Nigerian Postgraduate Medical Journal

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 26  |  Issue : 2  |  Page : 87--93

Patient–Doctor relationship in underserved environment: A cross-sectional study of attitudinal orientation, practice inclination, barriers and benefits among medical practitioners in Abia State, Nigeria


Gabriel Uche Pascal Iloh1, Obianma Nneka Onya2, Uche Ngozi Nwamoh3, Prince Ezenwa Ndubueze Onyemachi4, Miracle Erinma Chukwuonye1, Ezinne Uchamma Godswill-Uko5,  
1 Department of Family Medicine, Federal Medical Centre, Umuahia, Nigeria
2 Department of Family Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
3 Department of Community Medicine, Federal Medical Centre, Port Harcourt, Nigeria
4 Department of Community Medicine, Abia State University Teaching Hospital, Aba, Abia State, Nigeria
5 Department of Anaesthesiology, Federal Medical Centre, Umuahia, Nigeria

Correspondence Address:
Dr. Gabriel Uche Pascal Iloh
Department of Family Medicine, Federal Medical Centre, Umuahia, Abia State
Nigeria

Abstract

Background: Healthcare has become complex requiring balance of ever-increasing demands on physicians against humanness of medicine. As the impetus for the delivery of patient-centred care grows, there is need to study the attitude and practice orientations of medical practitioners to patient–doctor relationship (PDR). The study was aimed at describing the attitude, practice, barriers and benefits of PDR among medical practitioners in Abia State. Participants and Methods: A descriptive cross-sectional study was carried out on 210 medical practitioners in Abia State who were consecutively recruited for the study. Data were collected using self-administered questionnaire that elicited information on attitude, practice, barriers and benefits of PDR. Attitude was assessed with the 18-item Patient-Practitioner Orientation Scale (PPOS) with subscales of caring and sharing. Results: The age of the participants ranged from 26 to 77 years with the mean of 36 ± 8.4 years. There were 173 (82.4%) male. The caring attitude score (mean = 3.57 ± 0.80) was higher than sharing (mean = 3.42 ± 0.65) (P = 0.036). Practice was predominantly doctor-centred (86.7%) than patient-centred (64.3%, P < 0.0001). The most common barrier to PDR was patient–doctor communication, while the most common benefit of PDR was improvement in patient satisfaction. Medical practitioners with duration of practice <10 years had significantly higher mean scores in attitudinal subscale of caring when compared with those with duration of practice ≥10 years (P < 0.0001). The study participants with duration of practice ≥10 years had significantly higher adequate practice (75.0%) of patient-centred care when compared with their counterparts with duration of practice <10 years (47.6%) (P = 0.00005). Conclusion: The attitude to caring did not translate to comparative disposition to sharing. The practice was more doctor-centred than patient-centred. The most common barrier and benefit of PDR were communication drawbacks and improvement in patient satisfaction, respectively. Duration of practice was associated with caring attitude and practice of patient-centred care, respectively.



How to cite this article:
Iloh GU, Onya ON, Nwamoh UN, Onyemachi PE, Chukwuonye ME, Godswill-Uko EU. Patient–Doctor relationship in underserved environment: A cross-sectional study of attitudinal orientation, practice inclination, barriers and benefits among medical practitioners in Abia State, Nigeria.Niger Postgrad Med J 2019;26:87-93


How to cite this URL:
Iloh GU, Onya ON, Nwamoh UN, Onyemachi PE, Chukwuonye ME, Godswill-Uko EU. Patient–Doctor relationship in underserved environment: A cross-sectional study of attitudinal orientation, practice inclination, barriers and benefits among medical practitioners in Abia State, Nigeria. Niger Postgrad Med J [serial online] 2019 [cited 2019 Sep 21 ];26:87-93
Available from: http://www.npmj.org/text.asp?2019/26/2/87/259908


Full Text

 Introduction



Despite tremendous advances in the science of medicine, patient–doctor relationship (PDR) remains a keystone in the quality of healthcare.[1],[2],[3] PDR is a patient-centred care that is an important component of contemporary medical ethics[4] and is becoming more relevant in the current healthcare settings in both developed[5],[6] and developing countries.[7],[8] Globally, there is increasing interest among medical practitioners and other stakeholders in the healthcare industry to understand the concept of PDR in a hospital environment.[1],[4],[6] As a concept, PDR refers to fiduciary relationship of mutual respect, trust and confidence.[9] It involves two-way communication between the patient and the doctor that is the central part of the practice of science and art of medicine.[10],[11] The patient–doctor consultation process has been described as a value chain involving effective communication, establishing rapport, patient disclosure of emotional cues and concerns, doctors expression of empathy and positive reappraisal of concerns.[12] With changing ecology of care, patients are demanding for their participation in the process of care[5],[11],[13] as well as sharing of information on care decisions.[5],[14]

In recent years, several models of patient–doctor interactions in healthcare environment have been documented in biomedical literature, with predominant emphasis on participatory care rather than paternalistic care.[15],[16] Among these models of patient–doctor encounters are the biomedicopsychosocial care of Engel,[2] patient-centred care of Michael Balint[16] and Oslerian tradition by William Osler.[3] These approaches to patient care emphasise the humanness of medicine in diverse care settings, defining care process as distinct from just treatment of diseases. It involves interface of biomedical, behavioural and social approaches to care and considers multiple influences that produce patients biomedical dysfunctions.[1],[16]

The concepts of caring[5],[12],[13] and sharing[14] dimensions of PDR in the process of care have been subjects of global interests and debate with variable reports for and against PDR in the healthcare environment. However, researchers[1],[5],[12],[14] have shown that involvement of patients in decision concerning the management of their health conditions benefits the patient, doctor and health facility. This invariably leads to patient and doctors satisfaction with care,[12] avoid dysfunctional consultations,[5],[12] delivery of high-quality care,[17] patient-centred care,[18] improves patient–doctor communication,[19] congruence on patient–doctor encounter,[20] matching of doctor orientation to patient agenda[12] and trusting relationship between patient and physician.[5],[21] Functional PDR has been documented to decrease medical errors,[22] reduce malpractice suits,[23] establishes continuity of care,[24] promotes adherence to therapeutic and prophylactic treatments[25] and impact favourably on outcome of care.[26] Research studies on PDR have been reported in developed[5],[6] and developing countries;[7],[8] from perspectives of physicians[5],[7] and patients;[5],[6] different clinical settings among primary care patients,[27],[28] cancer patients[29] with majority of the reports showing that effective PDR leads to delivery of care that are attuned to patients concerns with emphasis on measures aimed at enhancing patient participation in the care process as well as interventions targeted on patients health information, education, communication[30] and empowerment.[31]

Various research tools have been designed to assess PDR with different psychometric characteristics.[32] These tools include 18-item Patient-Practitioner Orientation Scale (PPOS-18),[20] Patient-Provider Orientation Scale (PPOS-D12),[6] Patient-Doctor Relationship Questionnaire (PDR-9),[27],[28] Patient-Doctor Depth of Relationship Scale-8[33] and Difficult Doctor-Patient Relationship Questionnaire-10.[34] However, the choice of any tool should be guided by the study settings and objectives of the study on PDR. The PPOS-18 has been validated and used in a variety of clinical contexts and cross-culturally adapted for understanding patient-centred care.[6],[7],[20],[32]

Despite tremendous advances in medical science, studies have shown that PDR in the healthcare environment is under siege[4],[9] and patient's daily experience widespread violation of ethical principles of PDR in health facilities, particularly in underserved settings.[9],[22] The principles of PDRs were developed to narrow the gap between universal abstract theories and real-life relationships in Patient–Doctor encounters.[9],[22] In Nigeria, the extant medical practice is faced, with changing patient and societal attributes requiring moral sensitivity and ethical reasoning.[9],[35] With the increasing awareness of rights of patients in the region, Nigerian patients have the right to all information about their care[36] and should not be subordinated to doctors in therapeutic and prophylactic decision-making on their medical care. Although the concept of PDR has received significant physicians and patients attention in published studies globally,[5],[6],[20],[27],[28],[32] there is a paucity of published research on PDR among medical practitioners in Nigeria. Evaluation of the gap in the knowledge on PDR among medical practitioners in Abia State is quintessential in unravelling the practitioners' behavioural predisposition to the tenets of PDR. As the impetus for the delivery of patient-centred care grows in Nigeria, there is need to study the attitude and practice of medical practitioners to PDR. It is against this backdrop that this study was designed to describe attitude, practice, barriers and benefits of PDR in a cross-section of medical practitioners in Abia State.

 Participants and Methods



Ethical certification was obtained from the Health Research and Ethics Committee of Federal Medical Centre, Umuahia, with reference number FMC/QEH/G.596/Vol. 10/236 dated 10th April 2017. Informed consent was also obtained from the respondents included in the study. This was a descriptive cross-sectional study carried out on 210 private and public medical practitioners who participated in continuing professional development (CPD) program for 2017 Physicians week of Nigerian Medical Association (NMA), Abia State, held on 23 October 2017 or CPD program organised by Directorate of Postgraduate Studies (DPGS) of Federal Medical Centre (FMC) Umuahia, Nigeria, for medical professionals in Abia State, on 3 and 4 May 2017. The questionnaire tool was administered to each eligible medical practitioner once either during CPD program organised by NMA, Abia State, during the Physicians week or by DPGS of FMC, Umuahia, respectively. The inclusion criteria were private and public medical practitioners in Abia State who participated in the 2017 Physicians week CPD program by NMA, Abia State or CPD program organised by DPGS of FMC, Umuahia, Nigeria for medical professionals in Abia State.

The sample size for the study was determined using online sample size calculating software for descriptive study (www.surveysystem.com), accessed on 1 February 2017. The input criteria for sample size estimation were set at 95% confidence level, confidence interval of 5 and accessible sample of 300 medical practitioners based on the previous Abia State Physicians week and FMC, Umuahia CPD attendance registers. This gave a sample size estimate of 169 participants. The sample size calculating software assumed maximum possible proportion of 50% (0.50) which produced maximum possible sample size. To deal with non-response, the estimated sample size was increased by 20% non-response proportion, thus sample size = n/1 – non-response proportion at 20%. This gave a sample size of 211 respondents. However, sample size of 210 respondents was used for the study.

The study instrument consisted of sections on demographic data such as age, sex and years of practice. Other information included attitudinal orientation, practice inclination, barriers and benefits of PDR. Attitude was assessed with pre-validated 18-items PPOS.[20] Each item is rated on a 6-point Likert scale responses of strongly agree, somewhat agree, agree, disagree, somewhat disagree and strongly disagree. A total score, ranging from patient-centred to doctor-centred can be calculated in addition to two subscores. The first 9-item subscale was on caring, while the second 9-item subscale was on sharing. Higher scores on the subscale of caring indicated that the respondent was more doctor-centred, while higher scores on subscale of sharing indicated that the respondent was more patient-centred. Sharing referred to the extent to which the respondents believed that patients should be part of decision-making in the healthcare environment. Caring was the extent to which the respondents understood patient feelings and expectations as critical elements in the treatment process.

Practice orientation was assessed in the previous 12 months using questionnaire that was designed by the authors through robust review of literature on practice, benefits and barriers to PDR.[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31] The face validity of the sections of the instrument on practice orientation, barriers and benefits were evaluated by a panel of knowledgeable experts in legal medicine, field of epidemiology, bioethics and health science research and publications who were not part of the study. The questionnaire was pre-tested using ten medical doctors from FMC, Umuahia, Abia State. Those used for the pre-testing of the study instrument were excluded from the final study. The pre-testing was done to find out how the questions would interact with the respondents and ensure there were no ambiguities. However, no change was necessary after the pre-testing as the questions were interpreted with the same meaning as intended. The usability of the instrument was evaluated to determine the administration, interpretation by participants and authors. The usability criteria[37] for the use of an instrument where there was no existing pre-validated tool were met for the validated and pre-tested sections of the questionnaire tool. Doctor-centred inclination indicated a respondent belief that care process should be paternalistic and more attuned to doctor's preferences, values and concerns, while patient-centred inclination reflected a respondent belief that care process is participatory, shared, respectful and responsive to the patients values, preferences and needs. Adequate practice of doctor-centred and patient-centred care referred to all-time response to question on practice inclination in the previous 12 months, respectively, while inadequate practice of doctor-centred and patient-centred care meant most times, sometimes, rarely and never responses to question on practice inclination in the previous 12 months, respectively. The questionnaire was self-administered since the participants were health literate.

Data generated were analysed using the Statistical Package for Social Sciences software Version 21 (IBM SPSS, New York, USA) for the calculation of frequencies and percentages for categorical variables and mean for continuous variables. Chi-square test was used to test for significance of association between categorical variables and Student's t-test for continuous variables. In all cases, P < 0.05 was considered statistically significant.

 Results



Of the 210 medical professionals who participated in the study, 187 (89.1%) were age < 50 years), while 23 (10.9%) were aged 50 years and above. The age of the participants ranged from 26 to 77 years with the mean age of 36 ± 8.4 years. There were 173 male (82.4%) and 37 female (17.6%) [Table 1].{Table 1}

On the association of mean caring and sharing attitudinal scores of the PPOS of the study participants, the mean caring attitudinal score (3.57 ± 0.80) was higher than the mean sharing attitudinal score (3.42 ± 0.65), and the difference was statistically significant (t-test = 2.112; P = 0.036). Chi-square analysis of the association between doctor-centred and patient-centred practice inclination of the study participants showed that adequate practice of doctor-centred care (182) (86.7%) was higher than adequate practice of patient-centred care (135) (64.3%) and the difference was statistically significant (χ2 = 28.36; P < 0.0001) [Table 2].{Table 2}

On the knowledge of barriers and benefits of PDR among the study participants, the most common barrier to PDR known by the participants was patient–doctor communication (100.0%) while the least was patient belief in care and was known by 186 (88.6%) of the participants. All (100%) of the participants knew that PDR was beneficial in improving patient-doctor satisfaction with care, while the least known was improvement in patient enablement and empowerment (69.5%) [Table 3].{Table 3}

On the relationship of the characteristics of the study participants with caring and sharing PPOS attitudinal orientation, medical practitioners with duration of practice of <10 years had significantly higher mean scores (4.40 ± 0.20) in the attitudinal subscale of caring when compared with their counterparts with duration of practice ≥10 years (3.71 ± 0.42) (t-test = 23.00; P < 0.0001). The mean scores of all the other subscales of caring and sharing domains of PPOS were not statistically significant [Table 4].{Table 4}

On the association of the characteristics of the study participants with practice inclination to doctor-centred and patient-centred care, patient-centred practice was significantly associated with duration of practice (χ2 = 16.39; P = 0.00005). The study participants with duration of practice of ≥10 years had significantly higher adequate practice (75.0%) of patient-centred care when compared with their counterparts with duration of practice of <10 years (47.6%). Other explanatory variables save sex (χ2 = 12.131; P = 0.0005) were not significantly associated [Table 5].{Table 5}

 Discussion



The attitudinal orientation of the respondents was predominantly attuned to caring than sharing. The findings of this study are in consonance with the reports from Nigeria[7] and other parts of the world[5],[12],[20] that medical practitioners have higher caring attitude than sharing attitude. The caring attitudinal orientation recognises the patient as a person with a 'disease', whereas the sharing attitudinal inclination sees the patient as a whole person rather than a disease.[5],[19] Traditionally, medical practitioners exert referent, coercive and expert power, but at present, there is paradigm shift of this power towards shared decision-making.[9],[14] Medical practitioners should, therefore, see the patient as someone similar to him and be prepared to share information on the care process[14] in addition to developing the agenda during patient–doctor consultation.[35] Literally, the medical practitioner is an expert in the medical science that enables him to make a management decision that affects the patient as a whole, but the patient is an expert in his own body, his perception and illness experience, feelings, ideas and functional disabilities. If the patient is not involved in his care, what to expect, how to manage the health condition, the patient may become further depersonalised and distanced from the medical practitioner. However, shared decision-making process should take into consideration the uniqueness of individual patient attributes, expectations, life priorities and environmental situation. There is, therefore, the need for medical practitioners to understand that 'caring' is sociophysiologically[4],[13] and ethically inadequate for standard patient management.[4],[22],[36] Medical practitioners should have a matching orientation to PDR through shared decision-making in order to transform PDR into a worthwhile experience for the patients, especially in resource-constrained settings where there are limited options for standard patient care.

This study has shown that the study participants were more inclined to the practice of doctor-centred care (paternalism) rather than patient-centred care (partnership). The findings this study is in tandem with traditional biomedical model of care which emphasised body–mind dualism, reductionism and detached observer[38] but contrasts with the current global standard of care which recognised patient-centred care as the cornerstone for high quality of care.[2],[3],[16],[17],[39] Although patient-centred care is a relatively recent concept of interest in clinical practice, global organisations[17],[39] and majority of medical practitioners[5],[6],[25] are accepting it as a standard of care which involves treating patients as partners and involving them in shared decision-making. The patient-centred care is expected to change the belief of medical practitioners during patient encounter in healthcare setting from 'I and the patient' into 'I am the patient' or at least 'I might be the patient'.[40] The patient-centred care is acclimatised with whole person-centred care, participatory care and shared decision-making and is the need of the moment, especially in underserved environment[9],[22],[36] where there is growing societal discontent with healthcare delivery system.[41] There is, therefore, the need for medical practitioners to promote patient-centred care which engages the patients and enhances consultation experiences and other diverse favourable patient care outcomes.

The most common benefit known by the respondents was improvement in patient satisfaction with care. This finding is in accord with the previous reports on the benefits of PDR in Nigeria[7] and other parts of the world.[5],[12],[20] According to these research studies,[5],[7],[12],[20] PDR is most satisfactory to the patient, the practitioner and productive to the healthcare system. This satisfaction with care leads to patient–doctor fit during consultations,[12] trusting PDR,[5],[21] concordance on management plan[20],[26] and patient–doctor attitudinal symmetry in the healthcare process.[42] Of great interest is that patients are highly satisfied when their medical doctor has a matching orientation to PDR through shared decision-making. Medical practitioners should appreciate the uniqueness of individual patients encounter and provide a consultation that promotes patients satisfaction with care. The medical doctor should see himself as a 'medicine' for the holistic care of the patient and need to administer 'himself' to the patient as well as recognise the 'dose' needed by the patient in every patient–doctor encounter. This attitudinal disposition of medical doctor as a 'medicine' for the patient helps to restore the connectedness of the humanness of medicine which engineers and engenders satisfaction with care. Satisfaction with care is vital for patients physical, social, mental, emotional and spiritual well-being and is the royal pathway to holistic care.[41] Patient satisfaction with care therefore should be in the hearts of every medical practitioner during patient–doctor consultations.

The most common barrier to PDR was patient–doctor communication. The finding of this study has buttressed reports from Nigeria[7] and other parts of the world[19],[23],[25] that effective patient-doctor communication is critical and central element in PDR. According to these research reports,[7],[19],[23],[25] patient–doctor communication positively or negatively affects patient outcome such as satisfaction with care amongst others. It is the positive and effective patient–doctor communication that begets relationship in the process of care. Patient–doctor communication barriers arise when medical practitioner focuses on disease and their management rather the person that has the disease[3],[11],[38] his proximal and distal contextual factors and other determinants of patients illness experience.[38] Overcoming communication barrier in PDR helps to improve the social image of the medical practitioner specifically to the patients and generally to the society at large. It is clinically imperative for medical practitioners to know that beside clinical and surgical skills[43] and competence, patient-centred communication is associated with patient satisfaction with quality of care,[44] patient safety in healthcare environment[25] and fewer malpractice complaints and lawsuits.[9],[22],[23] Medical practitioners should therefore make use of the communication skills to leave best and indelible impressions on the minds of the patients. The most pre-eminent thing a medical doctor should communicate to his patient is total care and this makes patient–doctor communication more efficacious, altruistic and patient-centred.

Caring attitudinal orientation was related with duration of practice. Medical practitioners with duration practice of <10 years had higher mean caring score compared to their counterparts with duration of practice 10 years and more. This finding is in congruence with the previous reports from Nigeria[9],[22],[36],[41] that duration of practice of <10 years influences receptivity and acceptability of information on the precepts of patient–doctor interactions which begets positive and effective patient–doctor communication, relationship and satisfaction with quality of healthcare. This could be a reflection the fact that effective communication on patient–doctor encounter requires patience and experience which affords a wider scope for information exchange between the patient and the medical practitioner. Medical professionals irrespective of the duration of practice should serve as advocate for functional and satisfying PDR through dedicated approaches that protect and promote PDR, particularly at the point of care interface. This will ensure sustenance of patient satisfaction with doctor's consultation and safeguard the integrity of the medical profession. It is therefore quintessential that every practitioner of the noble art and science of medicine be aware of the benefits of PDR in order to provide acceptable level of care. This will go a long way to improve quality of healthcare received by the consumers of healthcare goods and services, especially in underserved environment where there are limited options for standard patients care. Building trusting and satisfying PDR irrespective of duration of practice is a professional calling of every medical practitioner involved in the care of the modern day patient.

Patient-centred inclination was associated with years of practice. The study participants with years of practice of 10 years and more had higher adequate practice inclination to patient-centred care when compared with those with years of practice of <10 years. This finding could be a reflection of the sagging patient–doctor interaction during traditional medical clerkship and pertinent physical examinations among practitioners with duration of practice <10 years.[10],[43],[45],[46] Admittedly, medicine is a dichotomous discipline with one part being 'a science' and the other part 'an art'. The art of medicine is patient-centred, while the science of medicine is disease and doctor-centred.[2],[10],[11] Medical practitioners with years of practice of 10 years and more are more likely to have patient-orientated mindset rather than doctor-oriented mindset which involves treating patients as partners and engaging them in decision-making.[47] The findings of this study call for the promotion of patient-centred care which enhances consultation experiences and other diverse patient care outcome.[33] It is, therefore, necessary to emphasise the power of humanness of medicine in patient-centred care which is the need of the hour, especially in Nigeria where there is growing discontent with healthcare delivery system.

Study limitations

The attitude and practice of PDR were based on respondents' subjective responses and were not verified. However, there is a tendency to underreport episodes of breaches of the tenets of PDR in addition to social desirable responses.

 Conclusion



The attitudinal orientation to caring did not translate to comparative disposition to sharing. The practice inclination was more doctor-centred than patient-centred. The most common barrier and benefit of PDR were communication drawbacks and improvement in patient satisfaction with care, respectively. Duration of practice was associated with caring attitude and practice of patient-centred care, respectively. PDR should be the focus of intensive continuing medical education and professional development among medical practitioners in addition to greater emphasis on communication aimed at improving patient's satisfaction with care, especially, in resource-poor settings where there are limited options for effective and efficient healthcare delivery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Adler HM. Toward a biopsychosocial understanding of the patient-physician relationship: An emerging dialogue. J Gen Intern Med 2007;22:280-5.
2Engel GL. From biomedical to biopsychosocial. Being scientific in the human domain. Psychosomatics 1997;38:521-8.
3Bryan CS. What is the Oslerian tradition? Ann Intern Med 1994;120:682-7.
4Smith DH. Ethics in the doctor-patient relationship. Crit Care Clin 1996;12:179-97.
5Krupat E, Bell RA, Kravitz RL, Thom D, Azari R. When physicians and patients think alike: Patient-centered beliefs and their impact on satisfaction and trust. J Fam Pract 2001;50:1057-62.
6Kiessling C, Fabry G, Fischer M, Steiner C, Langewitz W. Deutsche übersetzung und konstruktvalidierung des “patient-provider-orientation scale” (PPOS-D12). Psychother Psych Med 2014;64:122-7.
7Abiola T, Udofia O, Abdullahi AT. Patient-doctor relationship: The practice orientation of doctors in Kano. Niger J Clin Pract 2014;17:241-7.
8Onotai LO, Ibekwe U. The perception of doctor-patient relationship of otorhinolaryngology clinics of the University of Port Harcourt Teaching Hospital (UPTH) Nigeria. Port Harcourt Med J 2011;6:65-73.
9Iloh GU, Onyemachi PE, Chukwuonye ME, Ifedigbo CV. Medical ethics in a resource-constrained setting: A cross-sectional study of awareness, attitude, practice, violations of its principles and ethical dilemmas experienced by medical professionals in Abia state, Nigeria. BLDE Univ J Health Sci 2018;3:89-96.
10Saunders J. The practice of clinical medicine as an art and as a science. Med Humanit 2000;26:18-22.
11Aryeh L, Goldberg BA. Re-thinking the art of medicine while healing is no longer sufficient. J Gen Pract 2014;2:140.
12Krupat E, Yeager CM, Putnam SM. Patient role orientations, doctor-patient fit, and visit satisfaction. Psychol Health 2000;15:707-19.
13Adler HM. The sociophysiology of caring in the doctor-patient relationship. J Gen Intern Med 2002;17:874-81.
14Sandman L, Munthe C. Shared decision making, paternalism and patient choice. Health Care Anal 2010;18:60-84.
15Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA 1992;267:2221-6.
16Henningsen P. Still modern? Developing the biopsychosocial model for the 21st century. J Psychosom Res 2015;79:362-3.
17IOM Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: IOM Committee on Quality of Health Care in America; 2001.
18Taylor K. Paternalism, participation and partnership – The evolution of patient centeredness in the consultation. Patient Educ Couns 2009;74:150-5.
19Ishikawa H, Hashimoto H, Kiuchi T. The evolving concept of “patient-centeredness” in patient-physician communication research. Soc Sci Med 2013;96:147-53.
20Krupat E, Rosenkranz SL, Yeager CM, Barnard K, Putnam SM, Inui TS. The practice orientations of physicians and patients: The effect of doctor-patient congruence on satisfaction. Patient Educ Couns 2000;39:49-59.
21Chin JJ. Doctor-patient relationship: A covenant of trust. Singapore Med J 2001;42:579-81.
22Iloh GU, Chuku A, Amadi AN. Medical errors in Nigeria: A cross-sectional study of medical practitioners in Abia state. Arch Med Health Sci 2017;5:44-9.
23Levinson W. Physician-patient communication. A key to malpractice prevention. JAMA 1994;272:1619-20.
24Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018;8:e021161.
25Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: A meta-analysis. Med Care 2009;47:826-34.
26Kelley JM, Kraft-Todd G, Schapira L, Kossowsky J, Riess H. The influence of the patient-clinician relationship on healthcare outcomes: A systematic review and meta-analysis of randomized controlled trials. PLoS One 2014;9:e94207.
27Porcerelli JH, Murdoch W, Morris P, Fowler S. The patient-doctor relationship questionnaire (PDRQ-9) in primary care: A validity study. J Clin Psychol Med Settings 2014;21:291-6.
28Van der Filtz-Cornelis CM, Van Oppen P, Van Marwijk HW, De Beurs E, Van Dyok R. A patient-doctor relationship questionnaire (PDR-9) in primary care: Development and psychometric evaluation. Gen Hosp Psychiatry 2004;26:115-20.
29Chan CM, Azman WA. Attitudes and role orientations on doctor-patient fit and patient satisfaction in cancer care. Singapore Med J 2012;53:52-6.
30Haywood K, Marshall S, Fitzpatrick R. Patient participation in the consultation process: A structured review of intervention strategies. Patient Educ Couns 2006;63:12-23.
31Anderson RM, Funnell MM. Patient empowerment: Reflections on the challenge of fostering the adoption of a new paradigm. Patient Educ Couns 2005;57:153-7.
32Eveleigh RM, Muskens E, van Ravesteijn H, van Dijk I, van Rijswijk E, Lucassen P, et al. An overview of 19 instruments assessing the doctor-patient relationship: Different models or concepts are used. J Clin Epidemiol 2012;65:10-5.
33Ridd MJ, Lewis G, Peters TJ, Salisbury C. Patient-doctor depth-of-relationship scale: Development and validation. Ann Fam Med 2011;9:538-45.
34Hahn SR, Kroenke K, Spitzer RL, Brody D, Williams JB, Linzer M, et al. The difficult patient: Prevalence, psychopathology, and functional impairment. J Gen Intern Med 1996;11:1-8.
35Okokon IB, Ogbonna UK. The consultation in primary care: Physician attributes that influence patients' satisfaction in Calabar, Nigeria. J Gen Pract 2013;2:135.
36Iloh GU, Amadi AN, Chukwuonye ME, Ifedigbo CV, Orji UN. Patient's rights in an underserved Nigerian environment: A cross-sectional study of attitude and practice orientation of medical professionals in Abia state. BLDE Univ J Health Sci 2017;2:97-104.
37Biddix JP. Quantitative Methods: instrument Validity, Reliability, Usability, Research Rundowns. Available from: https://researchrundowns.com.instrument. [Last accessed on 2018 Dec 04].
38Inem V. Foundational knowledge for the practice of Family Medicine in West Africa. Lagos: Gbola Awujoola Press; 2016. p. 49-60.
39The Joint Commission. What did the doctor say? Improving Health Literacy to Protect Patient Safety; 2007. Available from: http://www.jointcommission.org/assets/1/18/improving_health_literacy.pdf. [Last accessed on 2017 May 29].
40Kusnanto H, Agustian D, Hilmanto D. Biopsychosocial model of illnesses in primary care: A hermeneutic literature review. J Family Med Prim Care 2018;7:497-500.
41Iloh GU. Quality of care in Africa: Managing patients' expectations and renewing their confidence in service delivery: The best baseline for calibration in Africa. In: Saldana JR, editor. Quality of Health Care: From Evidence to Implementation. New York: Nova Publishers; 2015. p. 269-90.
42Cvengros JA, Christensen AJ, Hillis SL, Rosenthal GE. Patient and physician attitudes in the health care context: Attitudinal symmetry predicts patient satisfaction and adherence. Ann Behav Med 2007;33:262-8.
43Fred HL. On the sagging of medical professionalism. Binocul Vis Strabismus Q 2005;20:12.
44Zandbelt LC, Smets EM, Oort FJ, Godfried MH, de Haes HC. Patient participation in the medical specialist encounter: Does physicians' patient-centred communication matter? Patient Educ Couns 2007;65:396-406.
45Akl KF, Damra HS, Melhem MJ. Decline of the medical history and physical examination. Indian J Pediatr 2012;79:676-7.
46Jones T, Glover L. Exploring the psychological processes underlying touch: Lessons from the Alexander technique. Clin Psychol Psychother 2014;21:140-53.
47Duggan PS, Geller G, Cooper LA, Beach MC. The moral nature of patient-centeredness: Is it “just the right thing to do𕢝? Patient Educ Couns 2006;62:271-6.