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Behavioral Indices in Medical Care Outcome: The Working Alliance, Adherence, and Related Factors

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Abstract

Background

The working alliance has been shown to be a consistent predictor of patient outcome and satisfaction in psychotherapy. This study examines the role of the working alliance and related behavioral indices in predicting medical outcome.

Objective

Cognitive and emotional dimensions of the physician–patient relationship were examined in relation to patients’ ratings of physician empathy, physician multicultural competence, perceived utility of treatment, and patients’ adherence self-efficacy. These factors were then examined as part of a theoretical framework using path analyses to explain patient self-reported adherence to and satisfaction with treatment.

Design

The study was based on an ex-post facto field correlation design.

Participants

One hundred fifty-two adult outpatients from a neurology clinic at Bellevue Hospital, a large municipal hospital in New York City, participated in the study.

Interventions

Surveys given to participants.

Measurements

We used the following measurements: Physician–Patient Working Alliance Scale, Perceived Utility Scale, Treatment Adherence Self-Efficacy Scale, Medical Outcome Study Adherence Scale, Physician Empathy Questionnaire, Physician Multicultural Competence Questionnaire, Medical Patient Satisfaction Questionnaire.

Main Results

The effect sizes for adherence are between 0.07 and 0.21 and for satisfaction between 0.10 to >0.50. Regression and path analyses showed that ratings of physician multicultural competence and patient adherence self-efficacy beliefs predicted patient adherence (SB = 0.34) and (SB = 0.30) and satisfaction (SB = 0.18) and (SB = 0.12), respectively. Working alliance ratings also predicted patient satisfaction (SB = 0.49).

Conclusions

Psychological and interpersonal dimensions of medical care are related to patient adherence and satisfaction. Medical care providers may be able to use these dimensions to target and improve health care outcomes.

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References

  1. Fuertes JN, Mislowack A, Bennett J, et al. The physician patient working alliance. Patient Educ Couns. 2007;66:29–36.

    Article  PubMed  Google Scholar 

  2. Laine C, Davidoff F. Patient-centered medicine. A professional evolution. JAMA. 1996;275:152–6.

    Article  PubMed  CAS  Google Scholar 

  3. Christensen AJ, Johnson JA. Patient adherence with medical treatment regimens: an interactive approach. Curr Dir Psychol Sci. 2002;11:94–7.

    Article  Google Scholar 

  4. Bordin E. The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, and Practice. 1979;16:252–60.

    Article  Google Scholar 

  5. Wampold BE. Outcomes of individual counseling and psychotherapy: empirical evidence addressing two fundamental questions. In: Brown SD, Lent RW, eds. Handbook of Counseling Psychology. 3rd ed. New York: Wiley; 2000. pp. 3711–39.

    Google Scholar 

  6. Gelso CJ, Carter JA. The relationship in counseling and psychotherapy: components, consequences, and theoretical antecedents. J Couns Psychol. 1985;13:155–244.

    Article  Google Scholar 

  7. Zinn W. The empathic physician. Arch Intern Med. 1993;153:306–12.

    Article  PubMed  CAS  Google Scholar 

  8. Rogers AI. The cornerstone of medicine: the physician–patient relationship. Am J Gastroenterol. 2007;102:1594–5.

    Article  PubMed  Google Scholar 

  9. Silvester J, Patterson F, Koczwara A, Ferguson E. “Trust me...” Psychological and behavioral predictors of perceived physician empathy. J Appl Psychol. 2007;92:519–27.

    Article  PubMed  Google Scholar 

  10. Davis MH. Empathy: A Social Psychological Approach. Boulder, CO: Westview Press; 1996.

    Google Scholar 

  11. Larson EB, Yao X. Clinical empathy as emotional labor in the patient-physician relationship. JAMA. 2005;293:1100–6.

    Article  PubMed  CAS  Google Scholar 

  12. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Veloksi JJ, Magee M. The Jefferson Scale of Physician Empathy: further psychometric data and differences by gender and specialty at item level. Acad Med. 2002;77(10 Suppl):S58–60.

    Article  PubMed  Google Scholar 

  13. Engle GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129–36.

    Article  Google Scholar 

  14. DiMatteo MR, Hays RD, Gritz ER, et al. Patient adherence to cancer control regimens: scale development and initial validation. Psychol Assess. 1993;5:102–12.

    Article  Google Scholar 

  15. Ronis DL, Harel Y. Health beliefs and breast examination behaviors: analyses of linear structural relations. Psychol Health. 1989;3:259–85.

    Article  Google Scholar 

  16. Sutton SR, Eiser JR. The decision to wear a seat belt: the role of cognitive factors, fear, and prior behaviour. Psychol Health. 1990;4:111–23.

    Article  Google Scholar 

  17. Bandura A. Self-efficacy: The Exercise of Control. New York: W.H. Freeman; 1997.

    Google Scholar 

  18. Catz SL, Kelly JA, Bogart LM, Benotsch EG, McAuliffe TL. Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychol. 2000;19:124–33.

    Article  PubMed  CAS  Google Scholar 

  19. Eldred LJ, Wu AW, Chaisson RE, Moore RD. Adherence to antiretroviral and pneumocystis prophylaxis in HIV disease. J Acquir Immune Defic Syndr. 1998;18:117–25.

    CAS  Google Scholar 

  20. Zebracki K, Drotar D. Outcome expectancy and self-efficacy in adolescent asthma self-management. Child Health Care. 2004;33:133–49.

    Article  Google Scholar 

  21. Bandura A, Cioffi D, Taylor CB, Brouillard ME. Perceived self-efficacy in coping with cognitive stressors and opioid activation. J Pers Soc Psychol. 1988;55:479–88.

    Article  PubMed  CAS  Google Scholar 

  22. Jensen MP, Turner JA, Romano JM. Self-efficacy and outcome expectancies: relationship to chronic pain coping strategies and adjustment. Pain. 1991;44:263–9.

    Article  PubMed  CAS  Google Scholar 

  23. Rokke PD, Fleming-Ficek S, Siemens NM, Hegstad HJ. Self-efficacy and choice of coping strategies for tolerating acute pain. J Behav Med. 2004;27:343–60.

    Article  PubMed  Google Scholar 

  24. Berg JS, Dischler J, Wagner DJ, Raia JJ, Palmer-Shevlin N. Medication compliance: a healthcare problem. Ann Pharmacother. 1993;27(9 Suppl):S1–24.

    PubMed  CAS  Google Scholar 

  25. Kripalani S, Yao X, Haynes RB. Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med. 2007;167:540–50.

    Article  PubMed  Google Scholar 

  26. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487–97.

    Article  PubMed  CAS  Google Scholar 

  27. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Lawrence Earlbaum Associates; 1988.

    Google Scholar 

  28. Tracey TJ, Kokotovic AM. Factor structure of the Working Alliance Inventory. Psychol Assess. 1989;1:207–10.

    Article  Google Scholar 

  29. Hays RD. The Medical Outcomes Study (MOS) Measures of Patient Adherence. 1994. Available at: http://www.rand.org/health/surveys/MOS.adherence.measures.pdf. Accessed February 11, 2005.

  30. LaFromboise TD, Coleman HLK, Hernandez A. Development and factor structure of the Cross-Cultural Counseling Inventory-Revised. Prof Psychol Res Pr. 1991;22:380–88.

    Article  Google Scholar 

  31. Garber MC, Nau DP, Erickson SR, Aikens JE, Lawrence JB. The concordance of self-report with other measures of medication adherence: a summary of the literature. Med Care. 2004;42:649–52.

    Article  PubMed  Google Scholar 

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Acknowledgements

This study was funded by a grant from the Office of Research and Sponsored Programs at Fordham University.

Conflict of Interest

None disclosed.

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Authors and Affiliations

  1. Division of Psychological & Educational Services, Counseling Psychology Program, Fordham University, Graduate School of Education, Room 1008, 113 West 60th Street, New York, NY, 10023, USA

    Jairo N. Fuertes PhD & Jessie A. Fontanella

  2. New York University School of Medicine, New York, USA

    Laura S. Boylan MD

Authors
  1. Jairo N. Fuertes PhD
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  2. Laura S. Boylan MD
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  3. Jessie A. Fontanella
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Correspondence to Jairo N. Fuertes PhD.

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Fuertes, J.N., Boylan, L.S. & Fontanella, J.A. Behavioral Indices in Medical Care Outcome: The Working Alliance, Adherence, and Related Factors. J GEN INTERN MED 24, 80–85 (2009). https://doi.org/10.1007/s11606-008-0841-4

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  • DOI: https://doi.org/10.1007/s11606-008-0841-4

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