A Survey of Patient Perspectives on Approach to Health Care: Focus on Physician Competency and Compassion

Quantitative data

Survey responses were abstracted, coded, and entered into a database by trained research personnel (K.H., K.G., B.L.). STATA version 13 was used to analyze the data. Ordinal logistic regression was performed to determine the predictive effect of demographic factors.

Qualitative data

Free-text responses for each vignette were reviewed and assessed for major themes relevant across all cases and subthemes pertinent to each case individually. A coding scheme based on the major themes and subthemes was developed. Two investigators (C.A.V., K.H.) independently coded 200 responses from each case or until thematic saturation was reached. Inter-rater reliability was established through an iterative process of consensus building between the two researchers (C.A.V., K.H.). All authors then met to discuss and establish the themes and subthemes. Representative quotes for each major theme were identified and compiled for illustrative purposes.

Explicit beliefs regarding the value of compassion and competence

In surgical vignettes where physician competence was more often preferred, respondents reflect on the importance of a physician’s technical skills, the fear of permanent consequences resulting from incompetence, and that perhaps compassion was not the physician’s role, and instead may be provided by other members of the care team. Similar sentiments were shared in the pediatric cases where physician competence was preferred, but physician compassion was very important. In contrast, the end-of-life vignette where compassion was most often preferred, respondents noted the importance of making the patient and family feel cared for and that the mental and psychosocial health of the patient became a higher priority. In chronic care vignettes, preferences for physician competence and compassion varied. Respondents reflected on the importance of the physician’s ability to provide counsel on both medical management and lifestyle changes, while also understanding the patient’s limitations, adjusting therapeutic regimens, and modifying expectations of compliance accordingly.

Even in vignettes where the majority of respondents preferred competence (e.g., surgery) or compassion (e.g., end of life), a distinct role for both qualities remains (Table 3). Among surgical vignettes, respondents often noted that although physician competence is the priority, a physician’s compassion had a substantial impact on patient entrustment. Respect for the patient’s autonomy and decision-making abilities was also important, as was their perception that the physician actually cared about them and would act in their best interest should a complication arise. Furthermore, respondents often reflected on the importance of a compassionate approach once competency had been established, suggesting a complex interplay between these two qualities. In the end-of-life vignette, respondents often reported that although physician compassion was prioritized, physician competence was important, and impacted their confidence in the physician’s accurate diagnosis and prognosis. Additionally, establishing physician competence may provide some reassurance that all avenues of treatment had been explored, that the physician was open to considering other treatment options, and that they would support the patient and their family even at the end of life.

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Table 3.

Role of Compassion in a Scenario Where Competency Was Scored High (Surgery) and Role of Competence in a Scenario Where Compassion Was Scored High (End of Life).

Case type	Reflective quotes
Surgery	“I would want the physician to show compassion in order to trust her completely.” (ID 413)“Cataract surgery is very common, but it still is an invasive procedure involving very delicate and important structures. I would like the physician to be kind and courteous, explain the risks and the procedure itself to ensure I am comfortable during it.” (ID 419)“Competence but if they aren’t compassionate I may feel as if they wouldn’t care if they made an error during surgery. So, compassion is key too.” (ID 460)“Surgery in the hands of an incompetent surgeon has greater risks. Compassion can help surgeons make decisions in the best interest of patients.” (ID 538)“To do the surgery well is most important, assuming the doctor doing the diagnosing is also doing the surgery. Compassion is less essential for this quick surgery but still could be useful to mitigate risks if the patient in uninformed, emotional, or has a physical twitch.” (ID 578)“Because of the importance on restoring my eyesight and not making an error which would alter one’s life immediately. Compassion is important in listening and caring for the patient’s needs, but secondary in this scenario.” (ID 582)“Tough choice—in this case. Competence since surgery is involved but compassion might motivate the physician to describe and explain the risks more thoughtfully.” (ID 585)“But I feel a doctor must have some compassion and take time to answer any questions.” (ID 642)
End of life	“Competence would be important in terms of an accurate diagnosis, but compassion would be more important with end of life plans.” (ID 460)“Compassion since it’s likely that this diagnosis is right and therefore palliative measures and attitude would be more important.” (ID 461)“There is an assumption that the doctor’s information is correct. If it’s true, then compassion is more important.” (ID 456)“The doctor needs to be competent enough to offer appropriate supportive treatment but more importantly to be compassionate to my particular feelings and situation.” (ID 474)“If the diagnosis is correct.” (ID 496)“It might be nice for the physician to have a nice bedside manner when he tells you that you will die soon BUT he better be RIGHT.” (selected competence) (ID 501)“Although I want a doctor who is sure of the outcome, as it is the end of my life and a sensitive and emotional time, I need a doctor to be aware of my feelings and respect my decisions.” (ID 513)“While competence has a lot to do with the accuracy of the prognosis; compassion is important in the empathy involved in what the doctor suggests for how I live out my final days.” (ID 622)“Both are important to me. I would want a doctor who is competent in this area, so his diagnosis would be accurate, and information delivered with sympathy and compassion.” (ID 635)“Obviously, If I’m dying, competence is less important to me except in terms of management of symptoms. Compassion in my doctor at this point will have an important affect within a process that challenges my family and me.” (ID 643)“Compassion would mean more to me if I were dying but also need to have good decisions made about what could be done for me.” (ID 289)“If the physician is simply giving me the facts and not actually performing any procedures.” (ID 309)

Impact of emotional and mental health on medical experiences

Table 4 displays quotes on how respondents define and choose compassion or competence and the influence their emotional health had on their decisions. Respondents’ desired outcomes were often similar between vignettes, but the ways in which they expected the situation to be approached were very different. Among surgical vignettes, a preference for physician competence was often influenced by the desire for confidence in the physician’s skill and comfort knowing they are in capable hands. A preference for physician compassion was also influenced by a respondent’s desire for confidence and trust in their physician, but some responded that this could only be established once the physician demonstrated competence. Similarly, in pediatric vignettes, a preference for physician competence was influenced by the respondent’s desire for confidence in their skill and ability, whereas a preference for physician compassion was often associated with the desire for reassurance and respect for the emotional challenges the parent or guardian and child experience, particularly in serious conditions such as pediatric cancers.

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Table 4.

Impact of Emotional and Mental Health Across Vignettes.

Scenario	Competence	Compassion
Preference for competence
Cataract surgery	“It means I know they are educated and experienced at the surgery. I would feel more comfortable with the surgery if I know the physician is competent.” (ID 340)“I think that while eyesight is extremely personal and emotional, knowing that my physician is capable and ready to perform the necessary procedure would provide me enough comfort.” (ID 401)	“I lean more emotional on the spectrum. I am more likely to trust someone who shows me emotion.” (ID 421)“As what’s done can’t be reversed. The physician has to have enough empathy in order to stop the procedure and make sure the patient is comfortable and calm during this scenario to risk possible alarm and injury.” (ID 404)
Brain surgery	“Here competence is more important since it would be important in belief for a cure.” (ID 126)“Competence, Life altering/serious conditions should be diagnosed properly eliminating any unnecessary stress for patient.” (ID 3)	“This surgery is far more impactful to the patient than case 1, the surgeon must show empathy for the patient to feel she’s in good hands.” (ID 180)“I would go with compassion because the risks associated with the surgery are so great that I might not want to take them. A compassionate doctor would support me in that decision.” (ID 439)
Heart failure	“Competence is important for the duration. It would stress me to see a doctor with less competence and more compassion.” (ID 109)“Competence. I would need to know realistically what is happening and going to happen, so I can plan my end of life.” (ID 16)	“One physician’s concern and compassion are key to one’s persistence in this situation.” (ID 126)“The way the specialist approaches my situation may have a significant effect on how I deal with my prognosis.” (ID 159)
Pediatric scenarios	“Trusting a doctor to care for a loved one is scary, and I’d choose a competent doctor over a compassionate one.” (ID 190)“Physician needs to give parent confidence that this recommended treatment is the best option.” (ID 180)	“Compassion for the child’s emotional state as well as the parents.” (ID 32)“My daughter is young and both she and I will be very concerned. We’ll need reassurance.” (ID 133)
Preference for compassion
End of life	“I need correct answers to be able to prepare myself for death.” (ID 589)“Competence because I’d still would want to know what I was facing and from a technical standpoint more than emotional.” (ID 111)	“If I’m going to die anyway then my mental health becomes the priority.” (ID 354)“Since end of life is involved I would need guidance I could trust for help me get through both mentally and pain wise and/or assisted suicide.” (ID 471)
No significant preference
Diabetes	“Diabetic diet and regular exercise are easy enough to understand but hard for many to do. Emotional support is important in maintaining compliance.” (ID 53)“You are dealing with many emotional issues along with health issues.” (ID 313)	“A compassionate physician would offer emotional support and resources to help me manage a new lifestyle with diabetes.” (ID 586)“Diabetes is very common among Americans, so the compassion would be more important is being told you have a life long illness can be devastating.”(ID 209)

Type and frequency of health care exposure

Physician compassion was identified as key when subjecting a child to painful tests or procedures, particularly when considering the long-term consequences of physician interactions on the child’s health. In the end-of-life vignette, many respondents noted that mental and emotional health becomes a higher priority when dying, thus suggesting a preference for physician compassion. Others noted that they would prefer less focus on their emotional well-being and greater focus on understanding the technical complexities of their illness and the impact on prognosis. Among vignettes dealing with the chronic disease management, a preference for physician competence was often influenced by the respondent’s desire for confidence in the physician’s knowledge, whereas a preference for physician compassion was influenced by a desire for emotional support at diagnosis and to ensure long-term treatment compliance and resilience.

Perceived role of the physician in various clinical vignettes

A desire for a more compassionate or competent approach to care was reflective of the different roles participants looked to their physician to fulfill. Although physician competence was vital, it was insufficient in providing “effective” medical care and must be used in conjunction with a more compassionate approach. As reflected in the responses, compassion is multifaceted and utilized in a variety of ways depending on the scenario and the physician’s roles.

The perceived role of the physician was discussed extensively by respondents in the various clinical vignettes. Six roles emerge with regard to the physician–patient relationship: healer, advocate, counselor, friend, educator, and enforcer. Table 5 displays how participants defined the specific roles and their reflective quotes.

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Table 5.

Perceived Role of a Physician.

Role	Definition	Reflective quotes
Healer	The physician is responsible for extension of life by identifying and allocating cure or treatment.	“I rely on the physician’s expertise and skill to bring about healing, not his/her bedside manner.” (ID 511)“Competence because I would need him to use what knowledge he did have to keep me alive as long as possible.” (ID 25)“The physician’s competence could help find a life extending solution.” (ID 337)
Advocate	The physician is knowledgeable about treatment options and appreciates the patient’s values and preferences, guiding them through choices that ensure quality of life, autonomy, and dignity.	“Physician compassion would probably be more important as the surgeon decides which disability to choose/avoid. I want a physician who understands what is important to me.” (ID 170)“…Because I would choose not to have this surgery. A compassionate surgeon would be kinder with my decision.” (ID 94)“[At end of life] there is likely nothing else the doctor can do medically. However, she or he can make you comfortable and respect your wishes.” (ID 562)
Counselor	The physician delivers emotional support and guidance related to challenges with disease, treatment, and lifestyle changes.	“I would want my doctor to walk with me as an individual patient to understand my specific circumstances and my anticipated challenges.” (ID 611)“Diabetes is very treatable/manageable…so it would be more important that the doctor care enough to coach me through it and support me through lifestyle changes.” (ID 597)“The life style changes required would require coaching, understanding and “hand holding” if they are to be achieved.” (ID 81)
Friend	The physician is reported to be a friend, companion, or confidante.	“I want them to not pick the surest bet or easiest choice from a technical standpoint but rather think of me as their friend or themselves and choose what is best long term for quality of life.” (ID 328)“Not there to make a new friend- there to save my eyesight.” (ID 348)“I don’t need to be their “friend”, but I DO expect competence on their side.” (ID 639)
Educator	The physician gives the necessary information and options to the patient without opinion or guidance, leaving decision-making to the patient and family.	“Firm information on the indications and contraindications of each option so I may make my own informed choices.” (ID 48)“Explain all outcomes and possible options so I can decide what is best for me at this time.” (ID 118)“I would want to know what to expect in the coming days or weeks.” (ID 245)
Enforcer	The physician gives clear instructions to the patient in order to manage the disease, treatment effects, and/or lifestyle modifications.	“Competence—apparently I need to be told to make time or I’m going to die. Here are the things I have to do.” (ID 346)“Compassion is not required here. In fact, the opposite approach is best. Scare me into losing weight.”(384)“Competence—it sounds like I would need ‘tough love.’” (ID 11)

Although patient preferences regarding the role of the physician varied greatly, many participants preferred to engage in a more team-based approach to managing their health. In addition to a healer and educator, the respondents looked to their physician to fulfill the role of a counselor; someone who provides compassionate guidance as they navigate individualized treatments and lifestyle changes. This role may grow overtime as patients began to view their physician as a friend with whom they may celebrate their successes, vent their frustrations, and disclose their failures. Conversely, there were also individuals who desired the more traditional approach to care. Respondents reported personal responsibility or blame for their health conditions and looked to a physician to provide strict instruction and goals they should try to achieve as a way to improve health long term. In the event that someone failed to meet these goals, the respondents preferred their physician to take on the role of an enforcer by conveying realistic depictions to motivate them into making changes.