January 2006 | Back to Table of Contents

Clinical and Health Affairs

Factors Influencing Patients' Choice of Primary Medical Doctors

By Matthew E. Bernard, M.D., Jesse C. Sadikman, M.D., and Caren L. Sadikman, M.D.

Abstract
This study investigated factors that influence adult patients’ choice of primary care physicians and aimed to determine whether patients know the difference between internal medicine and family medicine. One thousand patients who had seen their primary care physician in either the family medicine or internal medicine department at Mayo Clinic in 2001 were sent a questionnaire to determine 1) the factors that influenced their choice of physician and 2) their knowledge of the characteristics of both specialties. Forty-six percent of the patients responded. Patients most often cited the doctor’s “Approach to patient care” and “Interpersonal skills/communication” as affecting their choice of physician. Results also showed patient knowledge of the difference between family medicine and internal medicine was poor. The authors conclude that patients must be educated about the differences in the training of and care provided by different types of primary care physicians.

Primary care physicians offer a valuable service to patients. They emphasize disease prevention, continuity of care, health maintenance, and health education. They treat acute and chronic illnesses and provide appropriate referrals when indicated. Four major medical specialties provide primary care: general internal medicine, family medicine, obstetrics and gynecology, and general pediatrics. Why and how do patients choose a physician from among these different specialties? 

Previous studies have investigated the process of selecting a primary care physician. Glassman and Glassman found that 60% of women choose their obstetrician by using information gathered from friends, relatives, or nurses.¹ Crane and Lynch identified courtesy, competence, reputation, and interpersonal skills as key factors in patients’ selection criteria.² Winter argued that convenience is the most important factor.³ The Future of Family Medicine project identified 5 important factors: insurance coverage, location, availability, basic communication skills, and age and experience as being important to patients’ decisions.⁴ A review by Lewis examined the related issue of patient satisfaction.⁵ Twelve key elements of patient satisfaction were identified: overall satisfaction, access, cost, overall quality, humanness, competence, information provided, bureaucratic arrangements, physical facilities, attention to psychosocial issues, continuity of care, and outcome of care. It is fair to extrapolate that all of these factors influence patients’ choice of primary medical doctors.

Differences in practice styles of family medicine and internal medicine physicians were studied by Bertakis et al.⁶ Those differences, as measured by physician observers, were believed to originate from the way the physicians are trained. Internal medicine physicians were found to be more “technical” (ie, they spent more time taking the medical history, doing the physical examination, and treating disease) in their delivery of health care. Family medicine physicians were more focused on health counseling and patients’ behaviors that relate to health. Despite the difference in practice styles, no difference in patient outcomes was found, as measured by the patients’ self-reported health status.⁶ Patient outcomes were more related to specific physician behaviors than to the physician’s specialty.

Do patients actively choose one specialty over another, or do they choose primary medical doctors on the basis of referrals, convenience, and other practicalities? Are patients knowledgeable about the differences in training for various specialties? Lewis et al reported that 50% of patients mistakenly think that general internists care for children, and 25% mistakenly believe that internists provide obstetrical care.⁷ The Future of Family Medicine project, a joint initiative by the Family Medicine Working Party and the Academic Family Medicine Organizations, confirmed that the public has “a hard time differentiating family medicine from . . . general internal medicine.”⁴ The primary goals of this study were to determine 1) the factors influencing adult patients’ choice of a primary medical doctor and 2) if patients’ knowledge about family medicine and internal medicine influences their decisions.

Methods
We used our electronic appointment system to identify Mayo Clinic patients who had been seen by their self-selected primary care doctor in internal medicine or family medicine at least once in 2001. The following subgroups of patients were excluded: patients younger than 18 years of age, deceased patients, local Federal Medical Center patients, patients whose names were on a “no-contact” list, and patients who denied research authorization of their records. After removing those with exclusions from the recruitment list, 500 patients from each department were randomly selected by computer to receive a survey about their choice of doctor. Names and addresses were reviewed to ensure that the same person or household did not receive the survey twice. There was no follow-up or second mailing for nonrespondents. The study was approved by the Mayo Foundation Institutional Review Board.

The survey consisted of 4 sections of multiple-choice and checklist questions. The first question was, “Do you consider this doctor to be your primary care doctor?” If respondents answered “Yes,” they were asked to select from a 13-item checklist all of their reasons for choosing their primary care doctor. The options included recommendation by another person, preference of 1 doctor to care for the whole family, preference for a doctor who specializes in adult medicine, the doctor’s approach to patient care, insurance requirements, the doctor’s availability, the doctor’s interpersonal and communication skills, the doctor’s sex (whether the same as or different from the patient’s), and the doctor’s age. Logistical factors such as location of the office, physical accessibility of the office, and ease of parking were not included because the 2 practices surveyed were located in the same building with the same parking structure. After respondents checked all relevant reasons, they ranked their top 3 reasons in order of importance. Patients who answered “No” to question 1 were excluded from further analysis.

The second part of the survey consisted of 6 multiple-choice questions to determine whether patients correctly identified the department in which their primary care doctor worked (family medicine or internal medicine) and where the patient’s family members received primary care.

The third part of the survey aimed to assess patients’ knowledge of the differences between family medicine and internal medicine. Eleven statements were made about physician training and practice scope (eg, “Trained in obstetrical care,” “Sees patients of all ages,” “Sees only adult patients”) and the 2 specialties’ practice philosophies (eg, “Is attuned to the role of family dynamics”).^5,6 Patients checked “Yes,” “No,” or “Don’t know” to indicate whether they thought the statements applied to family medicine, internal medicine, or both.

The fourth part of the survey collected demographic information, including the patient’s age, sex, education level, and the ages of family members living in the household. Information about ethnicity was not collected because institutional data show our patient population to be 97% to 98% white.

Demographic variables and survey responses were summarized using standard descriptive statistics. These analyses were conducted first with the entire set of subjects and then separately for patients in family medicine and internal medicine. The chi-square test (SAS/STAT) was used to compare characteristics and reasons for selecting a primary care physician in family medicine and internal medicine. Answers to questions assessing patient knowledge about the practice scopes in the primary care specialties were judged as correct or incorrect, and the percentages of correct responses were determined. The responses were then compared using the chi-square test to assess knowledge in each group regarding their own provider area and the alternative provider area.

Results
Demographics The response rate to the survey was 46%. The number of internal medicine group respondents (227) was not significantly different from the number of family medicine group respondents (235). The internal medicine group ranged in age from 22 to 95 years, with a mean ± SD age of 62.5 ± 15 years, and 59% were women. The family medicine group had a mean ± SD age of 49.3 ± 15 years (range, 18 to 91 years), and 67% were women. The difference in age between the groups was statistically significant (P<.001). The percentage of male and female respondents was not significantly different between the groups. In each group, 15 patients responded “No” to question 1 and were excluded from further analysis.

A large proportion of patients (53% for family medicine and 43% for internal medicine) had been seeing their primary care doctor for more than 8 years. Only 7% of each group had been seeing their doctor for 1 year or less. Family size was significantly different between the 2 groups; 98 family medicine patients (42%), compared with 36 internal medicine patients (16%), had 1 to 3 children younger than 17 years living at home (P<.001). Education level was also significantly different between the patient groups. Forty-one internal medicine patients had a graduate degree (18%) compared with 24 (10%) of the family medicine patients (P=.02).

Factors Influencing Primary Physician Selection Using the checklist on the survey, patients identified reasons for selecting their primary care doctor and then ranked the 3 most important reasons from their list. The reasons most often chosen, for both the family medicine and internal medicine groups, were “Approach to patient care” and “Interpersonal skills/communication” (Table 1). “Approach to patient care” was selected by 83% of the family medicine patients and 80% of the internal medicine patients. “Interpersonal skills/communication” was checked by 77% of the family medicine patients and 67% of the internal medicine patients. The third most selected reason differed between the 2 groups, with 46% of internal medicine patients choosing “Availability” and 48% of family medicine patients choosing “Importance of having one doctor for the family.”

By univariate logistic regression, 3 factors were significantly different between internal medicine and family medicine respondents. Patients who prefer a doctor who specializes in adult medicine were 6 times more likely to see an internal medicine physician; 36% of internal medicine patients selected this as a reason, compared with 7% of family medicine patients (P<.001)(Table 1). Patients who prefer a doctor younger than themselves were 4 times more likely to go to an internal medicine physician (P<.001). Patients who prefer 1 doctor to care for the whole family were more likely to go to a family medicine physician (P<.001).

Although 43% of the patients indicated that they chose their doctor because “This doctor was recommended to me,” recommendation was not often selected as one of the most important reasons for either patient group. Preference for a doctor of the same sex was chosen by a total of 23% of all patients but was rarely selected as one of the top 3 reasons. The remaining reasons received negligible responses. Insurance coverage was not a factor because the patients’ insurance allowed them to choose any primary medical doctor at Mayo Clinic.

Primary Care for Other Household Members Patients were asked if their primary care physicians also provided care to the other adults (18 years or older) and children (younger than 18 years) in their household. Of the family medicine respondents, 65% said that their primary doctor provided care to other adults in their household. Of the internal medicine respondents, 32% said their primary doctor provided care to other household adults.

For family medicine respondents with children in the household, 70% said that their primary care physician saw some or all of their children. Of the internal medicine respondents with children, 21% said that the primary care physician for their children was in the family medicine department, and 43% said that their children’s doctor was in the pediatrics department.

Knowledge about Family Medicine and Internal Medicine The results for the questions that tested patients’ knowledge of specific characteristics of family medicine and internal medicine physicians are outlined in Table 2. Overall, patients had a poor understanding of the differences between family medicine and internal medicine physicians in terms of the training that they receive, the patients they care for, and the care they deliver. For example, 34% of internal medicine patients correctly answered the statement “Provides care for patients of all ages.” Sixty-seven percent of family medicine patients were aware that family medicine physicians are trained in obstetrics, and 24% of internal medicine patients knew that their physician was not trained in obstetrical care.

Patients were also asked about the philosophies of their physicians’ specialties (Table 3). Respondents were asked whether they felt their physicians’ specialties were attuned to preventive care, family dynamics, psychosocial issues, and continuity of care. A greater percentage of family medicine patients felt that their physicians promoted these 4 attributes than did internal medicine patients.

The scores on all of the questions pertaining to physicians’ training, scope of care provided, and philosophies were analyzed as a group. Overall, both family and internal medicine patients scored similarly on these questions. When the scores were analyzed by department, the family medicine patients better understood family medicine, and internal medicine patients better understood internal medicine (P<.001) (Table 4). The scores were also analyzed according to age. The 307 patients younger than 65 years scored better on these questions, with a median of 12 correct, compared with a median of 6 correct for the 152 patients 65 years and older (P=.001).

Discussion
This study was undertaken to further elucidate some of the factors that influence patients’ choice of a primary care doctor, with a focus on the differences between internal medicine and family medicine patients. Our patient population most often reported choosing a primary care physician based on the doctor’s approach to care, interpersonal and communication skills, and availability. Family medicine patients valued having 1 doctor for the whole family, and internal medicine patients preferred doctors who specialized in adult medicine and who were younger than themselves. The patients’ age, level of education, and family size also influenced their decisions. A greater percentage of internal medicine patients had graduate degrees and preferred doctors who specialize in adult medicine than did family medicine patients. Family medicine patients preferred having 1 doctor to care for the entire family. All these results corroborate previous studies indicating that patients actively choose either family medicine or internal medicine physicians on the basis of their needs and their perception of the physician’s training and scope of care.^6,7

When asked to choose the reasons for selecting their primary care physicians, family medicine and internal medicine patients both rated the physician’s “Approach to patient care” and his or her “Interpersonal skills/communication” as most important. This finding is consistent with findings from the Future of Family Medicine project.⁴ The training of physicians in internal medicine and family medicine should continue to emphasize the need for an inviting approach to patient care and good interpersonal skills.

Family medicine patients selected “Interpersonal skills/communication” as a reason for choosing their doctor more often than did internal medicine patients. Indeed, 90% of family medicine patients felt that family physicians are attuned to the role of family dynamics, and 83% felt that family physicians are attuned to psychosocial issues affecting their patients.

Other studies found that patients choose their doctors on the basis of recommendations from friends.^1,2 In this study, 43% of the respondents cited the statement “This doctor was recommended to me” as a reason for choosing their doctor, but very few ranked this reason among their top 3. Interestingly, in our population whose mean ages were 49 years (family medicine) and 63 years (internal medicine), few patients wanted a doctor older than themselves. This contrasts with other studies that found age and experience to be deciding and desirable factors in choosing a doctor.

Continuity of care was also important to both groups. About half the respondents in each group (53% for family medicine and 43% for internal medicine) had been seeing their primary care doctor for more than 8 years. However, more family members of family medicine patients received care from the same physician than did family members of internal medicine patients.

Results showed a general lack of knowledge and understanding of the differences between family and internal medicine as has been demonstrated in previous studies.^1,6,7 This lack of knowledge has the potential to lead to a discrepancy between patients’ expectations and their clinical experience and thus result in decreased patient satisfaction. It is necessary to first elucidate the actual philosophical and patient care differences among the primary care specialties and then to educate the public. This will allow patients to make an informed decision about their doctor.

This study had several limitations. Sample response, although adequate for statistical comparison, was less than 50%. The demographics of the sample population were limited by the demographics of the local population. Rochester, Minnesota, has a fairly homogeneous population with little racial and ethnic diversity. Thus, these results may be transferrable only to other practices or areas of the country with similar demographics. Further, the patients in our study receive their primary care at a large academic center. Results may differ in smaller, nonacademic settings.

The phrase “Approach to patient care” was meant to represent physicians’ medical management of a problem (ie, their treatment plan), but this was not stated explicitly in the survey and was thus open to interpretation by respondents. It is conceivable that the patients understood this response to mean their physicians’ interpersonal skills and bedside manner. Given the positive correlation of this response with “Interpersonal skills/communication”—82% of all patients checked “Approach to patient care” and 72% checked “Interpersonal skills”—patients may have interpreted these phrases similarly. Other phrases that may have been too broad and open to interpretation were “Is attuned to family dynamics” and “Is attuned to psychosocial issues.” However, given the importance that patients placed on these 2 items, it is necessary to further break down these areas in an effort to define specific characteristics.

This study is helpful in further understanding how and why patients choose their primary physician and how they distinguish between family medicine and internal medicine. These results help define areas of strength for family and internal medicine physicians to emphasize in order to distinguish themselves and areas of perceived weaknesses to address. Specifically, internal medicine physicians can emphasize their specialization in adult medicine. Their weaknesses perceived by our patient population—interpersonal skills, attunement to family dynamics, and psychosocial aspects of patient care—were the family physicians’ perceived strengths. Family medicine physicians should, therefore, emphasize these qualities, in addition to promoting their ability to care for the entire family. Equally important, family physicians need to educate the public on the scope of care they deliver, the training they receive, and their status as specialists in outpatient primary care. MM

Matthew Bernard is a consultant in the department of family medicine at Mayo Clinic and an assistant professor of family medicine in the Mayo Clinic College of Medicine. Jesse Sadikman is a resident in family medicine and Caren Sadikman is a resident in physical medicine and rehabilitation in the Mayo School of Graduate Medical Education.

References
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2. Crane FG, Lynch JE. Consumer selection of physicians and dentists: an examination of choice criteria and cue usage. J Health Care Mark 1988;8(3):16-9.
3. Winter FW. Computerized secondary data approaches to health care location decisions. J Health Care Mark. 1986;6(2):67-75.
4. Martin JC, Avant RF, Bowman MA, et al, The Future of Family Medicine Project Leadership Committee. The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2 Suppl 1:S3-S32.
5. Lewis JR. Patient views on quality care in general practice: literature review. Soc Sci Med. 1994;39(5):655-70.
6. Bertakis KD, Callahan EJ, Helms LJ, Azari R, Robbins JA, Miller J. Physician practice styles and patient outcomes: differences between family practice and general internal medicine. Med Care. 1998;36(6):879-91.
7. Lewis CL, Wickstrom GC, Kolar MM, et al. Patient preferences for care by general internists and specialists in the ambulatory setting. J Gen Intern Med. 2000;15(2):75-83.