The Psychological Attitude of Patients toward Health Practitioners in Lebanon.

BACKGROUND: Patients often complain about their doctor's attitude toward them. They describe the interaction that they have with some doctors as quick, cold, discourteous, or hardhearted. Although this does not apply to all Lebanese doctors, it does apply to some. AIMS: The purpose of this study was to (1) examine the general perception of satisfaction, trust, and openness that Lebanese patients hold toward the work, office, personal, and social characteristics of their doctors - physician or dentist; and (2) identify the aspects on which a Lebanese health practitioner should focus to improve his/her practice.
MATERIALS AND METHODS: A convenient sample of 450 individuals from an area housing nine hospitals and hundreds of private clinics in Greater Beirut were surveyed regarding the qualities of their health practitioners. They were asked to complete a nine-page, 85-item, anonymous, and voluntary questionnaire that dealt with the medical and dental practice in Lebanon. Participants were older than 18 years and mentally competent. None was physicians, dentists, or nurses. The questionnaire was open-ended and initially pretested and piloted among a random sample.
RESULTS: Four hundred-fifteen (92%) individuals responded. Participants were from different ages, genders, geographical areas, educational backgrounds, and professions. The doctor traits most preferred by the Lebanese public were found to be: Empathy (90%), professionalism (87%), miscellaneous traits (86%), and academics (81%).
CONCLUSION: The results support the conventional wisdom that the idealized perception of a doctor as a care-giving, compassionate, knowledgeable, well-appearing, and healthy role model still holds true within the Lebanese community.

Introduction

Hippocrates once said that a doctor should “be clean in person, well-dressed, and anointed with sweet-smelling unguents.” Since his days, doctors have become more aware of the importance of their public image and appearance because this image often affects the doctor-patient relationship. Even in primitive societies, the way the healer dressed was part of the healing ritual itself.[1] Indeed, a clean, carefully dressed physician/dentist might communicate that patient contact is an important event that requires careful preparation while unkempt and carelessly dressed physicians/dentists may be perceived as unskilled and uncaring.[23] Therefore, the ways in which a doctor, whether a physician or a dentist, manages his/her work and office, and demonstrates his/her personal and professional qualities are vital to the patient's perception of the quality of medical care being provided.

From early years onward, relationships are fundamental; no human endures birth and grows normally without the corporeal and expressive engagement of a caregiver. This arrangement continues to have critical consequences all through the life cycle.[456] Likewise, the doctor-patient relationship is fundamental to the deliverance of premium medical care and has been shown to affect contentment and a variety of other biological, psychological, and social outcomes.[1] While patients may not be able to evaluate whether a medical procedure has been properly executed, they can and do, however, respond to the manner in which a service is provided. The quality of interaction between the patient and the healthcare provider is a critical component of patient-perceived quality of care. In many instances, patients change doctors not because of poor diagnostic and surgical skills, but because of poor communication.[7]

The purpose of this study, then, was to:

Examine the general perceptions of satisfaction, trust, and openness that Lebanese patients hold toward the work, office, personal, and social characteristics of their doctors — physicians or dentists; and

Identify the aspects on which a Lebanese health practitioner should focus to improve his/her practice in general.

Materials and Methods

Study design and ethical permission

This cross-sectional survey was conducted between September and December of 2014. Upon providing informed consent, participants completed a designed and customized questionnaire about their preferences for the personal and professional characteristics and work and office ethics of their health providers (physicians and dentists). Permission to conduct the study was obtained from the Institutional Review Board at the Lebanese University, and participant data were de-identified, as we waived the requirement for written consent.

Study setting and population

Lebanon is a small republic that has always been at the crossroads of three continents and the direct way between the West and the Arab world. Its location has shaped its unique cultural identity of religious and ethnic diversity.[8] At present, 18 religious communities comprise the Lebanese population. Numerically, the Sunnite, Shiite, Druze, Maronite, Greek orthodox, Greek Catholic, Syriac, and Armenian communities are the most important.[9] This unique demographic constitution and ethnic diversity among the Lebanese people will help us better understand the psychological attitudes of patients toward their physicians and dentists.

As the capital, Beirut is considered to be one of the most cosmopolitan and religiously diverse cities of Lebanon and the Middle East.[10] For this reason, the study questionnaire was distributed in the Greater Beirut area, a region housing nine hospitals and hundreds of private clinics. We covered wide areas to include participants from different cultural, ethnic, religious, socioeconomic, professional and educational backgrounds.

A total of 415 participants from different vicinities were interviewed. While a majority of participants came from the capital city, others resided in cities in the North (Tripoli, Batroun, Koura); South (Saydoun, Tyre, Nabatieh, Bint Jbeil); and East (Shtoura, Zahle, Baalbeck) regions of Lebanon.

This type of sample was selected to guarantee a minimal level of generalizability. Hence, the views of the people echoed in this study do not depict that of a definite area or definite socioeconomic group in Lebanon; rather, it discloses a communal attitude on the part of the Lebanese people.

Sampling

The Central Administration for Statistics estimated Lebanon's population in 2007 to be approximately 3,759,136. The original Lebanese population in Greater Beirut has been estimated to be 1,845,840.[11]

Taking a 50% response distribution to attain the largest sample size possible, a 5% margin of error and a 95% confidence interval, the minimum number of participants recommended to have a representative sample was calculated to be 385. We had a sample size of 415.

Health practitioners including physicians, dentists, and nurses were barred to guarantee impartiality. Participants were Lebanese, over 18 years (18 is the legal age when medical choices can be made independently) and judged to be mentally competent. Participants must have seen a physician or a dentist at least once during the year in which the study took place.

Measure

A nine-page, 85-item, anonymous, voluntary, and self-administered questionnaire was designed and adapted to explore the psychological attitudes of satisfaction (contentment), trust, and openness that patients show in response to their health provider's (physician and/or dentist) personal attributes, professional qualities, and work and office environment. The questionnaire included open-ended questions at the end and was initially pretested and piloted among a random sample to examine its practicability and lucidity and to ensure that participants would not provide what they may well pick out to be publicly enviable responses. Confidentiality was protected and guaranteed as any form of written consent was waived.

The questionnaire was structured in two parts. The first part of the questionnaire required demographic and general information about the participants (gender, age, profession, and level of academic education). The second part required the participants to evaluate the characteristics that, according to their own beliefs and perceptions, a physician/dentist must have.

The questionnaire contained items about the many features related to a physician/dentist's empathy, professionalism, academic qualifications, and additional miscellaneous factors. It was previously deemed valid and reliable after being piloted among a random sample and evaluated by the Faculty of Medical Sciences and the Faculty of Dental Medicine at the Lebanese University.

Data processing and analysis

Patients rated their attitudes in response to various characteristics associated with their healthcare provider along a Likert scale ranging from 1 (very negative) to 7 (very positive). A lower score was indicative of a participant's poorer psychological well-being in response to the specific healthcare provider characteristic being referenced. Likewise, a higher score indicated better psychological well-being. Scores of one, two, and three were considered to be negative, whereas scores of five, six, and seven were considered to be positive. A score of four was categorized as neutral. The analyses were performed using Microsoft Excel and IBM Statistical Package for the Social Sciences (SPSS) (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0, IBM Corp., Armonk, NY).

Results

This convenient sample included 185 males (45%) and 230 females (55%). The mean age was 26.69 years. Detailed demographic characteristics of the sample can be seen in Table 1.

Table 1

Sample profile (n = 415)

The analyses identified four broad categories of desirable characteristics in a doctor (physician/dentist). The traits most desired by sample participants included empathy (90%), professionalism (87%), miscellaneous traits (86%), and academics (81%).

A sorting by precedence of the desired empathetic qualities showed that the Lebanese public perceived being polite and gentle (99%), showing interest in the patient's illness (97%), being compassionate (~93%), and asking about patient's symptoms (90%) as the most important characteristics in a doctor.

The most desired professional qualities by the Lebanese public were indicated as follows: Maintaining confidentiality (100%), using sterile (98%) and new (97%) equipment, punctuality (93%), and writing detailed prescriptions (91%). A majority of the participants disapproved of interruptions (77%), such as someone knocking on the door or the doctor having to take a call as well as the doctor having bad handwriting (61%). An interesting finding was that 95% of the participants appreciated a doctor who showed respect to other colleagues in the profession.

The Lebanese public preferred an up-to-date (97%), experienced and well-known doctor (93%). Interestingly, 83% of the public wanted their doctor to use modern medicine and to convince the patient to not seek alternative treatments. When asked to elaborate, participants showed discontent with alternative medical procedures and products. Participants encouraged the use of a foreign language and medical vocabulary to explain symptoms and other information (73%) and preferred a doctor with a medical degree from a foreign country (61%). When asked to elaborate on the latter, most participants preferred doctors with North American or European medical backgrounds.

Other factors preferred by the Lebanese public regarding a doctor's lifestyle and workplace included: Having a clean pleasant office (100%), wearing a white coat (99%), living a healthy lifestyle (91%), having a good-looking appearance (85%), dressing conservatively (80%), maintaining proper waiting rooms (79%), and having inexpensive fees (56%). It should be mentioned that 29% of the participants felt negatively toward inexpensive fees. When asked to elaborate, most of these participants responded with the belief that less expensive doctors do not provide quality healthcare. Interestingly, negative qualities of a healthcare provider, as indicated by the participants, included having long nails (100%) and smoking (97%). A detailed evaluation of the physician/dentist's qualities can be viewed in Table 2.

Table 2

The participants’ detailed responses to factors related to the doctor's empathy, professionalism, academic and other qualities — Greater Beirut, Lebanon, 2014

Regarding dentists specifically, 91% of the participants wanted their dentist to explain proper brushing and flossing techniques and to advise them in their selection of the best type of brush and toothpaste. Furthermore, 86% demanded that their dentist wears gloves, a mask and goggles while performing a treatment or operation. In addition, 99% wanted the dentist's chair to be comfortable and relaxing.

Discussion

The doctor-patient relationship is focused on the delivery of high quality medical care. Beginning the minute, the patient schedules an appointment and enters the waiting room and ending with the patient leaving the doctor's office and paying his/her fees, the quality of care provided to the patient should give him/her satisfaction. We desired to address the patient's whole experience with the physician/dentist.

Our results conform to those produced by the European Task Force on Patient Evaluations of General Practice (EUROPEP) that showed humanness to be of the most valued traits in a healthcare provider.[12] Similarly, in the West of Scotland, Pellegrino revealed that the most essential requirement of general practice is to have a physician/dentist who pays attention and does not rush the patient.[13] Other studies by Mowen et al.,[14] Dunn et al.,[15] and Short[16] echo findings similar to those demonstrated in our study.

The emotional outlay required to construct a caring doctor-patient relationship can be justified on humanitarian basis as well as on the direct physiologic intervention.[171819] The experience of feeling cared for in a relationship reduces the release of stress hormones and shifts the neuroendocrine system toward homeostasis[17] by generating both acute and chronic diminutions in the activity of the hypothalamic-pituitary-adrenal axis.[20] Siegel,[21] Shortt and Pennebaker[22] report that just the act of taking the patient's medical history can alleviate some of the patient's stress.

In matters of professionalism, we noticed that participants preferred a doctor who asks about their symptoms and writes detailed prescriptions. Our results conform to Adler's by showing that Lebanese patients are interested in participating in the process of their own healing.[23] They want to be engaged in conversations during the exam and feel negative about interruptions. They also prefer their doctor to write prescriptions in clear handwriting. We believe that these preferences stem from the patient's need to improve oral and written communications. This is different from the stereotypical image that some may have about the paternal role of the doctor in the doctor-patient relationship, whereby the doctor dictates and the patient must follow.

Lebanese patients emphasized “punctuality” as an important virtue, whereby patient satisfaction was inversely related to waiting. Time spent waiting can be psychologically painful because it causes the patient to give up more productive, rewarding activities. Moreover, the fact that waiting for healthcare is situationally stressful increases the patient's anxiety and the length of his/her perceived wait time.[14]

When asked for reasons for putting less weight on scientific traits, participants replied that they already believed in the scientific credentials of their doctors. For them, the issue lies in the fact that most health practitioners are short of further dexterities that are evenly significant in their communication with patients. A study by Arawi showed similar results.[12] This finding does not necessarily suggest that technical skills are less imperative than personal skills, but it does suggest that the former are trickier for patients to judge.[7151624]

In addition, even though physical appearance is not a substitute for good clinical skills, it plays an imperative part in the progress of the doctor-patient relationship.[23] Our results indicate that Lebanese patients still prefer to see their doctors dressed in traditional formal attire (99% preferred a white coat). The key motive for questioning the use of a white coat was our concern about the new concept of the doctor-patient relationship that adopts a more egalitarian relationship between the doctor and his patient rather than a paternalistic one; Adler[23] and Carter[25] have claimed that the white coat has become a menace to patients. In Denmark and England, it is now rare to see a primary physician wearing a white coat while in Sweden, Finland, and Norway many still wear it.[19] We further noted that none of the participants reported being impressed by a doctor who is overweight, has long nails, or smokes.

We agree with Arneill and Devlin that the environment plays a vital role in conveying empathy, warmth, and friendliness even before the patient interacts with staff.[7] These soothing factors can distract the patients from their worries and decrease their levels of anxiety. In our survey, participants preferred the waiting room and the physician/dentist's office to be modern, stylish and equipped with up-to-date magazines and new furniture. Data showed cleanliness and sterilization to be very important in the setting as well.

Strengths and limitations

This study succeeded in examining the general perceptions of satisfaction, trust, and openness that Lebanese patients hold toward the work, office, personal, and social characteristics of their doctors — physicians or dentists. It showed that:

A doctor's compassion, care, and interest relieve patients from distressing emotions;

Punctuality, respect, and secrecy are virtuous and desirable qualities in a doctor;

Lebanese patients want to understand and participate in the management of their own treatments;

Lebanese patients view doctors as role models in health, well-being, and appearance; and

Doctors must aim to best benefit themselves as givers and patients as receivers.

The study provides additional guidance in identifying the aspects on which a Lebanese health practitioner should focus to improve his/her practice in general.

Regarding limitations, this study could have been performed in a wider region and with a larger sample. The sample utilized was a haphazard convenient sample. Therefore, it may not be representative, and the results may not be generalizable. Nevertheless, the study generated noteworthy data and can be used as the basis for future research in Lebanon and elsewhere in the region.

The setting of the study played a role in having a younger sample with a relatively high academic and educational background. The setting included areas around seven university medical centers. Students and workers who attend these universities or work at these medical centers were more available to participate in the study. In addition, the study lacked economic data related to the patients’ pursuit of healthcare.

Conclusion

The idealistic perception of the doctor as a care-giving, compassionate, knowledgeable, well appearing, and healthy role model still holds true within a convenient sample of the Lebanese community.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.