST questions by their family physicians was viewed as essential to our study.

Therefore, the objectives of field testing the WAST were to assess its validity and reliability in the general population within the context of the family practice setting; to determine the comfort levels of family physicians administering the WAST, their perceptions of its ability to help them identify abused women, and their willingness to continue using it in their practices; and to determine the self-reported comfort of patients with being asked the WAST questions by their family physicians.

Our study was approved by the Review Board for Health Sciences Research Involving Human Subjects at the University of Western Ontario.

Methods

Setting

Our study was conducted in the offices of family physicians located in London, Ontario, Canada, and the surrounding area. The recruitment and data collection took place from March 1997 to August 1998.

Instruments

The WAST. Although the original version of the WAST consisted of 7 questions, an eighth question (“Has your partner ever abused you sexually?”) was added for our study (Figure). This question was thought to be clinically important when assessing women who screen positive on the WAST-Short. The 2 questions that make up the WAST-Short assess the degree of relationship tension and the amount of difficulty that the woman and her partner have in working out arguments on a scale of 1 to 3.

Scores on the WAST-Short are computed on the basis of a criterion cutoff score of 1, which involves assigning a score of 1 to the most extreme positive responses for each of the 2 items (ie, “a lot of tension” and “great difficulty”) and a score of 0 to the other response options.¹⁸ The remaining 6 questions are used to gain a more complete assessment of the abuse by asking the respondent to rate the frequency of various feelings and experiences on a scale from 1 (often) to 3 (never). The WAST items are recoded and summed to calculate the overall score.

The Abuse Risk Inventory. The Abuse Risk Inventory (ARI) is a 25-item self-report measure used in the identification of woman abuse and is also described as being useful in the assessment process.³⁰ Respondents rate 25 items on the basis of frequency of occurrence using a 4-point scale ranging from “rarely or never” to “always.” A score of 50 or higher suggests that the respondent may be in an abusive situation or at risk for abuse.³⁰ The ARI has demonstrated reliability (a=.91).30

Physician and Patient Comfort with the WAST Questionnaires. These self-report questionnaires were used to determine the level of comfort of physicians and patients with asking or being asked each of the WAST questions. Responses were given using a 4-point scale ranging from 1 (not at all comfortable) to 4 (very comfortable).

Prior Knowledge Questionnaire. This questionnaire assessed a physician’s previous or concurrent relationships with the patient and her partner by identifying various contexts (eg, workplace, leisure) through which the physician is connected with the patient and her partner in the role other than as the family physician. This questionnaire was included because of the potential influence of the physician’s personal relationship with the patient and her partner on both the patient’s willingness to disclose abuse and the physician’s comfort in inquiring about it.

The Perceived Usefulness Questionnaire. This questionnaire asked physicians to respond to the following statements using a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree): “The wording of the WAST was clear”; “The WAST helped me to identify women who are abused”; “I feel better able to identify women who are abused using the WAST”; and “I felt comfortable asking questions on the WAST.” Physicians were also asked to indicate whether they would continue to use the WAST in their practice using the same 5-point scale.

Physician Participants

Our goal was to achieve a stratified random sample of 20 physicians practicing in urban and rural settings from a sampling frame of 400 family physicians in London, Ontario, Canada, and the surrounding area. The family physician investigators telephoned a total of 44 physicians who were selected from the sampling frame using a random numbers table. This followed the recruitment process reported by Borgeil and colleagues.³¹ Physicians who agreed to participate in our study were mailed a letter of information, a consent form, and directions for the study protocol, including how to administer the WAST and a list of community resources for women who were abused.

Patient Participants

For patients, we followed the recommendations of DeVellis, who has outlined a sample size range with a minimum of 200 and a maximum of 1000 respondents to explore the factorial validity of a new measure.³² To ensure that sufficient variability would exist across responses, we aimed for a moderate sample size of approximately 300 subjects.

To be included in our study the women patients were required to be older than 18 years; attending for a periodic health examination, for prenatal care, or with acute symptoms of illness; English speaking; unaccompanied by another person; currently involved in an intimate relationship (married or common law); and they had to consider the attending physician their primary care physician.

Instrument Administration

The 20 participating physicians were asked to administer the WAST to 15 to 20 consecutive women patients who met the inclusion criteria and consented to participate in the study. At the conclusion of each patient visit the physicians were requested to complete the WAST comfort questionnaire and the prior knowledge questionnaire. When the data collection was completed they were asked to report their perceptions of the WAST.

Each woman was approached by the research assistant in one of the physician’s examining rooms before her visit with the family physician. The research assistant explained the study, provided the patient with a letter of information, and if she agreed to participate supplied a consent form for signature. During the patient recruitment process, the research assistant maintained a written log describing eligible and ineligible patients, reasons for refusal, and other pertinent data, such as the physician’s knowledge of whether a patient was in an abusive relationship. At the conclusion of the physician-patient encounter, the research assistant met with the patient in a private area and asked her to complete the ARI and the measure assessing her comfort with the WAST questions asked.

Data Analysis

To determine the reliability and validity of the WAST, we calculated Cronbach a and Pearson correlation coefficients for the WAST and the ARI. Differences in both the nominal-level demographic information of patients and the responses of physicians and patients to the study measures on the basis of selected variables (family practice certification status for physicians, positive versus negative screen for patients) were analyzed using cross-tabulations and chi-square calculations. Differences in interval and ratio level measures (including demographic information and scale totals) were analyzed with independent samples Student t tests. Analyses involving the length of time physicians had been in practice were conducted using a computed variable (1997 minus year of graduation), which was then recoded into the decade of graduation. Scoring of the WAST involved recoding the responses to reflect a higher score for higher reported frequency of experiences and then summing the WAST scores for individuals who answered all 8 items. ARI scores were calculated for respondents who had answered all 25 items using the procedure outlined by Yegidis.³⁰

Results

Validity and Reliability of the WAST in the Family Practice Context Overall WAST and ARI scores were correlated (r=0.69, P=.01). The WAST was found to be a reliable measure in the family practice context, achieving a coefficient a of 0.75, indicating good internal consistency.

Physician Characteristics

To secure the 20 family physicians required for the study, we had to contact 44 physicians randomly selected from the sampling frame, yielding an acceptance rate of 45.5%. The final sample of physicians consisted of 7 women and 13 men. The average number of years since graduation was 22.9 (range=6-46 years). There were 8 physicians in rural practice and 12 from the city of London, Ontario. Fourteen were in a group practice arrangement, and 14 were certificants of the College of Family Physicians of Canada (CFPC). There were no significant differences between the physicians who agreed to participate and those who declined, on the basis of sex, certification status, years since graduation, practice type (solo vs group), and practice location (urban vs rural).

Patient Characteristics

A total of 456 patients were asked to participate in our study. Fifty-seven women were deemed ineligible on the basis of the inclusion criteria, resulting in 399 eligible patients. Ninety-two (23.1%) of these refused, giving lack of time, degree of sickness, and discomfort in discussing personal issues as their reasons. Thus the final sample included 307 women.

The average age of these patients was 46.2 years (range=18-86 years). The majority (87.6%) were married or in a common-law relationship. The patients were primarily white (97.6%), and 44.7% reported having postsecondary education. More than half of the subjects (58.9%) were employed, and 58.7% reported an annual household income of more than $30,000 (Table 1).

Of the 307 patients screened, 26 (8.5%) were identified by the WAST-Short as experiencing abuse. The demographics of the sample for those who screened positive and negative for abuse are provided in Table 1. No significant differences were found. However, the 26 women who screened positive for abuse reported a wide range of income levels, with 9 women (34.6%) indicating an annual income of more than $50,000.

Table 2 shows the individual WAST item responses and overall scores for the total sample divided into 2 groups: those who screened positive for experiencing abuse and those who screened negative. Significant differences were found between the 2 groups for each item and for the overall WAST scores.

Physician Perceptions of and Comfort with the WAST

The majority of the physicians (85%) thought the wording of the WAST was clear. Sixty-five percent indicated that it assisted them in identifying women who were abused, and 70% felt more confident in identifying abused women when using the WAST. Also, 75% of physicians reported that they would continue to use the WAST in their practice. We did not systematically inquire about a physician’s previous knowledge of a patient’s experience with abuse. However, this information was often reported to the research assistant anecdotally, who then recorded these conversations in her logbook. According to the logbook entries, 6 of the physicians had been aware of previous abuse experienced by some of the women participating in the study.

All the physicians were comfortable with the items on the WAST, as indicated by a mean score of 3.6 on the question “How comfortable were you in asking your patients the WAST questions?” (1=not at all comfortable; 4=very comfortable).

There was a significant association between the number of years since graduation and the reported comfort level of physicians with asking each of the WAST questions; those who had been in practice for a greater length of time were more comfortable than more recent graduates. For example, 85.7% and 100% of physicians who graduated in the 1950s and 1960s, respectively, reported feeling very comfortable asking question 8, compared with 62.1% and 0% of graduates from the 1980s and 1990s, respectively (P <.001). This trend was consistent for each of the WAST items. No significant differences were found in the level of comfort of the physicians on 6 of the WAST questions on the basis of certification status. However, this was not the case when asking the 2 items related to physical abuse, which had smaller proportions of physicians with CFPC certification feeling very comfortable compared with the noncertificants (57.4% vs 76.7% and 60.6% vs 78.1% on questions 4 and 6, respectively; P <.05). Higher proportions of women physicians than men reported being very comfortable when asking the WAST questions addressing physical, emotional, and sexual abuse (77.9% vs 54.9%; 74.8% vs 52.0%; and 77.9% vs 53.8%, respectively; P <.001). There was no association found between the comfort level of physicians and their previous knowledge of their patients.

Patient Comfort with the WAST

For all the WAST items, a minimum of 91% of the women reported being comfortable or very comfortable when asked the questions by their family physician. The average comfort level score across all items was 3.6 (Table 3). However, the abused women were significantly less comfortable than the nonabused women with the questions that addressed physical and sexual abuse (including the question asking whether arguments resulted in a violent outcome) with all 3 questions achieving a significance level of P <.05.

Discussion

The 8-item WAST was found to be a reliable and valid measure in the family practice context among the general population. The WAST-Short identified 26 women (8.5% of the sample) as experiencing abuse, and there was a significant difference between the abused and nonabused women on their total WAST scores. Although not directly transferable, these findings are noteworthy when compared with a 1993 survey of 12,300 Canadian women older than 18 years reporting that 10% of women had experienced violence in the 12 months before the survey.³³

There were no differences in the demographic characteristics between the women who screened positive for abuse and those who screened negative. However, there was a wider range of income reported by the 26 women who screened positive. This finding supports the literature, which indicates that woman abuse is present at all economic levels and in all social classes.^34,35

Both the patients and their family physicians reported they were comfortable with the WAST, and the comfort level scores of the physicians remained high despite the increasingly sensitive nature of the questions. This strong endorsement suggests that the WAST should be applied in the family practice setting. The majority of physicians perceived the WAST to be helpful for identifying women experiencing abuse and indicated their intentions to continue using it.

Physicians who had been practicing longer expressed more comfort with asking the WAST questions than did their colleagues with less experience. This may reflect their greater awareness of the important role played by psychosocial factors in the lives and health of their patients.

Tudiver and Permaul-Woods³⁶ found no difference in the perceived diagnostic skills for identifying woman abuse between certificants and noncertificants of the CFPC. Our study findings indicate that certificants were less comfortable in asking the 2 questions about physical abuse. Despite their reluctance to ask these questions, the majority of physicians with CFPC certification indicated their commitment to continue using the WAST. The ultimate test will be to see if family physicians persist in the application of the WAST despite fears of opening a “Pandora’s box”⁷ or “a can of worms”.⁸

Some authors have considered the influence of physician sex on the level of comfort of physicians inquiring about abuse.^37,38 In our study the women physicians reported more comfort than the men in asking about emotional, physical, and sexual abuse.

The vast majority of women patients were comfortable in being asked the WAST questions. However, those who screened positive for abuse did express less comfort with questions related to physical and sexual abuse. These findings suggest that for some patients discussing abuse with their family physician may be problematic. They may view physical violence as socially unacceptable behavior and thus a taboo subject for discussion. It may also reflect the patient’s feelings of shame, fear, guilt, and self blame.^11,22,24,25 An environment promoting safety, confidentiality, respect, trust, caring, validation, and a nonjudgemental atmosphere is necessary when screening for abuse.^{22,23,27,29,39}

Compared with a decade ago, several reliable and valid screening tools for detecting woman abuse are now available for use by primary care physicians.^18,40-42 The WAST joins the menu of screening tools from which physicians can choose. Its future use is supported by the reported physician and patient comfort levels with its questions being asked during the clinical encounter.

Limitations

Our study was based on a sample of family physicians drawn from a single geographic area, which limits the generalizability of the findings to physicians in other regions. Also, because of the recruitment method physicians may have agreed to participate because of their previous knowledge of the recruiter’s expertise in the field of abuse, resulting in a biased sample. Although the majority of physicians indicated that they would continue to use the WAST in the future we did not ask them how this would occur. Our recommendation would be that at minimum the WAST-Short be administered to women presenting for routine visits, including complete physical examinations and prenatal care as well as acute complaints.

As reported, we did not systematically inquire about the physician’s previous knowledge of the past abuse of a participant. Furthermore, we did not document if a specific intervention transpired with the women identified as abused. These issues are paramount if screening tools for woman abuse are to be viewed as useful and effective in addressing this serious problem. Future studies should include ways to assess and evaluate both interventions and patient outcomes.

The occurrence of abuse in this group of patients may have been underestimated. The information spontaneously offered by some patients at the time of their refusal to participate in our study suggests that they were in an abusive relationship. This reflects the reality of conducting research on a sensitive issue. Also, the preponderance of white English-speaking middle-class women in our study may limit the generalizability to more diverse populations.

However, these limitations do not detract from the important findings of our study, which demonstrates that the WAST-Short questionnaire identifies women experiencing abuse, and the full 8-item WAST helps family physicians explore the extent of that abuse. Finally, and perhaps of most clinical significance, both patients and family physicians were comfortable with the incorporation of WAST into the clinical encounter.

Acknowledgments

Our study was supported by a grant from Searle Canada. The conclusions are those of the authors, and no endorsement by Searle Canada is intended or should be inferred.

Family physicians are in an optimal position to identify women who are victims of abuse, because they are often the first point of contact in the medical arena. However, recent studies indicate that family physicians continue to be reticent in accepting this responsibility, thus contributing to the underdetection of woman abuse.^1,2 For almost 2 decades family medicine educators and researchers have made a concerted effort to understand and increase identification and treatment of woman abuse by family physicians.^1-17 As part of this initiative, our focus has been on the development of a screening tool for family physicians to use in the context of a routine office visit or a well-woman examination to identify and assess women who are experiencing emotional, physical, or sexual abuse by their partners.^8,18

The Woman Abuse Screening Tool (WAST), which consists of 7 questions, was developed and pilot tested using purposive samples of abused and nonabused women.¹⁸ It was found to have high internal consistency among this sample ({a} =0.95). It also demonstrated construct validity, with total scores correlating highly (r=0.96) with scores on the Abuse Risk Inventory (ARI).¹⁸ The validation study also provided evidence of discriminant validity, finding significant differences in the scores of abused and nonabused women both on individual items and on the overall scores.¹⁸

The first 2 questions of the WAST (“In general, how would you describe your relationship: a lot of tension, some tension, no tension?” and “Do you and your partner work out arguments: with great difficulty, some difficulty, no difficulty?” constitute the WAST-Short, which has been an effective tool for initially screening for the presence of abuse.¹⁸ The screening tool correctly classified 91.7% of the abused women and 100% of the nonabused women in the validation study.¹⁸ These 2 questions were also identified by the abused women in the validation study as those with which they would be most comfortable if asked by their family physicians. The remaining questions on the WAST were used to gain a more complete assessment of the abuse. In the validation study there were significant differences found between the abused and nonabused women on the mean overall WAST scores (18 vs 8.8, respectively; P <.001).

To establish the generalizability of the WAST, we field-tested it by having family physicians ask the questions of adult women in the general population who were presenting for routine visits (complete physical examination or prenatal care) as well as acute complaints.¹⁹ Although reported interest of family physicians in having a brief screening tool had been the genesis of this program of study, their comfort in using the WAST during a clinical encounter had not been assessed.⁸ Also, determining the level of comfort of women patients being asked the WAST questions by a family physician during an actual office visit versus a hypothetical encounter (as was the case in the validation study) was viewed as important.¹⁸

Inquiring about abuse has been found to cause discomfort for both physicians and women patients. It has been noted previously that family physicians remain reluctant to delve into the issue of woman abuse in spite of the fact that educating physicians about this abuse (including the use of a screening protocol) has been shown to significantly increase the detection rates of abused women in emergency departments.^20,21 Also, both patients and physicians have indicated that the discomfort of physicians with issues of abuse may deter them from inquiring about this topic.^7,8,22,23 Data from previous studies showing a decline in detection once a formal assessment protocol is discontinued emphasize the importance of maintaining a continuous screening approach if woman abuse is to be detected.²¹ Thus knowledge of the level of comfort physicians have in using the WAST and whether it aided in their identification of woman abuse and determining their ongoing commitment to use it required investigation.

Women are often reluctant to disclose abuse to their family physicians for numerous reasons, including shame, denial, fear of reprisal by their partner, a tendency to minimize or normalize the abuse, fear of a negative or punitive response by their physician, or assignment of power and control to the physician.^6,24-26 However, studies have shown that when women feel understood, listened to, and validated by their physicians they are more inclined to discuss the abuse.^27-29 Also, previous studies with abused women^22,23,27-29 have found that they want their physicians to take responsibility for asking questions about abuse and to do so in a manner that is caring, respectful, and supportive. Thus, determining the comfort of women being asked the WAST questions by their family physicians was viewed as essential to our study.

Therefore, the objectives of field testing the WAST were to assess its validity and reliability in the general population within the context of the family practice setting; to determine the comfort levels of family physicians administering the WAST, their perceptions of its ability to help them identify abused women, and their willingness to continue using it in their practices; and to determine the self-reported comfort of patients with being asked the WAST questions by their family physicians.

Our study was approved by the Review Board for Health Sciences Research Involving Human Subjects at the University of Western Ontario.

Methods

Setting

Our study was conducted in the offices of family physicians located in London, Ontario, Canada, and the surrounding area. The recruitment and data collection took place from March 1997 to August 1998.

Instruments

The WAST. Although the original version of the WAST consisted of 7 questions, an eighth question (“Has your partner ever abused you sexually?”) was added for our study (Figure). This question was thought to be clinically important when assessing women who screen positive on the WAST-Short. The 2 questions that make up the WAST-Short assess the degree of relationship tension and the amount of difficulty that the woman and her partner have in working out arguments on a scale of 1 to 3.

Scores on the WAST-Short are computed on the basis of a criterion cutoff score of 1, which involves assigning a score of 1 to the most extreme positive responses for each of the 2 items (ie, “a lot of tension” and “great difficulty”) and a score of 0 to the other response options.¹⁸ The remaining 6 questions are used to gain a more complete assessment of the abuse by asking the respondent to rate the frequency of various feelings and experiences on a scale from 1 (often) to 3 (never). The WAST items are recoded and summed to calculate the overall score.

The Abuse Risk Inventory. The Abuse Risk Inventory (ARI) is a 25-item self-report measure used in the identification of woman abuse and is also described as being useful in the assessment process.³⁰ Respondents rate 25 items on the basis of frequency of occurrence using a 4-point scale ranging from “rarely or never” to “always.” A score of 50 or higher suggests that the respondent may be in an abusive situation or at risk for abuse.³⁰ The ARI has demonstrated reliability (a=.91).30

Physician and Patient Comfort with the WAST Questionnaires. These self-report questionnaires were used to determine the level of comfort of physicians and patients with asking or being asked each of the WAST questions. Responses were given using a 4-point scale ranging from 1 (not at all comfortable) to 4 (very comfortable).

Prior Knowledge Questionnaire. This questionnaire assessed a physician’s previous or concurrent relationships with the patient and her partner by identifying various contexts (eg, workplace, leisure) through which the physician is connected with the patient and her partner in the role other than as the family physician. This questionnaire was included because of the potential influence of the physician’s personal relationship with the patient and her partner on both the patient’s willingness to disclose abuse and the physician’s comfort in inquiring about it.

The Perceived Usefulness Questionnaire. This questionnaire asked physicians to respond to the following statements using a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree): “The wording of the WAST was clear”; “The WAST helped me to identify women who are abused”; “I feel better able to identify women who are abused using the WAST”; and “I felt comfortable asking questions on the WAST.” Physicians were also asked to indicate whether they would continue to use the WAST in their practice using the same 5-point scale.

Physician Participants

Our goal was to achieve a stratified random sample of 20 physicians practicing in urban and rural settings from a sampling frame of 400 family physicians in London, Ontario, Canada, and the surrounding area. The family physician investigators telephoned a total of 44 physicians who were selected from the sampling frame using a random numbers table. This followed the recruitment process reported by Borgeil and colleagues.³¹ Physicians who agreed to participate in our study were mailed a letter of information, a consent form, and directions for the study protocol, including how to administer the WAST and a list of community resources for women who were abused.

Patient Participants

For patients, we followed the recommendations of DeVellis, who has outlined a sample size range with a minimum of 200 and a maximum of 1000 respondents to explore the factorial validity of a new measure.³² To ensure that sufficient variability would exist across responses, we aimed for a moderate sample size of approximately 300 subjects.

To be included in our study the women patients were required to be older than 18 years; attending for a periodic health examination, for prenatal care, or with acute symptoms of illness; English speaking; unaccompanied by another person; currently involved in an intimate relationship (married or common law); and they had to consider the attending physician their primary care physician.

Instrument Administration

The 20 participating physicians were asked to administer the WAST to 15 to 20 consecutive women patients who met the inclusion criteria and consented to participate in the study. At the conclusion of each patient visit the physicians were requested to complete the WAST comfort questionnaire and the prior knowledge questionnaire. When the data collection was completed they were asked to report their perceptions of the WAST.

Each woman was approached by the research assistant in one of the physician’s examining rooms before her visit with the family physician. The research assistant explained the study, provided the patient with a letter of information, and if she agreed to participate supplied a consent form for signature. During the patient recruitment process, the research assistant maintained a written log describing eligible and ineligible patients, reasons for refusal, and other pertinent data, such as the physician’s knowledge of whether a patient was in an abusive relationship. At the conclusion of the physician-patient encounter, the research assistant met with the patient in a private area and asked her to complete the ARI and the measure assessing her comfort with the WAST questions asked.

Data Analysis

To determine the reliability and validity of the WAST, we calculated Cronbach a and Pearson correlation coefficients for the WAST and the ARI. Differences in both the nominal-level demographic information of patients and the responses of physicians and patients to the study measures on the basis of selected variables (family practice certification status for physicians, positive versus negative screen for patients) were analyzed using cross-tabulations and chi-square calculations. Differences in interval and ratio level measures (including demographic information and scale totals) were analyzed with independent samples Student t tests. Analyses involving the length of time physicians had been in practice were conducted using a computed variable (1997 minus year of graduation), which was then recoded into the decade of graduation. Scoring of the WAST involved recoding the responses to reflect a higher score for higher reported frequency of experiences and then summing the WAST scores for individuals who answered all 8 items. ARI scores were calculated for respondents who had answered all 25 items using the procedure outlined by Yegidis.³⁰

Results

Validity and Reliability of the WAST in the Family Practice Context Overall WAST and ARI scores were correlated (r=0.69, P=.01). The WAST was found to be a reliable measure in the family practice context, achieving a coefficient a of 0.75, indicating good internal consistency.

Physician Characteristics

To secure the 20 family physicians required for the study, we had to contact 44 physicians randomly selected from the sampling frame, yielding an acceptance rate of 45.5%. The final sample of physicians consisted of 7 women and 13 men. The average number of years since graduation was 22.9 (range=6-46 years). There were 8 physicians in rural practice and 12 from the city of London, Ontario. Fourteen were in a group practice arrangement, and 14 were certificants of the College of Family Physicians of Canada (CFPC). There were no significant differences between the physicians who agreed to participate and those who declined, on the basis of sex, certification status, years since graduation, practice type (solo vs group), and practice location (urban vs rural).

Patient Characteristics

A total of 456 patients were asked to participate in our study. Fifty-seven women were deemed ineligible on the basis of the inclusion criteria, resulting in 399 eligible patients. Ninety-two (23.1%) of these refused, giving lack of time, degree of sickness, and discomfort in discussing personal issues as their reasons. Thus the final sample included 307 women.

The average age of these patients was 46.2 years (range=18-86 years). The majority (87.6%) were married or in a common-law relationship. The patients were primarily white (97.6%), and 44.7% reported having postsecondary education. More than half of the subjects (58.9%) were employed, and 58.7% reported an annual household income of more than $30,000 (Table 1).

Of the 307 patients screened, 26 (8.5%) were identified by the WAST-Short as experiencing abuse. The demographics of the sample for those who screened positive and negative for abuse are provided in Table 1. No significant differences were found. However, the 26 women who screened positive for abuse reported a wide range of income levels, with 9 women (34.6%) indicating an annual income of more than $50,000.

Table 2 shows the individual WAST item responses and overall scores for the total sample divided into 2 groups: those who screened positive for experiencing abuse and those who screened negative. Significant differences were found between the 2 groups for each item and for the overall WAST scores.

Physician Perceptions of and Comfort with the WAST

The majority of the physicians (85%) thought the wording of the WAST was clear. Sixty-five percent indicated that it assisted them in identifying women who were abused, and 70% felt more confident in identifying abused women when using the WAST. Also, 75% of physicians reported that they would continue to use the WAST in their practice. We did not systematically inquire about a physician’s previous knowledge of a patient’s experience with abuse. However, this information was often reported to the research assistant anecdotally, who then recorded these conversations in her logbook. According to the logbook entries, 6 of the physicians had been aware of previous abuse experienced by some of the women participating in the study.

All the physicians were comfortable with the items on the WAST, as indicated by a mean score of 3.6 on the question “How comfortable were you in asking your patients the WAST questions?” (1=not at all comfortable; 4=very comfortable).

There was a significant association between the number of years since graduation and the reported comfort level of physicians with asking each of the WAST questions; those who had been in practice for a greater length of time were more comfortable than more recent graduates. For example, 85.7% and 100% of physicians who graduated in the 1950s and 1960s, respectively, reported feeling very comfortable asking question 8, compared with 62.1% and 0% of graduates from the 1980s and 1990s, respectively (P <.001). This trend was consistent for each of the WAST items. No significant differences were found in the level of comfort of the physicians on 6 of the WAST questions on the basis of certification status. However, this was not the case when asking the 2 items related to physical abuse, which had smaller proportions of physicians with CFPC certification feeling very comfortable compared with the noncertificants (57.4% vs 76.7% and 60.6% vs 78.1% on questions 4 and 6, respectively; P <.05). Higher proportions of women physicians than men reported being very comfortable when asking the WAST questions addressing physical, emotional, and sexual abuse (77.9% vs 54.9%; 74.8% vs 52.0%; and 77.9% vs 53.8%, respectively; P <.001). There was no association found between the comfort level of physicians and their previous knowledge of their patients.

Patient Comfort with the WAST

For all the WAST items, a minimum of 91% of the women reported being comfortable or very comfortable when asked the questions by their family physician. The average comfort level score across all items was 3.6 (Table 3). However, the abused women were significantly less comfortable than the nonabused women with the questions that addressed physical and sexual abuse (including the question asking whether arguments resulted in a violent outcome) with all 3 questions achieving a significance level of P <.05.

Discussion

The 8-item WAST was found to be a reliable and valid measure in the family practice context among the general population. The WAST-Short identified 26 women (8.5% of the sample) as experiencing abuse, and there was a significant difference between the abused and nonabused women on their total WAST scores. Although not directly transferable, these findings are noteworthy when compared with a 1993 survey of 12,300 Canadian women older than 18 years reporting that 10% of women had experienced violence in the 12 months before the survey.³³

There were no differences in the demographic characteristics between the women who screened positive for abuse and those who screened negative. However, there was a wider range of income reported by the 26 women who screened positive. This finding supports the literature, which indicates that woman abuse is present at all economic levels and in all social classes.^34,35

Both the patients and their family physicians reported they were comfortable with the WAST, and the comfort level scores of the physicians remained high despite the increasingly sensitive nature of the questions. This strong endorsement suggests that the WAST should be applied in the family practice setting. The majority of physicians perceived the WAST to be helpful for identifying women experiencing abuse and indicated their intentions to continue using it.

Physicians who had been practicing longer expressed more comfort with asking the WAST questions than did their colleagues with less experience. This may reflect their greater awareness of the important role played by psychosocial factors in the lives and health of their patients.

Tudiver and Permaul-Woods³⁶ found no difference in the perceived diagnostic skills for identifying woman abuse between certificants and noncertificants of the CFPC. Our study findings indicate that certificants were less comfortable in asking the 2 questions about physical abuse. Despite their reluctance to ask these questions, the majority of physicians with CFPC certification indicated their commitment to continue using the WAST. The ultimate test will be to see if family physicians persist in the application of the WAST despite fears of opening a “Pandora’s box”⁷ or “a can of worms”.⁸

Some authors have considered the influence of physician sex on the level of comfort of physicians inquiring about abuse.^37,38 In our study the women physicians reported more comfort than the men in asking about emotional, physical, and sexual abuse.

The vast majority of women patients were comfortable in being asked the WAST questions. However, those who screened positive for abuse did express less comfort with questions related to physical and sexual abuse. These findings suggest that for some patients discussing abuse with their family physician may be problematic. They may view physical violence as socially unacceptable behavior and thus a taboo subject for discussion. It may also reflect the patient’s feelings of shame, fear, guilt, and self blame.^11,22,24,25 An environment promoting safety, confidentiality, respect, trust, caring, validation, and a nonjudgemental atmosphere is necessary when screening for abuse.^{22,23,27,29,39}

Compared with a decade ago, several reliable and valid screening tools for detecting woman abuse are now available for use by primary care physicians.^18,40-42 The WAST joins the menu of screening tools from which physicians can choose. Its future use is supported by the reported physician and patient comfort levels with its questions being asked during the clinical encounter.

Limitations

Our study was based on a sample of family physicians drawn from a single geographic area, which limits the generalizability of the findings to physicians in other regions. Also, because of the recruitment method physicians may have agreed to participate because of their previous knowledge of the recruiter’s expertise in the field of abuse, resulting in a biased sample. Although the majority of physicians indicated that they would continue to use the WAST in the future we did not ask them how this would occur. Our recommendation would be that at minimum the WAST-Short be administered to women presenting for routine visits, including complete physical examinations and prenatal care as well as acute complaints.

As reported, we did not systematically inquire about the physician’s previous knowledge of the past abuse of a participant. Furthermore, we did not document if a specific intervention transpired with the women identified as abused. These issues are paramount if screening tools for woman abuse are to be viewed as useful and effective in addressing this serious problem. Future studies should include ways to assess and evaluate both interventions and patient outcomes.

The occurrence of abuse in this group of patients may have been underestimated. The information spontaneously offered by some patients at the time of their refusal to participate in our study suggests that they were in an abusive relationship. This reflects the reality of conducting research on a sensitive issue. Also, the preponderance of white English-speaking middle-class women in our study may limit the generalizability to more diverse populations.

However, these limitations do not detract from the important findings of our study, which demonstrates that the WAST-Short questionnaire identifies women experiencing abuse, and the full 8-item WAST helps family physicians explore the extent of that abuse. Finally, and perhaps of most clinical significance, both patients and family physicians were comfortable with the incorporation of WAST into the clinical encounter.

Acknowledgments

Our study was supported by a grant from Searle Canada. The conclusions are those of the authors, and no endorsement by Searle Canada is intended or should be inferred.

Family physicians are in an optimal position to identify women who are victims of abuse, because they are often the first point of contact in the medical arena. However, recent studies indicate that family physicians continue to be reticent in accepting this responsibility, thus contributing to the underdetection of woman abuse.^1,2 For almost 2 decades family medicine educators and researchers have made a concerted effort to understand and increase identification and treatment of woman abuse by family physicians.^1-17 As part of this initiative, our focus has been on the development of a screening tool for family physicians to use in the context of a routine office visit or a well-woman examination to identify and assess women who are experiencing emotional, physical, or sexual abuse by their partners.^8,18

The Woman Abuse Screening Tool (WAST), which consists of 7 questions, was developed and pilot tested using purposive samples of abused and nonabused women.¹⁸ It was found to have high internal consistency among this sample ({a} =0.95). It also demonstrated construct validity, with total scores correlating highly (r=0.96) with scores on the Abuse Risk Inventory (ARI).¹⁸ The validation study also provided evidence of discriminant validity, finding significant differences in the scores of abused and nonabused women both on individual items and on the overall scores.¹⁸

The first 2 questions of the WAST (“In general, how would you describe your relationship: a lot of tension, some tension, no tension?” and “Do you and your partner work out arguments: with great difficulty, some difficulty, no difficulty?” constitute the WAST-Short, which has been an effective tool for initially screening for the presence of abuse.¹⁸ The screening tool correctly classified 91.7% of the abused women and 100% of the nonabused women in the validation study.¹⁸ These 2 questions were also identified by the abused women in the validation study as those with which they would be most comfortable if asked by their family physicians. The remaining questions on the WAST were used to gain a more complete assessment of the abuse. In the validation study there were significant differences found between the abused and nonabused women on the mean overall WAST scores (18 vs 8.8, respectively; P <.001).

To establish the generalizability of the WAST, we field-tested it by having family physicians ask the questions of adult women in the general population who were presenting for routine visits (complete physical examination or prenatal care) as well as acute complaints.¹⁹ Although reported interest of family physicians in having a brief screening tool had been the genesis of this program of study, their comfort in using the WAST during a clinical encounter had not been assessed.⁸ Also, determining the level of comfort of women patients being asked the WAST questions by a family physician during an actual office visit versus a hypothetical encounter (as was the case in the validation study) was viewed as important.¹⁸

Inquiring about abuse has been found to cause discomfort for both physicians and women patients. It has been noted previously that family physicians remain reluctant to delve into the issue of woman abuse in spite of the fact that educating physicians about this abuse (including the use of a screening protocol) has been shown to significantly increase the detection rates of abused women in emergency departments.^20,21 Also, both patients and physicians have indicated that the discomfort of physicians with issues of abuse may deter them from inquiring about this topic.^7,8,22,23 Data from previous studies showing a decline in detection once a formal assessment protocol is discontinued emphasize the importance of maintaining a continuous screening approach if woman abuse is to be detected.²¹ Thus knowledge of the level of comfort physicians have in using the WAST and whether it aided in their identification of woman abuse and determining their ongoing commitment to use it required investigation.

Women are often reluctant to disclose abuse to their family physicians for numerous reasons, including shame, denial, fear of reprisal by their partner, a tendency to minimize or normalize the abuse, fear of a negative or punitive response by their physician, or assignment of power and control to the physician.^6,24-26 However, studies have shown that when women feel understood, listened to, and validated by their physicians they are more inclined to discuss the abuse.^27-29 Also, previous studies with abused women^22,23,27-29 have found that they want their physicians to take responsibility for asking questions about abuse and to do so in a manner that is caring, respectful, and supportive. Thus, determining the comfort of women being asked the WAST questions by their family physicians was viewed as essential to our study.

Therefore, the objectives of field testing the WAST were to assess its validity and reliability in the general population within the context of the family practice setting; to determine the comfort levels of family physicians administering the WAST, their perceptions of its ability to help them identify abused women, and their willingness to continue using it in their practices; and to determine the self-reported comfort of patients with being asked the WAST questions by their family physicians.

Our study was approved by the Review Board for Health Sciences Research Involving Human Subjects at the University of Western Ontario.

Methods

Setting

Our study was conducted in the offices of family physicians located in London, Ontario, Canada, and the surrounding area. The recruitment and data collection took place from March 1997 to August 1998.

Instruments

The WAST. Although the original version of the WAST consisted of 7 questions, an eighth question (“Has your partner ever abused you sexually?”) was added for our study (Figure). This question was thought to be clinically important when assessing women who screen positive on the WAST-Short. The 2 questions that make up the WAST-Short assess the degree of relationship tension and the amount of difficulty that the woman and her partner have in working out arguments on a scale of 1 to 3.

Scores on the WAST-Short are computed on the basis of a criterion cutoff score of 1, which involves assigning a score of 1 to the most extreme positive responses for each of the 2 items (ie, “a lot of tension” and “great difficulty”) and a score of 0 to the other response options.¹⁸ The remaining 6 questions are used to gain a more complete assessment of the abuse by asking the respondent to rate the frequency of various feelings and experiences on a scale from 1 (often) to 3 (never). The WAST items are recoded and summed to calculate the overall score.

The Abuse Risk Inventory. The Abuse Risk Inventory (ARI) is a 25-item self-report measure used in the identification of woman abuse and is also described as being useful in the assessment process.³⁰ Respondents rate 25 items on the basis of frequency of occurrence using a 4-point scale ranging from “rarely or never” to “always.” A score of 50 or higher suggests that the respondent may be in an abusive situation or at risk for abuse.³⁰ The ARI has demonstrated reliability (a=.91).30

Physician and Patient Comfort with the WAST Questionnaires. These self-report questionnaires were used to determine the level of comfort of physicians and patients with asking or being asked each of the WAST questions. Responses were given using a 4-point scale ranging from 1 (not at all comfortable) to 4 (very comfortable).

Prior Knowledge Questionnaire. This questionnaire assessed a physician’s previous or concurrent relationships with the patient and her partner by identifying various contexts (eg, workplace, leisure) through which the physician is connected with the patient and her partner in the role other than as the family physician. This questionnaire was included because of the potential influence of the physician’s personal relationship with the patient and her partner on both the patient’s willingness to disclose abuse and the physician’s comfort in inquiring about it.

The Perceived Usefulness Questionnaire. This questionnaire asked physicians to respond to the following statements using a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree): “The wording of the WAST was clear”; “The WAST helped me to identify women who are abused”; “I feel better able to identify women who are abused using the WAST”; and “I felt comfortable asking questions on the WAST.” Physicians were also asked to indicate whether they would continue to use the WAST in their practice using the same 5-point scale.

Physician Participants

Our goal was to achieve a stratified random sample of 20 physicians practicing in urban and rural settings from a sampling frame of 400 family physicians in London, Ontario, Canada, and the surrounding area. The family physician investigators telephoned a total of 44 physicians who were selected from the sampling frame using a random numbers table. This followed the recruitment process reported by Borgeil and colleagues.³¹ Physicians who agreed to participate in our study were mailed a letter of information, a consent form, and directions for the study protocol, including how to administer the WAST and a list of community resources for women who were abused.

Patient Participants

For patients, we followed the recommendations of DeVellis, who has outlined a sample size range with a minimum of 200 and a maximum of 1000 respondents to explore the factorial validity of a new measure.³² To ensure that sufficient variability would exist across responses, we aimed for a moderate sample size of approximately 300 subjects.

To be included in our study the women patients were required to be older than 18 years; attending for a periodic health examination, for prenatal care, or with acute symptoms of illness; English speaking; unaccompanied by another person; currently involved in an intimate relationship (married or common law); and they had to consider the attending physician their primary care physician.

Instrument Administration

The 20 participating physicians were asked to administer the WAST to 15 to 20 consecutive women patients who met the inclusion criteria and consented to participate in the study. At the conclusion of each patient visit the physicians were requested to complete the WAST comfort questionnaire and the prior knowledge questionnaire. When the data collection was completed they were asked to report their perceptions of the WAST.

Each woman was approached by the research assistant in one of the physician’s examining rooms before her visit with the family physician. The research assistant explained the study, provided the patient with a letter of information, and if she agreed to participate supplied a consent form for signature. During the patient recruitment process, the research assistant maintained a written log describing eligible and ineligible patients, reasons for refusal, and other pertinent data, such as the physician’s knowledge of whether a patient was in an abusive relationship. At the conclusion of the physician-patient encounter, the research assistant met with the patient in a private area and asked her to complete the ARI and the measure assessing her comfort with the WAST questions asked.

Data Analysis

To determine the reliability and validity of the WAST, we calculated Cronbach a and Pearson correlation coefficients for the WAST and the ARI. Differences in both the nominal-level demographic information of patients and the responses of physicians and patients to the study measures on the basis of selected variables (family practice certification status for physicians, positive versus negative screen for patients) were analyzed using cross-tabulations and chi-square calculations. Differences in interval and ratio level measures (including demographic information and scale totals) were analyzed with independent samples Student t tests. Analyses involving the length of time physicians had been in practice were conducted using a computed variable (1997 minus year of graduation), which was then recoded into the decade of graduation. Scoring of the WAST involved recoding the responses to reflect a higher score for higher reported frequency of experiences and then summing the WAST scores for individuals who answered all 8 items. ARI scores were calculated for respondents who had answered all 25 items using the procedure outlined by Yegidis.³⁰

Results

Validity and Reliability of the WAST in the Family Practice Context Overall WAST and ARI scores were correlated (r=0.69, P=.01). The WAST was found to be a reliable measure in the family practice context, achieving a coefficient a of 0.75, indicating good internal consistency.

Physician Characteristics

To secure the 20 family physicians required for the study, we had to contact 44 physicians randomly selected from the sampling frame, yielding an acceptance rate of 45.5%. The final sample of physicians consisted of 7 women and 13 men. The average number of years since graduation was 22.9 (range=6-46 years). There were 8 physicians in rural practice and 12 from the city of London, Ontario. Fourteen were in a group practice arrangement, and 14 were certificants of the College of Family Physicians of Canada (CFPC). There were no significant differences between the physicians who agreed to participate and those who declined, on the basis of sex, certification status, years since graduation, practice type (solo vs group), and practice location (urban vs rural).

Patient Characteristics

A total of 456 patients were asked to participate in our study. Fifty-seven women were deemed ineligible on the basis of the inclusion criteria, resulting in 399 eligible patients. Ninety-two (23.1%) of these refused, giving lack of time, degree of sickness, and discomfort in discussing personal issues as their reasons. Thus the final sample included 307 women.

The average age of these patients was 46.2 years (range=18-86 years). The majority (87.6%) were married or in a common-law relationship. The patients were primarily white (97.6%), and 44.7% reported having postsecondary education. More than half of the subjects (58.9%) were employed, and 58.7% reported an annual household income of more than $30,000 (Table 1).

Of the 307 patients screened, 26 (8.5%) were identified by the WAST-Short as experiencing abuse. The demographics of the sample for those who screened positive and negative for abuse are provided in Table 1. No significant differences were found. However, the 26 women who screened positive for abuse reported a wide range of income levels, with 9 women (34.6%) indicating an annual income of more than $50,000.

Table 2 shows the individual WAST item responses and overall scores for the total sample divided into 2 groups: those who screened positive for experiencing abuse and those who screened negative. Significant differences were found between the 2 groups for each item and for the overall WAST scores.

Physician Perceptions of and Comfort with the WAST

The majority of the physicians (85%) thought the wording of the WAST was clear. Sixty-five percent indicated that it assisted them in identifying women who were abused, and 70% felt more confident in identifying abused women when using the WAST. Also, 75% of physicians reported that they would continue to use the WAST in their practice. We did not systematically inquire about a physician’s previous knowledge of a patient’s experience with abuse. However, this information was often reported to the research assistant anecdotally, who then recorded these conversations in her logbook. According to the logbook entries, 6 of the physicians had been aware of previous abuse experienced by some of the women participating in the study.

All the physicians were comfortable with the items on the WAST, as indicated by a mean score of 3.6 on the question “How comfortable were you in asking your patients the WAST questions?” (1=not at all comfortable; 4=very comfortable).

There was a significant association between the number of years since graduation and the reported comfort level of physicians with asking each of the WAST questions; those who had been in practice for a greater length of time were more comfortable than more recent graduates. For example, 85.7% and 100% of physicians who graduated in the 1950s and 1960s, respectively, reported feeling very comfortable asking question 8, compared with 62.1% and 0% of graduates from the 1980s and 1990s, respectively (P <.001). This trend was consistent for each of the WAST items. No significant differences were found in the level of comfort of the physicians on 6 of the WAST questions on the basis of certification status. However, this was not the case when asking the 2 items related to physical abuse, which had smaller proportions of physicians with CFPC certification feeling very comfortable compared with the noncertificants (57.4% vs 76.7% and 60.6% vs 78.1% on questions 4 and 6, respectively; P <.05). Higher proportions of women physicians than men reported being very comfortable when asking the WAST questions addressing physical, emotional, and sexual abuse (77.9% vs 54.9%; 74.8% vs 52.0%; and 77.9% vs 53.8%, respectively; P <.001). There was no association found between the comfort level of physicians and their previous knowledge of their patients.

Patient Comfort with the WAST

For all the WAST items, a minimum of 91% of the women reported being comfortable or very comfortable when asked the questions by their family physician. The average comfort level score across all items was 3.6 (Table 3). However, the abused women were significantly less comfortable than the nonabused women with the questions that addressed physical and sexual abuse (including the question asking whether arguments resulted in a violent outcome) with all 3 questions achieving a significance level of P <.05.

Discussion

The 8-item WAST was found to be a reliable and valid measure in the family practice context among the general population. The WAST-Short identified 26 women (8.5% of the sample) as experiencing abuse, and there was a significant difference between the abused and nonabused women on their total WAST scores. Although not directly transferable, these findings are noteworthy when compared with a 1993 survey of 12,300 Canadian women older than 18 years reporting that 10% of women had experienced violence in the 12 months before the survey.³³

There were no differences in the demographic characteristics between the women who screened positive for abuse and those who screened negative. However, there was a wider range of income reported by the 26 women who screened positive. This finding supports the literature, which indicates that woman abuse is present at all economic levels and in all social classes.^34,35

Both the patients and their family physicians reported they were comfortable with the WAST, and the comfort level scores of the physicians remained high despite the increasingly sensitive nature of the questions. This strong endorsement suggests that the WAST should be applied in the family practice setting. The majority of physicians perceived the WAST to be helpful for identifying women experiencing abuse and indicated their intentions to continue using it.

Physicians who had been practicing longer expressed more comfort with asking the WAST questions than did their colleagues with less experience. This may reflect their greater awareness of the important role played by psychosocial factors in the lives and health of their patients.

Tudiver and Permaul-Woods³⁶ found no difference in the perceived diagnostic skills for identifying woman abuse between certificants and noncertificants of the CFPC. Our study findings indicate that certificants were less comfortable in asking the 2 questions about physical abuse. Despite their reluctance to ask these questions, the majority of physicians with CFPC certification indicated their commitment to continue using the WAST. The ultimate test will be to see if family physicians persist in the application of the WAST despite fears of opening a “Pandora’s box”⁷ or “a can of worms”.⁸

Some authors have considered the influence of physician sex on the level of comfort of physicians inquiring about abuse.^37,38 In our study the women physicians reported more comfort than the men in asking about emotional, physical, and sexual abuse.

The vast majority of women patients were comfortable in being asked the WAST questions. However, those who screened positive for abuse did express less comfort with questions related to physical and sexual abuse. These findings suggest that for some patients discussing abuse with their family physician may be problematic. They may view physical violence as socially unacceptable behavior and thus a taboo subject for discussion. It may also reflect the patient’s feelings of shame, fear, guilt, and self blame.^11,22,24,25 An environment promoting safety, confidentiality, respect, trust, caring, validation, and a nonjudgemental atmosphere is necessary when screening for abuse.^{22,23,27,29,39}

Compared with a decade ago, several reliable and valid screening tools for detecting woman abuse are now available for use by primary care physicians.^18,40-42 The WAST joins the menu of screening tools from which physicians can choose. Its future use is supported by the reported physician and patient comfort levels with its questions being asked during the clinical encounter.

Limitations

Our study was based on a sample of family physicians drawn from a single geographic area, which limits the generalizability of the findings to physicians in other regions. Also, because of the recruitment method physicians may have agreed to participate because of their previous knowledge of the recruiter’s expertise in the field of abuse, resulting in a biased sample. Although the majority of physicians indicated that they would continue to use the WAST in the future we did not ask them how this would occur. Our recommendation would be that at minimum the WAST-Short be administered to women presenting for routine visits, including complete physical examinations and prenatal care as well as acute complaints.

As reported, we did not systematically inquire about the physician’s previous knowledge of the past abuse of a participant. Furthermore, we did not document if a specific intervention transpired with the women identified as abused. These issues are paramount if screening tools for woman abuse are to be viewed as useful and effective in addressing this serious problem. Future studies should include ways to assess and evaluate both interventions and patient outcomes.

The occurrence of abuse in this group of patients may have been underestimated. The information spontaneously offered by some patients at the time of their refusal to participate in our study suggests that they were in an abusive relationship. This reflects the reality of conducting research on a sensitive issue. Also, the preponderance of white English-speaking middle-class women in our study may limit the generalizability to more diverse populations.

However, these limitations do not detract from the important findings of our study, which demonstrates that the WAST-Short questionnaire identifies women experiencing abuse, and the full 8-item WAST helps family physicians explore the extent of that abuse. Finally, and perhaps of most clinical significance, both patients and family physicians were comfortable with the incorporation of WAST into the clinical encounter.

Acknowledgments

Our study was supported by a grant from Searle Canada. The conclusions are those of the authors, and no endorsement by Searle Canada is intended or should be inferred.

Being patient centered is a core value of medicine for many physicians. The principles of patient-centered medicine date back to the ancient Greek school of Cos, which was interested in the particulars of each patient.¹ More recently similar concepts have arisen in a variety of fields of human endeavor: the concept of physical diagnosis and deeper diagnosis of Balint,² the client-centered therapy of Rogers,³ the total-person approach to patient problems in nursing of Neuman and Young,⁴ the biopsychosocial model of Engel,⁵ and the disease- versus patient-centered medical practice of Byrne and Long.⁶ In the past decade the patient-centered concepts of Gerteis and colleagues⁷ have been applied to the hospital setting.

In the setting of primary care, and specifically family practice, patient-centered concepts incorporate 6 interactive components. The first component is the physician’s exploration of both the patients’ disease and 4 dimensions of the illness experience including: their feelings about being ill, their ideas about what is wrong with them, the impact of the problem on their daily functioning, and their expectations of what should be done. The second component is the physician’s understanding of the whole person. The third component is the patient and physician finding common ground regarding management. In the fourth component the physician incorporates prevention and health promotion into the visit. The fifth component is the enhancement of the patient-physician relationship. Finally, the sixth component requires that patient-centered practice be realistic. Our study addresses the first 3 of these components. Being patient centered does not mean that physicians abdicate control to the patient⁸ but rather that they find common ground in understanding the patients and more fully respond to their unique needs.⁹

What are the benefits of being patient centered? Previous research of specific communication variables indicates that patient-centered encounters result in: (1) the duration of the office visit remaining the same^10,11 (2) better patient satisfaction,¹² (3) higher physician satisfaction,¹⁰ and (4) fewer malpractice complaints.¹³ We focus on 2 other outcomes: patients’ health and efficiency of care.

Methods

Our study was designed to test the hypothesis that adult patients whose first visit in an episode of illness is patient centered will, by 2 months after the first visit: (1) more frequently demonstrate recovery from the symptom (and recovery from the concern about the symptom); (2) demonstrate better self-reported health; and (3) experience less subsequent medical care (ie, fewer visits, diagnostic tests, and referrals), compared with patients whose visit is not patient centered.

Data Collection and Participants

For our observational cohort study data were collected at 5 points: (1) the research assistant identified eligible patients in the physician’s office before the visit; (2) the office encounter was audiotaped and scored for patient-centered communication; (3) the research assistant held a postencounter interview with the patient; (4) we assessed, by chart review, the use of medical care during the 2-month follow-up; and (5) we conducted a follow up telephone interview with patients 2-months after the encounter.

Physician Selection. Physicians were recruited from the 250 family physicians practicing in London, Ontario, Canada, and the surrounding area. They were randomized within strata to ensure a representative sample in terms of year of graduation and geographic location and were selected using a modified version of the method of Borgiel and colleagues.¹⁴

Patients. We approached patients who were older than 18 years and had 1 or more recurring problems who presented to their physician’s office. Patients were excluded if they were too ill or disabled to answer questions, had no presenting problem, were in the office for counseling, were accompanied by another person, were not fluent in English, were hard of hearing, or were cognitively impaired. They were approached before they saw the physician and were blind to the study hypotheses.

Sample Size Estimation. The sample size required for correlations of 0.20 to be detected with an a set at 0.05 (2 tailed) and a b set at 0.10 was 259¹⁵ patients. Further inflation by 10% to account for the effect of clustering on multiple regression¹⁶ was thought to be reasonable (259÷0.9=288). Expecting 75% to cooperate, we aimed to approach 384 patients (288÷0.75).

Measures*

Measure of Patient-Centered Communication Score. The patient-centered communication score is based on 3 of the 6 components of the model of patient-centered medicine.^17-20 The first component (exploring the disease and the illness experience) received a high score when the physician explored the patients’ symptoms, prompts, feelings, ideas, function, and expectations. The second component (understanding the whole person) received a high score when the physician elicited and explored issues relating to life cycle, personality, or life context, including family. The third component (finding common ground) received a high score when the physician clearly described the problem and the management plan, answered questions about them, and discussed and agreed on them with the patient. Scoring sheets and procedures are described in detail elsewhere.²¹ Scores could range from 0 (not at all patient centered) to 100 (very patient centered).

Interrater reliability has been established in earlier versions of the measure and for the current version (r=0.69, 0.84, and 0.80 among 3 raters,²² 0.91 among 2 raters,²³ and 0.83 for n=19 for our study). Intrarater reliability was 0.73 (n=20).

Correlations with global scores encompassing the 3 components supported the validity of the score (0.63 in an earlier study²³ and 0.85 for our study, n=46).

Patient Perception of Patient-Centeredness. Based on the patient-centered model, a series of 14 items developed and validated in previous studies^24,25 were used to assess the patients’ postencounter perceptions of how patient centered the interaction with the physician had been.† Items were averaged into: total score, a subscore on exploring the disease and illness experience, and finding common ground. Low scores represented patient centeredness.

Patient Recovery from Discomfort and Concerns. The primary health outcome was the recovery measure based on the patients’ self-administered report on visual analogue scales (VAS) of the severity of the symptom they identified as the main presenting problem and their concern about that problem at 2 points: the postencounter interview and the follow-up 2 months later.^26,27 VAS have been tested for reliability and validity in studies of pain and nausea (correlation of 0.75 with an intensity score).²⁶ Each of the symptom recovery variables was continuous.

Patient Health Status. The Medical Outcomes Study Short Form-36 (SF-36) was used to assess self-reported secondary health outcomes. This valid and reliable measure¹⁸ is a multidimensional assessment of: physical health, mental health, perception of health, social health, pain, and role function. All were continuous variables except role function, for which the distribution of scores necessitated dichotomizing.

Medical Care. The care provided during the 2 months following the audiotaped encounter was assessed by chart review (adapted from Bass and coworkers²⁴) by 3 medical doctors (I.R.M., J.O., J.J.) blind to the identity of the family physician and the patient, and also to the patient-centered scores. Items abstracted were: the total number of visits during the 2 months (continuous variable); the number and kind of diagnostic tests ordered during the 2 months that were relevant to the problems presented at the audiotaped visit (dichotomous); and the number and kinds of referrals made during the 2 months that were relevant to the problems presented at the audiotaped visit (dichotomous).

Analysis. The hypotheses were tested using multiple regression for continuous outcomes and multiple logistic regression for dichotomous outcomes,²⁹ both adjusted for the effect of the clustering of patients by physician using “procedure mixed” in SAS for continuous outcomes and using both “procedure logistic” and “procedure IML” in SAS for dichotomous outcomes.³⁰ The unit of analysis was the patient.

The following confounding variables were included in preliminary multivariable analyses on the basis of their univariable relationships with outcomes at the level of P <.10: age, sex, number of family members at home, desire to share feelings, who initiated the visit, tense personality, coping skills, concomitant health problems, social support, marital status (married vs other), concomitant life problems, number of visits to the physician in the previous 12 months, and main problem (1 of 5 groups: digestive, musculoskeletal, respiratory, skin, and other).

Because of substantial sample attrition with so many covariates, and because only 2 variables were consistently associated with the outcome measures, each subsequent multivariable analysis was conducted with each of the primary independent variables and the 2 covariates (patients’ main presenting problem and marital status).

Results

Descriptive Results

Of the 102 randomly selected family physicians, 83 were eligible because they were still practicing in the area and had adequate office space to accommodate the research assistant. Of these, 39 (47%) agreed to participate and completed the data collection. The participants were similar to the refusers [Table 1] in year of graduation, practice location (rural or urban; high or low socioeconomic status) and sex; however, participants were significantly more likely to be certificants of the College of Family Physicians of Canada than refusers (59% and 27%, respectively; P=.007).

Of 464 eligible patients, 334 (72%) agreed to participate. Nineteen (~6%) were lost to the study. The final 315 participants represented an overall participation rate of 68%; their age was representative of the eligible patients, but there was a higher proportion of men than in the total group of eligible patients.

[Table 2] shows that the slim majority of final participants were women, and most were middle aged and married. Typical of the city, approximately 4 in 10 had more than a high school education. The most common presenting problems were respiratory in nature.

[Table 3] shows the descriptive results for key variables.

Hypothesis Testing Results

The patient-centered communication scores (based on the audiotape analysis) were not significantly related to any of the health outcomes after adjusting for the clustering of patients within practices and after controlling for the 2 confounding variables. Similarly, patient-centered communication scores were not related to any of the 3 medical care outcomes.

Patient-centered communication scores (based on the audiotape analysis) were significantly correlated in the expected direction, with patient perceptions that the patient and physician found common ground (r =-0.16; P=.01). High scores (indicating very patient-centered communication) were correlated with low patient perception scores (indicating patient-centeredness). The 2 other patient perception scores (total patient perception score and the subscore on patient perception that the illness experience was explored) were not significantly associated with patient-centered communication scores.

The total score of patients’ perceptions that the visit was patient centered was associated with positive health outcomes after adjusting for the clustering of patients within practices and after controlling for the 2 confounding variables [Table 4]. Patients’ postencounter levels of discomfort were lower when they perceived the visit to have been patient centered than not.

A similar result occurred for 2 other patient health outcomes: the patients’ postencounter level of concern (P=.02), and the mental health dimension of the SF-36 measure assessed 2 months after the study visit (P=.05). The subscore of patient perceptions that the patient and physician found common ground was associated with one of the health outcomes, the patients’ postencounter level of concern (P=.04). There were no significant associations of the subscore on patients’ perceptions that the illness experience had been explored with any of the patient health outcome measures.

Patients who perceived that their visit had been patient centered received fewer diagnostic tests [Table 5] and referrals [Table 6] in the subsequent 2 months. The proportion receiving diagnostic tests rose from 14.6% in the group who perceived that the visit had been patient centered (total score), to 24.3% in the group who perceived the visit was not. The proportion who were referred doubled from approximately 8% to 16%. These relationships were found even more strongly for the subscore on patient perceptions that the patient and the physician found common ground, but were not found for the subscore on patient perceptions that their illness experience had been explored. The proportion receiving diagnostic tests quadrupled from 4.1% in the group who perceived that the patient and the physician found common ground, to 25.4% in the group who perceived that common ground had not been attained. The proportion who were referred doubled from 6.1% to 14.9%. The number of visits by the patient to the family physician during the subsequent 2 months was not significantly related to the patient perceptions of patient centeredness, although there was a trend (P=.11) with the average number of visits in 2 months in the 4 quartiles of patient perceptions as follows: 1.0, 0.8, 1.2, and 1.3.

Discussion

Pathway to Improved Patient Outcomes

Patient-centered practice was associated with improved patients’ health status and increased efficiency of care (reduced diagnostic tests and referrals). However, only 1 of the 2 measures of patient-centered practice showed this result, the measure of patients’ perceptions of the patient centeredness of the visit. The measure that was based on ratings of audiotaped physician-patient interactions, while related to the patients’ perception, was not directly related to health status or efficiency.

The relationship of patients’ perceptions of patient centeredness with their health and efficiency of care was both statistically and clinically significant. Specifically, recovery was improved by 6 points on a 100-point scale; diagnostic tests and referrals were half as frequent if the visit was perceived to be patient centered.

The associations we found may imply a potentially important pathway (which could be tested in future trials), such as the one shown in the [Figure]. The pathway suggests a process through which patient-physician communication influences patients’ health, by first influencing the patients’ perceptions of being a full participant in the discussions during the encounter. Such a pathway has been noted by Sobel, whose review suggested a pathway to explain the lack of a direct relationship between patient education programs and patient health where there was a relationship between patient perceptions about their health and health outcomes. Sobel called this pathway “a biology of self-confidence.”³¹ He and others³² stress the critical role of patient perceptions in the healing process, which highlight that a person’s subjective experience influences biology.

How do we understand the results that show the ratings of the audiotape were not directly related to the outcomes, but the patient-centered perception measure was related to outcomes? One interpretation is that observable skills are not as important as patient perceptions. Although there is some evidence that skills training can improve both physicians’ behavior and patients’ health,³³ our findings and those of Bensing and Sluijs³⁴ indicate that differences in interviewing skills may not be associated with patient responses. Physicians may learn to go through the motions of patient-centered interviewing without understanding what it means to be a truly attentive and responsive listener. The implications of the current findings for educators are that education about communication should go well beyond skills training to a deeper understanding of what it means to be a responsive partner for the patient, during both that phase of the visit in which the problem is discussed and when the discussion of treatment options occurs. Two examples of such education approaches are: small group discussions between patients and physicians to illustrate the patients’ experiences and needs, and reviews of videotaped interviews with standardized patients participating in the review. Placing prime importance on the patients’ perceptions recognizes the influence of these perceptions on the patients’ subsequent health and epitomizes being truly patient centered.

Views that the visit was patient centered included perceptions about the discussion of the problem (exploring the illness experience) as well as discussion and agreement about treatment options (finding common ground). There is a substantial body of research supporting the importance of these discussions. The Headache Study found that patients’ perceptions that a full discussion of the problem had taken place predicted resolution of headaches after 1 year.³⁴ In keeping with our results, which found that finding common ground was more strongly associated with outcomes than exploring the illness experience, Riccardi and Kurtz³⁶ stressed that the physicians’ explanation to the patients was the crucial phase of the visit. Also, a key outcome study has found that patient agreement with the physician about the nature of the treatment and the need for follow-up were strongly associated with their recovery.³⁷

Efficiency of Medical Care

We found that patient-centered practice (assessed by patients’ perceptions) was associated with the efficiency of care by reducing subsequent diagnostic tests and referrals by half, after controlling for key confounding variables. These results were both statistically significant and clinically significant. Also, the number of subsequent visits to the family physician was lower (although not significantly) when the patient perceived the study visit to be patient centered. Efficiency in health service delivery was also found in a randomized trial of compassionate care in the emergency department setting with homeless patients.³⁸ In their study of continuity of care in Norwegian general practice, Hjortdahl and Borchgrevink³⁹ found that diagnostic tests were 10 times more likely to be ordered for patients about whom physicians reported the least previous knowledge compared with patients in whom they had reported fullest knowledge. Also, patients had only half the chance of being referred if their physicians knew them and their history.³⁸

One possible interpretation of the results of our study is that patient-centered physicians order fewer tests and refer less often. However, countering this interpretation is the fact that individual physicians in our study showed a range of patient-centered scores, as well as a range in test ordering and referral. In addition, the statistical analysis took account of the clustering of patients within a physician’s practice.

An alternative interpretation is that patients’ perceptions may influence resource use in several ways. For example, increased participation during the visit may reduce patients’ anxiety and their perceived need for investigations and referrals. Alternatively, patients’ perception that the physician has not understood their problem may provoke insecurities resulting in a request for further medical interventions. Also, if patients openly express their discontent with the encounter there may be an increase in physicians’ anxiety and a lowering of their threshold for diagnostic uncertainty, resulting in further investigations and referrals.

Certainly the finding that the failure to be patient centered (as perceived by the patient) was related to higher rates of referral and diagnostic tests should be a concern for medical education and health care policy. Perhaps of most importance is that the patients’ experience of being a participating member in the discussion of the problem and the treatment process may translate into the patients’ reduced need for further investigation or referral—simultaneously reducing the physicians’ need as well.

These findings counter a common misconception: that being patient centered means responding to every whim of the patient, thereby increasing expenses to the health care system.

Limitations

Approximately 30% of the patients refused to participate, and although the participants represented the age distribution of eligible patients, men were overrepresented in the study. Nonetheless, sex was not identified as a confounding variable for the associations studied.

Although no measure of severity was possible, the variables representing concurrent health problems and concurrent life problems were considered in the analysis strategy. They were not related to the outcome variables and were therefore not entered into the multivariable analyses.

One interpretation of the lack of association between patient-centered scores on the audiotaped interviews and subsequent health outcomes may be that the audiotape measure has failed to capture the important essence of the dynamic interaction between physicians and patients. The measure had a number of strengths, however; it had been tested for reliability and validity (compared with a global rating), and it was based on a theoretical framework. Also, it was correlated with one component of the patient perception measure of a patient-centered interview, a finding which indicates that future research should be directed toward determining physicians’ skills and behaviors that correlate with the patients’ positive perceptions, especially the perception that common ground has been reached. Such behaviors could then be emphasized in clinical teaching.

It should be noted that the utilization data were available only from the participating practices and not from care received elsewhere. Although this is a limitation, it would be expected that this lack of data would minimize the current relationship between patient-centered practice and utilization, because patients with less favorable perceptions would be potentially more likely to seek care elsewhere. Also, drug costs and hospital costs were not included and require further study. Future research could also build on these results about resource utilization and assess the specific kinds and actual costs of the diagnostic tests and referrals.

It could be argued that the results of our study demonstrated simply that people with positive perceptions and less severe problems achieved better health and more efficient services. We counter this interpretation with 2 thoughts. First, the preliminary step in our analysis included confounding variables to control for a variety of relevant variables (ie, personality and concomitant health problems). Only 2 confounding variables were influential enough to remain in the final analysis: marital status and diagnostic code of the main presenting problem. Second, patient perceptions were not independent of the physician-patient visit. They were influenced significantly by the communication score based on the audiotaped encounter, implying that the measure of perceptions was tapping not merely the patients’ general outlook on life, but also an important interactive component of visits between patients and physicians.

Conclusions

Patient-centered practice was associated with improved health status (less discomfort, less concern, and better mental health) and increased efficiency of care (fewer diagnostic tests and referrals).

Patients’ perceptions of the patient centeredness of the visit, but not the measure of audiotaped interactions, were directly associated with the positive outcomes. The subscore on patients’ perception of finding common ground was more strongly associated with the positive outcomes than the subscore on patients’ perception about exploring the illness experience.

Medical education should go beyond skills training to encourage physicians’ responsiveness to the patients’ unique experience. Therefore, involving real patients and standardized patients in teaching programs is recommended.

Health service organizations must recognize that efficiencies accrue from patient-centered practice and encourage such practice through structures that enhance continuity of the patient-physician relationship and through meaningful education programs.

Acknowledgments

Our project was supported by a grant from the Health Care Systems Research Program of the Ministry of Health of Ontario. The setting of the project was the Thames Valley Family Practice Research Unit (TVFPRU), a health system-linked research unit funded by the Ministry of Health of Ontario. The opinions contained are those of the authors, and no official endorsement by the Ministry is intended or should be inferred. The TVFPRU is part of the Centre for Studies in Family Medicine, Department of Family Medicine, The University of Western Ontario, London, Canada.

Being patient centered is a core value of medicine for many physicians. The principles of patient-centered medicine date back to the ancient Greek school of Cos, which was interested in the particulars of each patient.¹ More recently similar concepts have arisen in a variety of fields of human endeavor: the concept of physical diagnosis and deeper diagnosis of Balint,² the client-centered therapy of Rogers,³ the total-person approach to patient problems in nursing of Neuman and Young,⁴ the biopsychosocial model of Engel,⁵ and the disease- versus patient-centered medical practice of Byrne and Long.⁶ In the past decade the patient-centered concepts of Gerteis and colleagues⁷ have been applied to the hospital setting.

In the setting of primary care, and specifically family practice, patient-centered concepts incorporate 6 interactive components. The first component is the physician’s exploration of both the patients’ disease and 4 dimensions of the illness experience including: their feelings about being ill, their ideas about what is wrong with them, the impact of the problem on their daily functioning, and their expectations of what should be done. The second component is the physician’s understanding of the whole person. The third component is the patient and physician finding common ground regarding management. In the fourth component the physician incorporates prevention and health promotion into the visit. The fifth component is the enhancement of the patient-physician relationship. Finally, the sixth component requires that patient-centered practice be realistic. Our study addresses the first 3 of these components. Being patient centered does not mean that physicians abdicate control to the patient⁸ but rather that they find common ground in understanding the patients and more fully respond to their unique needs.⁹

What are the benefits of being patient centered? Previous research of specific communication variables indicates that patient-centered encounters result in: (1) the duration of the office visit remaining the same^10,11 (2) better patient satisfaction,¹² (3) higher physician satisfaction,¹⁰ and (4) fewer malpractice complaints.¹³ We focus on 2 other outcomes: patients’ health and efficiency of care.

Methods

Our study was designed to test the hypothesis that adult patients whose first visit in an episode of illness is patient centered will, by 2 months after the first visit: (1) more frequently demonstrate recovery from the symptom (and recovery from the concern about the symptom); (2) demonstrate better self-reported health; and (3) experience less subsequent medical care (ie, fewer visits, diagnostic tests, and referrals), compared with patients whose visit is not patient centered.

Data Collection and Participants

For our observational cohort study data were collected at 5 points: (1) the research assistant identified eligible patients in the physician’s office before the visit; (2) the office encounter was audiotaped and scored for patient-centered communication; (3) the research assistant held a postencounter interview with the patient; (4) we assessed, by chart review, the use of medical care during the 2-month follow-up; and (5) we conducted a follow up telephone interview with patients 2-months after the encounter.

Physician Selection. Physicians were recruited from the 250 family physicians practicing in London, Ontario, Canada, and the surrounding area. They were randomized within strata to ensure a representative sample in terms of year of graduation and geographic location and were selected using a modified version of the method of Borgiel and colleagues.¹⁴

Patients. We approached patients who were older than 18 years and had 1 or more recurring problems who presented to their physician’s office. Patients were excluded if they were too ill or disabled to answer questions, had no presenting problem, were in the office for counseling, were accompanied by another person, were not fluent in English, were hard of hearing, or were cognitively impaired. They were approached before they saw the physician and were blind to the study hypotheses.

Sample Size Estimation. The sample size required for correlations of 0.20 to be detected with an a set at 0.05 (2 tailed) and a b set at 0.10 was 259¹⁵ patients. Further inflation by 10% to account for the effect of clustering on multiple regression¹⁶ was thought to be reasonable (259÷0.9=288). Expecting 75% to cooperate, we aimed to approach 384 patients (288÷0.75).

Measures*

Measure of Patient-Centered Communication Score. The patient-centered communication score is based on 3 of the 6 components of the model of patient-centered medicine.^17-20 The first component (exploring the disease and the illness experience) received a high score when the physician explored the patients’ symptoms, prompts, feelings, ideas, function, and expectations. The second component (understanding the whole person) received a high score when the physician elicited and explored issues relating to life cycle, personality, or life context, including family. The third component (finding common ground) received a high score when the physician clearly described the problem and the management plan, answered questions about them, and discussed and agreed on them with the patient. Scoring sheets and procedures are described in detail elsewhere.²¹ Scores could range from 0 (not at all patient centered) to 100 (very patient centered).

Interrater reliability has been established in earlier versions of the measure and for the current version (r=0.69, 0.84, and 0.80 among 3 raters,²² 0.91 among 2 raters,²³ and 0.83 for n=19 for our study). Intrarater reliability was 0.73 (n=20).

Correlations with global scores encompassing the 3 components supported the validity of the score (0.63 in an earlier study²³ and 0.85 for our study, n=46).

Patient Perception of Patient-Centeredness. Based on the patient-centered model, a series of 14 items developed and validated in previous studies^24,25 were used to assess the patients’ postencounter perceptions of how patient centered the interaction with the physician had been.† Items were averaged into: total score, a subscore on exploring the disease and illness experience, and finding common ground. Low scores represented patient centeredness.

Patient Recovery from Discomfort and Concerns. The primary health outcome was the recovery measure based on the patients’ self-administered report on visual analogue scales (VAS) of the severity of the symptom they identified as the main presenting problem and their concern about that problem at 2 points: the postencounter interview and the follow-up 2 months later.^26,27 VAS have been tested for reliability and validity in studies of pain and nausea (correlation of 0.75 with an intensity score).²⁶ Each of the symptom recovery variables was continuous.

Patient Health Status. The Medical Outcomes Study Short Form-36 (SF-36) was used to assess self-reported secondary health outcomes. This valid and reliable measure¹⁸ is a multidimensional assessment of: physical health, mental health, perception of health, social health, pain, and role function. All were continuous variables except role function, for which the distribution of scores necessitated dichotomizing.

Medical Care. The care provided during the 2 months following the audiotaped encounter was assessed by chart review (adapted from Bass and coworkers²⁴) by 3 medical doctors (I.R.M., J.O., J.J.) blind to the identity of the family physician and the patient, and also to the patient-centered scores. Items abstracted were: the total number of visits during the 2 months (continuous variable); the number and kind of diagnostic tests ordered during the 2 months that were relevant to the problems presented at the audiotaped visit (dichotomous); and the number and kinds of referrals made during the 2 months that were relevant to the problems presented at the audiotaped visit (dichotomous).

Analysis. The hypotheses were tested using multiple regression for continuous outcomes and multiple logistic regression for dichotomous outcomes,²⁹ both adjusted for the effect of the clustering of patients by physician using “procedure mixed” in SAS for continuous outcomes and using both “procedure logistic” and “procedure IML” in SAS for dichotomous outcomes.³⁰ The unit of analysis was the patient.

The following confounding variables were included in preliminary multivariable analyses on the basis of their univariable relationships with outcomes at the level of P <.10: age, sex, number of family members at home, desire to share feelings, who initiated the visit, tense personality, coping skills, concomitant health problems, social support, marital status (married vs other), concomitant life problems, number of visits to the physician in the previous 12 months, and main problem (1 of 5 groups: digestive, musculoskeletal, respiratory, skin, and other).

Because of substantial sample attrition with so many covariates, and because only 2 variables were consistently associated with the outcome measures, each subsequent multivariable analysis was conducted with each of the primary independent variables and the 2 covariates (patients’ main presenting problem and marital status).

Results

Descriptive Results

Of the 102 randomly selected family physicians, 83 were eligible because they were still practicing in the area and had adequate office space to accommodate the research assistant. Of these, 39 (47%) agreed to participate and completed the data collection. The participants were similar to the refusers [Table 1] in year of graduation, practice location (rural or urban; high or low socioeconomic status) and sex; however, participants were significantly more likely to be certificants of the College of Family Physicians of Canada than refusers (59% and 27%, respectively; P=.007).

Of 464 eligible patients, 334 (72%) agreed to participate. Nineteen (~6%) were lost to the study. The final 315 participants represented an overall participation rate of 68%; their age was representative of the eligible patients, but there was a higher proportion of men than in the total group of eligible patients.

[Table 2] shows that the slim majority of final participants were women, and most were middle aged and married. Typical of the city, approximately 4 in 10 had more than a high school education. The most common presenting problems were respiratory in nature.

[Table 3] shows the descriptive results for key variables.

Hypothesis Testing Results

The patient-centered communication scores (based on the audiotape analysis) were not significantly related to any of the health outcomes after adjusting for the clustering of patients within practices and after controlling for the 2 confounding variables. Similarly, patient-centered communication scores were not related to any of the 3 medical care outcomes.

Patient-centered communication scores (based on the audiotape analysis) were significantly correlated in the expected direction, with patient perceptions that the patient and physician found common ground (r =-0.16; P=.01). High scores (indicating very patient-centered communication) were correlated with low patient perception scores (indicating patient-centeredness). The 2 other patient perception scores (total patient perception score and the subscore on patient perception that the illness experience was explored) were not significantly associated with patient-centered communication scores.

The total score of patients’ perceptions that the visit was patient centered was associated with positive health outcomes after adjusting for the clustering of patients within practices and after controlling for the 2 confounding variables [Table 4]. Patients’ postencounter levels of discomfort were lower when they perceived the visit to have been patient centered than not.

A similar result occurred for 2 other patient health outcomes: the patients’ postencounter level of concern (P=.02), and the mental health dimension of the SF-36 measure assessed 2 months after the study visit (P=.05). The subscore of patient perceptions that the patient and physician found common ground was associated with one of the health outcomes, the patients’ postencounter level of concern (P=.04). There were no significant associations of the subscore on patients’ perceptions that the illness experience had been explored with any of the patient health outcome measures.

Patients who perceived that their visit had been patient centered received fewer diagnostic tests [Table 5] and referrals [Table 6] in the subsequent 2 months. The proportion receiving diagnostic tests rose from 14.6% in the group who perceived that the visit had been patient centered (total score), to 24.3% in the group who perceived the visit was not. The proportion who were referred doubled from approximately 8% to 16%. These relationships were found even more strongly for the subscore on patient perceptions that the patient and the physician found common ground, but were not found for the subscore on patient perceptions that their illness experience had been explored. The proportion receiving diagnostic tests quadrupled from 4.1% in the group who perceived that the patient and the physician found common ground, to 25.4% in the group who perceived that common ground had not been attained. The proportion who were referred doubled from 6.1% to 14.9%. The number of visits by the patient to the family physician during the subsequent 2 months was not significantly related to the patient perceptions of patient centeredness, although there was a trend (P=.11) with the average number of visits in 2 months in the 4 quartiles of patient perceptions as follows: 1.0, 0.8, 1.2, and 1.3.

Discussion

Pathway to Improved Patient Outcomes

Patient-centered practice was associated with improved patients’ health status and increased efficiency of care (reduced diagnostic tests and referrals). However, only 1 of the 2 measures of patient-centered practice showed this result, the measure of patients’ perceptions of the patient centeredness of the visit. The measure that was based on ratings of audiotaped physician-patient interactions, while related to the patients’ perception, was not directly related to health status or efficiency.

The relationship of patients’ perceptions of patient centeredness with their health and efficiency of care was both statistically and clinically significant. Specifically, recovery was improved by 6 points on a 100-point scale; diagnostic tests and referrals were half as frequent if the visit was perceived to be patient centered.

The associations we found may imply a potentially important pathway (which could be tested in future trials), such as the one shown in the [Figure]. The pathway suggests a process through which patient-physician communication influences patients’ health, by first influencing the patients’ perceptions of being a full participant in the discussions during the encounter. Such a pathway has been noted by Sobel, whose review suggested a pathway to explain the lack of a direct relationship between patient education programs and patient health where there was a relationship between patient perceptions about their health and health outcomes. Sobel called this pathway “a biology of self-confidence.”³¹ He and others³² stress the critical role of patient perceptions in the healing process, which highlight that a person’s subjective experience influences biology.

How do we understand the results that show the ratings of the audiotape were not directly related to the outcomes, but the patient-centered perception measure was related to outcomes? One interpretation is that observable skills are not as important as patient perceptions. Although there is some evidence that skills training can improve both physicians’ behavior and patients’ health,³³ our findings and those of Bensing and Sluijs³⁴ indicate that differences in interviewing skills may not be associated with patient responses. Physicians may learn to go through the motions of patient-centered interviewing without understanding what it means to be a truly attentive and responsive listener. The implications of the current findings for educators are that education about communication should go well beyond skills training to a deeper understanding of what it means to be a responsive partner for the patient, during both that phase of the visit in which the problem is discussed and when the discussion of treatment options occurs. Two examples of such education approaches are: small group discussions between patients and physicians to illustrate the patients’ experiences and needs, and reviews of videotaped interviews with standardized patients participating in the review. Placing prime importance on the patients’ perceptions recognizes the influence of these perceptions on the patients’ subsequent health and epitomizes being truly patient centered.

Views that the visit was patient centered included perceptions about the discussion of the problem (exploring the illness experience) as well as discussion and agreement about treatment options (finding common ground). There is a substantial body of research supporting the importance of these discussions. The Headache Study found that patients’ perceptions that a full discussion of the problem had taken place predicted resolution of headaches after 1 year.³⁴ In keeping with our results, which found that finding common ground was more strongly associated with outcomes than exploring the illness experience, Riccardi and Kurtz³⁶ stressed that the physicians’ explanation to the patients was the crucial phase of the visit. Also, a key outcome study has found that patient agreement with the physician about the nature of the treatment and the need for follow-up were strongly associated with their recovery.³⁷

Efficiency of Medical Care

We found that patient-centered practice (assessed by patients’ perceptions) was associated with the efficiency of care by reducing subsequent diagnostic tests and referrals by half, after controlling for key confounding variables. These results were both statistically significant and clinically significant. Also, the number of subsequent visits to the family physician was lower (although not significantly) when the patient perceived the study visit to be patient centered. Efficiency in health service delivery was also found in a randomized trial of compassionate care in the emergency department setting with homeless patients.³⁸ In their study of continuity of care in Norwegian general practice, Hjortdahl and Borchgrevink³⁹ found that diagnostic tests were 10 times more likely to be ordered for patients about whom physicians reported the least previous knowledge compared with patients in whom they had reported fullest knowledge. Also, patients had only half the chance of being referred if their physicians knew them and their history.³⁸

One possible interpretation of the results of our study is that patient-centered physicians order fewer tests and refer less often. However, countering this interpretation is the fact that individual physicians in our study showed a range of patient-centered scores, as well as a range in test ordering and referral. In addition, the statistical analysis took account of the clustering of patients within a physician’s practice.

An alternative interpretation is that patients’ perceptions may influence resource use in several ways. For example, increased participation during the visit may reduce patients’ anxiety and their perceived need for investigations and referrals. Alternatively, patients’ perception that the physician has not understood their problem may provoke insecurities resulting in a request for further medical interventions. Also, if patients openly express their discontent with the encounter there may be an increase in physicians’ anxiety and a lowering of their threshold for diagnostic uncertainty, resulting in further investigations and referrals.

Certainly the finding that the failure to be patient centered (as perceived by the patient) was related to higher rates of referral and diagnostic tests should be a concern for medical education and health care policy. Perhaps of most importance is that the patients’ experience of being a participating member in the discussion of the problem and the treatment process may translate into the patients’ reduced need for further investigation or referral—simultaneously reducing the physicians’ need as well.

These findings counter a common misconception: that being patient centered means responding to every whim of the patient, thereby increasing expenses to the health care system.

Limitations

Approximately 30% of the patients refused to participate, and although the participants represented the age distribution of eligible patients, men were overrepresented in the study. Nonetheless, sex was not identified as a confounding variable for the associations studied.

Although no measure of severity was possible, the variables representing concurrent health problems and concurrent life problems were considered in the analysis strategy. They were not related to the outcome variables and were therefore not entered into the multivariable analyses.

One interpretation of the lack of association between patient-centered scores on the audiotaped interviews and subsequent health outcomes may be that the audiotape measure has failed to capture the important essence of the dynamic interaction between physicians and patients. The measure had a number of strengths, however; it had been tested for reliability and validity (compared with a global rating), and it was based on a theoretical framework. Also, it was correlated with one component of the patient perception measure of a patient-centered interview, a finding which indicates that future research should be directed toward determining physicians’ skills and behaviors that correlate with the patients’ positive perceptions, especially the perception that common ground has been reached. Such behaviors could then be emphasized in clinical teaching.

It should be noted that the utilization data were available only from the participating practices and not from care received elsewhere. Although this is a limitation, it would be expected that this lack of data would minimize the current relationship between patient-centered practice and utilization, because patients with less favorable perceptions would be potentially more likely to seek care elsewhere. Also, drug costs and hospital costs were not included and require further study. Future research could also build on these results about resource utilization and assess the specific kinds and actual costs of the diagnostic tests and referrals.

It could be argued that the results of our study demonstrated simply that people with positive perceptions and less severe problems achieved better health and more efficient services. We counter this interpretation with 2 thoughts. First, the preliminary step in our analysis included confounding variables to control for a variety of relevant variables (ie, personality and concomitant health problems). Only 2 confounding variables were influential enough to remain in the final analysis: marital status and diagnostic code of the main presenting problem. Second, patient perceptions were not independent of the physician-patient visit. They were influenced significantly by the communication score based on the audiotaped encounter, implying that the measure of perceptions was tapping not merely the patients’ general outlook on life, but also an important interactive component of visits between patients and physicians.

Conclusions

Patient-centered practice was associated with improved health status (less discomfort, less concern, and better mental health) and increased efficiency of care (fewer diagnostic tests and referrals).

Patients’ perceptions of the patient centeredness of the visit, but not the measure of audiotaped interactions, were directly associated with the positive outcomes. The subscore on patients’ perception of finding common ground was more strongly associated with the positive outcomes than the subscore on patients’ perception about exploring the illness experience.

Medical education should go beyond skills training to encourage physicians’ responsiveness to the patients’ unique experience. Therefore, involving real patients and standardized patients in teaching programs is recommended.

Health service organizations must recognize that efficiencies accrue from patient-centered practice and encourage such practice through structures that enhance continuity of the patient-physician relationship and through meaningful education programs.

Acknowledgments

Our project was supported by a grant from the Health Care Systems Research Program of the Ministry of Health of Ontario. The setting of the project was the Thames Valley Family Practice Research Unit (TVFPRU), a health system-linked research unit funded by the Ministry of Health of Ontario. The opinions contained are those of the authors, and no official endorsement by the Ministry is intended or should be inferred. The TVFPRU is part of the Centre for Studies in Family Medicine, Department of Family Medicine, The University of Western Ontario, London, Canada.

Being patient centered is a core value of medicine for many physicians. The principles of patient-centered medicine date back to the ancient Greek school of Cos, which was interested in the particulars of each patient.¹ More recently similar concepts have arisen in a variety of fields of human endeavor: the concept of physical diagnosis and deeper diagnosis of Balint,² the client-centered therapy of Rogers,³ the total-person approach to patient problems in nursing of Neuman and Young,⁴ the biopsychosocial model of Engel,⁵ and the disease- versus patient-centered medical practice of Byrne and Long.⁶ In the past decade the patient-centered concepts of Gerteis and colleagues⁷ have been applied to the hospital setting.

In the setting of primary care, and specifically family practice, patient-centered concepts incorporate 6 interactive components. The first component is the physician’s exploration of both the patients’ disease and 4 dimensions of the illness experience including: their feelings about being ill, their ideas about what is wrong with them, the impact of the problem on their daily functioning, and their expectations of what should be done. The second component is the physician’s understanding of the whole person. The third component is the patient and physician finding common ground regarding management. In the fourth component the physician incorporates prevention and health promotion into the visit. The fifth component is the enhancement of the patient-physician relationship. Finally, the sixth component requires that patient-centered practice be realistic. Our study addresses the first 3 of these components. Being patient centered does not mean that physicians abdicate control to the patient⁸ but rather that they find common ground in understanding the patients and more fully respond to their unique needs.⁹

What are the benefits of being patient centered? Previous research of specific communication variables indicates that patient-centered encounters result in: (1) the duration of the office visit remaining the same^10,11 (2) better patient satisfaction,¹² (3) higher physician satisfaction,¹⁰ and (4) fewer malpractice complaints.¹³ We focus on 2 other outcomes: patients’ health and efficiency of care.

Methods

Our study was designed to test the hypothesis that adult patients whose first visit in an episode of illness is patient centered will, by 2 months after the first visit: (1) more frequently demonstrate recovery from the symptom (and recovery from the concern about the symptom); (2) demonstrate better self-reported health; and (3) experience less subsequent medical care (ie, fewer visits, diagnostic tests, and referrals), compared with patients whose visit is not patient centered.

Data Collection and Participants

For our observational cohort study data were collected at 5 points: (1) the research assistant identified eligible patients in the physician’s office before the visit; (2) the office encounter was audiotaped and scored for patient-centered communication; (3) the research assistant held a postencounter interview with the patient; (4) we assessed, by chart review, the use of medical care during the 2-month follow-up; and (5) we conducted a follow up telephone interview with patients 2-months after the encounter.

Physician Selection. Physicians were recruited from the 250 family physicians practicing in London, Ontario, Canada, and the surrounding area. They were randomized within strata to ensure a representative sample in terms of year of graduation and geographic location and were selected using a modified version of the method of Borgiel and colleagues.¹⁴

Patients. We approached patients who were older than 18 years and had 1 or more recurring problems who presented to their physician’s office. Patients were excluded if they were too ill or disabled to answer questions, had no presenting problem, were in the office for counseling, were accompanied by another person, were not fluent in English, were hard of hearing, or were cognitively impaired. They were approached before they saw the physician and were blind to the study hypotheses.

Sample Size Estimation. The sample size required for correlations of 0.20 to be detected with an a set at 0.05 (2 tailed) and a b set at 0.10 was 259¹⁵ patients. Further inflation by 10% to account for the effect of clustering on multiple regression¹⁶ was thought to be reasonable (259÷0.9=288). Expecting 75% to cooperate, we aimed to approach 384 patients (288÷0.75).

Measures*

Measure of Patient-Centered Communication Score. The patient-centered communication score is based on 3 of the 6 components of the model of patient-centered medicine.^17-20 The first component (exploring the disease and the illness experience) received a high score when the physician explored the patients’ symptoms, prompts, feelings, ideas, function, and expectations. The second component (understanding the whole person) received a high score when the physician elicited and explored issues relating to life cycle, personality, or life context, including family. The third component (finding common ground) received a high score when the physician clearly described the problem and the management plan, answered questions about them, and discussed and agreed on them with the patient. Scoring sheets and procedures are described in detail elsewhere.²¹ Scores could range from 0 (not at all patient centered) to 100 (very patient centered).

Interrater reliability has been established in earlier versions of the measure and for the current version (r=0.69, 0.84, and 0.80 among 3 raters,²² 0.91 among 2 raters,²³ and 0.83 for n=19 for our study). Intrarater reliability was 0.73 (n=20).

Correlations with global scores encompassing the 3 components supported the validity of the score (0.63 in an earlier study²³ and 0.85 for our study, n=46).

Patient Perception of Patient-Centeredness. Based on the patient-centered model, a series of 14 items developed and validated in previous studies^24,25 were used to assess the patients’ postencounter perceptions of how patient centered the interaction with the physician had been.† Items were averaged into: total score, a subscore on exploring the disease and illness experience, and finding common ground. Low scores represented patient centeredness.

Patient Recovery from Discomfort and Concerns. The primary health outcome was the recovery measure based on the patients’ self-administered report on visual analogue scales (VAS) of the severity of the symptom they identified as the main presenting problem and their concern about that problem at 2 points: the postencounter interview and the follow-up 2 months later.^26,27 VAS have been tested for reliability and validity in studies of pain and nausea (correlation of 0.75 with an intensity score).²⁶ Each of the symptom recovery variables was continuous.

Patient Health Status. The Medical Outcomes Study Short Form-36 (SF-36) was used to assess self-reported secondary health outcomes. This valid and reliable measure¹⁸ is a multidimensional assessment of: physical health, mental health, perception of health, social health, pain, and role function. All were continuous variables except role function, for which the distribution of scores necessitated dichotomizing.

Medical Care. The care provided during the 2 months following the audiotaped encounter was assessed by chart review (adapted from Bass and coworkers²⁴) by 3 medical doctors (I.R.M., J.O., J.J.) blind to the identity of the family physician and the patient, and also to the patient-centered scores. Items abstracted were: the total number of visits during the 2 months (continuous variable); the number and kind of diagnostic tests ordered during the 2 months that were relevant to the problems presented at the audiotaped visit (dichotomous); and the number and kinds of referrals made during the 2 months that were relevant to the problems presented at the audiotaped visit (dichotomous).

Analysis. The hypotheses were tested using multiple regression for continuous outcomes and multiple logistic regression for dichotomous outcomes,²⁹ both adjusted for the effect of the clustering of patients by physician using “procedure mixed” in SAS for continuous outcomes and using both “procedure logistic” and “procedure IML” in SAS for dichotomous outcomes.³⁰ The unit of analysis was the patient.

The following confounding variables were included in preliminary multivariable analyses on the basis of their univariable relationships with outcomes at the level of P <.10: age, sex, number of family members at home, desire to share feelings, who initiated the visit, tense personality, coping skills, concomitant health problems, social support, marital status (married vs other), concomitant life problems, number of visits to the physician in the previous 12 months, and main problem (1 of 5 groups: digestive, musculoskeletal, respiratory, skin, and other).

Because of substantial sample attrition with so many covariates, and because only 2 variables were consistently associated with the outcome measures, each subsequent multivariable analysis was conducted with each of the primary independent variables and the 2 covariates (patients’ main presenting problem and marital status).

Results

Descriptive Results

Of the 102 randomly selected family physicians, 83 were eligible because they were still practicing in the area and had adequate office space to accommodate the research assistant. Of these, 39 (47%) agreed to participate and completed the data collection. The participants were similar to the refusers [Table 1] in year of graduation, practice location (rural or urban; high or low socioeconomic status) and sex; however, participants were significantly more likely to be certificants of the College of Family Physicians of Canada than refusers (59% and 27%, respectively; P=.007).

Of 464 eligible patients, 334 (72%) agreed to participate. Nineteen (~6%) were lost to the study. The final 315 participants represented an overall participation rate of 68%; their age was representative of the eligible patients, but there was a higher proportion of men than in the total group of eligible patients.

[Table 2] shows that the slim majority of final participants were women, and most were middle aged and married. Typical of the city, approximately 4 in 10 had more than a high school education. The most common presenting problems were respiratory in nature.

[Table 3] shows the descriptive results for key variables.

Hypothesis Testing Results

The patient-centered communication scores (based on the audiotape analysis) were not significantly related to any of the health outcomes after adjusting for the clustering of patients within practices and after controlling for the 2 confounding variables. Similarly, patient-centered communication scores were not related to any of the 3 medical care outcomes.

Patient-centered communication scores (based on the audiotape analysis) were significantly correlated in the expected direction, with patient perceptions that the patient and physician found common ground (r =-0.16; P=.01). High scores (indicating very patient-centered communication) were correlated with low patient perception scores (indicating patient-centeredness). The 2 other patient perception scores (total patient perception score and the subscore on patient perception that the illness experience was explored) were not significantly associated with patient-centered communication scores.

The total score of patients’ perceptions that the visit was patient centered was associated with positive health outcomes after adjusting for the clustering of patients within practices and after controlling for the 2 confounding variables [Table 4]. Patients’ postencounter levels of discomfort were lower when they perceived the visit to have been patient centered than not.

A similar result occurred for 2 other patient health outcomes: the patients’ postencounter level of concern (P=.02), and the mental health dimension of the SF-36 measure assessed 2 months after the study visit (P=.05). The subscore of patient perceptions that the patient and physician found common ground was associated with one of the health outcomes, the patients’ postencounter level of concern (P=.04). There were no significant associations of the subscore on patients’ perceptions that the illness experience had been explored with any of the patient health outcome measures.

Patients who perceived that their visit had been patient centered received fewer diagnostic tests [Table 5] and referrals [Table 6] in the subsequent 2 months. The proportion receiving diagnostic tests rose from 14.6% in the group who perceived that the visit had been patient centered (total score), to 24.3% in the group who perceived the visit was not. The proportion who were referred doubled from approximately 8% to 16%. These relationships were found even more strongly for the subscore on patient perceptions that the patient and the physician found common ground, but were not found for the subscore on patient perceptions that their illness experience had been explored. The proportion receiving diagnostic tests quadrupled from 4.1% in the group who perceived that the patient and the physician found common ground, to 25.4% in the group who perceived that common ground had not been attained. The proportion who were referred doubled from 6.1% to 14.9%. The number of visits by the patient to the family physician during the subsequent 2 months was not significantly related to the patient perceptions of patient centeredness, although there was a trend (P=.11) with the average number of visits in 2 months in the 4 quartiles of patient perceptions as follows: 1.0, 0.8, 1.2, and 1.3.

Discussion

Pathway to Improved Patient Outcomes

Patient-centered practice was associated with improved patients’ health status and increased efficiency of care (reduced diagnostic tests and referrals). However, only 1 of the 2 measures of patient-centered practice showed this result, the measure of patients’ perceptions of the patient centeredness of the visit. The measure that was based on ratings of audiotaped physician-patient interactions, while related to the patients’ perception, was not directly related to health status or efficiency.

The relationship of patients’ perceptions of patient centeredness with their health and efficiency of care was both statistically and clinically significant. Specifically, recovery was improved by 6 points on a 100-point scale; diagnostic tests and referrals were half as frequent if the visit was perceived to be patient centered.

The associations we found may imply a potentially important pathway (which could be tested in future trials), such as the one shown in the [Figure]. The pathway suggests a process through which patient-physician communication influences patients’ health, by first influencing the patients’ perceptions of being a full participant in the discussions during the encounter. Such a pathway has been noted by Sobel, whose review suggested a pathway to explain the lack of a direct relationship between patient education programs and patient health where there was a relationship between patient perceptions about their health and health outcomes. Sobel called this pathway “a biology of self-confidence.”³¹ He and others³² stress the critical role of patient perceptions in the healing process, which highlight that a person’s subjective experience influences biology.

How do we understand the results that show the ratings of the audiotape were not directly related to the outcomes, but the patient-centered perception measure was related to outcomes? One interpretation is that observable skills are not as important as patient perceptions. Although there is some evidence that skills training can improve both physicians’ behavior and patients’ health,³³ our findings and those of Bensing and Sluijs³⁴ indicate that differences in interviewing skills may not be associated with patient responses. Physicians may learn to go through the motions of patient-centered interviewing without understanding what it means to be a truly attentive and responsive listener. The implications of the current findings for educators are that education about communication should go well beyond skills training to a deeper understanding of what it means to be a responsive partner for the patient, during both that phase of the visit in which the problem is discussed and when the discussion of treatment options occurs. Two examples of such education approaches are: small group discussions between patients and physicians to illustrate the patients’ experiences and needs, and reviews of videotaped interviews with standardized patients participating in the review. Placing prime importance on the patients’ perceptions recognizes the influence of these perceptions on the patients’ subsequent health and epitomizes being truly patient centered.

Views that the visit was patient centered included perceptions about the discussion of the problem (exploring the illness experience) as well as discussion and agreement about treatment options (finding common ground). There is a substantial body of research supporting the importance of these discussions. The Headache Study found that patients’ perceptions that a full discussion of the problem had taken place predicted resolution of headaches after 1 year.³⁴ In keeping with our results, which found that finding common ground was more strongly associated with outcomes than exploring the illness experience, Riccardi and Kurtz³⁶ stressed that the physicians’ explanation to the patients was the crucial phase of the visit. Also, a key outcome study has found that patient agreement with the physician about the nature of the treatment and the need for follow-up were strongly associated with their recovery.³⁷

Efficiency of Medical Care

We found that patient-centered practice (assessed by patients’ perceptions) was associated with the efficiency of care by reducing subsequent diagnostic tests and referrals by half, after controlling for key confounding variables. These results were both statistically significant and clinically significant. Also, the number of subsequent visits to the family physician was lower (although not significantly) when the patient perceived the study visit to be patient centered. Efficiency in health service delivery was also found in a randomized trial of compassionate care in the emergency department setting with homeless patients.³⁸ In their study of continuity of care in Norwegian general practice, Hjortdahl and Borchgrevink³⁹ found that diagnostic tests were 10 times more likely to be ordered for patients about whom physicians reported the least previous knowledge compared with patients in whom they had reported fullest knowledge. Also, patients had only half the chance of being referred if their physicians knew them and their history.³⁸

One possible interpretation of the results of our study is that patient-centered physicians order fewer tests and refer less often. However, countering this interpretation is the fact that individual physicians in our study showed a range of patient-centered scores, as well as a range in test ordering and referral. In addition, the statistical analysis took account of the clustering of patients within a physician’s practice.

An alternative interpretation is that patients’ perceptions may influence resource use in several ways. For example, increased participation during the visit may reduce patients’ anxiety and their perceived need for investigations and referrals. Alternatively, patients’ perception that the physician has not understood their problem may provoke insecurities resulting in a request for further medical interventions. Also, if patients openly express their discontent with the encounter there may be an increase in physicians’ anxiety and a lowering of their threshold for diagnostic uncertainty, resulting in further investigations and referrals.

Certainly the finding that the failure to be patient centered (as perceived by the patient) was related to higher rates of referral and diagnostic tests should be a concern for medical education and health care policy. Perhaps of most importance is that the patients’ experience of being a participating member in the discussion of the problem and the treatment process may translate into the patients’ reduced need for further investigation or referral—simultaneously reducing the physicians’ need as well.

These findings counter a common misconception: that being patient centered means responding to every whim of the patient, thereby increasing expenses to the health care system.

Limitations

Approximately 30% of the patients refused to participate, and although the participants represented the age distribution of eligible patients, men were overrepresented in the study. Nonetheless, sex was not identified as a confounding variable for the associations studied.

Although no measure of severity was possible, the variables representing concurrent health problems and concurrent life problems were considered in the analysis strategy. They were not related to the outcome variables and were therefore not entered into the multivariable analyses.

One interpretation of the lack of association between patient-centered scores on the audiotaped interviews and subsequent health outcomes may be that the audiotape measure has failed to capture the important essence of the dynamic interaction between physicians and patients. The measure had a number of strengths, however; it had been tested for reliability and validity (compared with a global rating), and it was based on a theoretical framework. Also, it was correlated with one component of the patient perception measure of a patient-centered interview, a finding which indicates that future research should be directed toward determining physicians’ skills and behaviors that correlate with the patients’ positive perceptions, especially the perception that common ground has been reached. Such behaviors could then be emphasized in clinical teaching.

It should be noted that the utilization data were available only from the participating practices and not from care received elsewhere. Although this is a limitation, it would be expected that this lack of data would minimize the current relationship between patient-centered practice and utilization, because patients with less favorable perceptions would be potentially more likely to seek care elsewhere. Also, drug costs and hospital costs were not included and require further study. Future research could also build on these results about resource utilization and assess the specific kinds and actual costs of the diagnostic tests and referrals.

It could be argued that the results of our study demonstrated simply that people with positive perceptions and less severe problems achieved better health and more efficient services. We counter this interpretation with 2 thoughts. First, the preliminary step in our analysis included confounding variables to control for a variety of relevant variables (ie, personality and concomitant health problems). Only 2 confounding variables were influential enough to remain in the final analysis: marital status and diagnostic code of the main presenting problem. Second, patient perceptions were not independent of the physician-patient visit. They were influenced significantly by the communication score based on the audiotaped encounter, implying that the measure of perceptions was tapping not merely the patients’ general outlook on life, but also an important interactive component of visits between patients and physicians.

Conclusions

Patient-centered practice was associated with improved health status (less discomfort, less concern, and better mental health) and increased efficiency of care (fewer diagnostic tests and referrals).

Patients’ perceptions of the patient centeredness of the visit, but not the measure of audiotaped interactions, were directly associated with the positive outcomes. The subscore on patients’ perception of finding common ground was more strongly associated with the positive outcomes than the subscore on patients’ perception about exploring the illness experience.

Medical education should go beyond skills training to encourage physicians’ responsiveness to the patients’ unique experience. Therefore, involving real patients and standardized patients in teaching programs is recommended.

Health service organizations must recognize that efficiencies accrue from patient-centered practice and encourage such practice through structures that enhance continuity of the patient-physician relationship and through meaningful education programs.

Acknowledgments

Our project was supported by a grant from the Health Care Systems Research Program of the Ministry of Health of Ontario. The setting of the project was the Thames Valley Family Practice Research Unit (TVFPRU), a health system-linked research unit funded by the Ministry of Health of Ontario. The opinions contained are those of the authors, and no official endorsement by the Ministry is intended or should be inferred. The TVFPRU is part of the Centre for Studies in Family Medicine, Department of Family Medicine, The University of Western Ontario, London, Canada.