Relationship-based health care in the United states

Presented at the World Medical Association “Patient Safety in Care and Research” September 11, 2003 Relationship-Based Health Care in the United States, United Kingdom, Canada, Germany, South Africa and Japan A Comparative Study of Patient and Physician Perceptions Worldwide Mike Magee, MD Mike Magee MD Is the Senior Fellow in the Humanities to the World Medical Association and Director of the Pfizer Medical Humanities Initiative. O VER THE PAST DECADES, a variety of global forces and trends have collided and conspired to fundamentally transform the delivery of health care. These forces include the emergence of the health consumer movement, the creation of the Internet, an explosion of scientific discoveries, the aging of populations worldwide, the emergence of evidence-based medicine, the monetarization of medicine with associated evolving strategies for cost control, and renewed interest in relationship-based health care models.1 Sociologists like James Coleman2, Nan Lin3 and Ron Burt4 have demonstrated that enduring social relationships are properly understood as investments in social capital, which through the reciprocal exchange of information and support, create new resources for individuals which otherwise would be impossible were they to go it alone. Recent studies in the United States have revealed that citizens believe the patient-physician relationship is second in importance only to family relation- Context A number of forces have transformed the practice of medicine in the past two decades. Evidence suggests that these forces are impacting on both patients and physicians and on their relationship with each other. Objectives To simultaneously survey patients’ and physicians’ perceptions of their relationship with each other in six countries on four continents. Design and Setting Patients and physicians were simultaneously studied in six countries using nationally representative telephone surveys between July 22, 2002 and October 13, 2002. 2506 interviews were conducted on patients (63% response rate) and 1201 interviews were conducted on physicians (58% response rate) using a random digit dialing (RDD) methodology. Participants Patients had to be at least 21 years of age. Physicians had to be general practitioners and in practice for five or more years. Main Outcome Measures Relative importance of patient-physician relationships compared to other critical relationships in society. Type of relationship as defined by patients and physicians. Levels of patient empowerment and self-management of care. Actual and ideal performance ratings in 5 dimensions in the humanistic domain (compassion, trust, understanding, patience, listening) and 5 dimensions in the access domain (access to physician, time with physician, appointment scheduling, choice of treatment, choice of specialist). Results The patient-physician relationship ranked second in importance to family relationships in all countries studied. Physicians were the leading source of health information, the most trusted source, and the source most likely to instigate positive behavioral change in patients in all countries studied. All countries agree that authoritarian paternalistic relationships between physicians and patients are relatively uncommon today. These relationships are being replaced by mutual partnerships or advisor models. Patients and physicians in all countries foresee future movement toward partnership and team based models. Compared to 10 years ago, most patients in all countries believe they ask more questions, make more choices, actively evaluate benefit and risk, and take better care of their own health. Patient’s confidence in managing their own health is very high in all countries except Japan. Physician confidence in patient’s self-management is lower than patients scoring in five of the six countries. In general, all cohorts rate physician humanistic performance higher than access performance. Physicians in all countries rate their ideal humanistic performance higher than do patients. In contrast, physicians in the United Kingdom and Germany rate their ideal access performance lower than the patients’ expectation for ideal access performance. In actual performance both in humanistic and access domains, physicians score themselves higher than do patients in 8 of the 10 dimensions. Patients and physicians scoring of opportunities for improvement is relatively well aligned in five of the six countries studied. The greatest variance in opportunity scores between patient and physician exists in the United Kingdom in both humanistic domain (17% difference) and access domain (26% difference) and in Germany in the access domain (19% difference), with patients seeing more opportunity than do physicians. Conclusions The findings indicate a fundamental shift in the patient-physician relationship away from an authoritarian and paternalistic model and toward partnership and team based approaches. Patients are significantly more confident and empowered than they were ten years ago. Physician confidence in patient self-management is more modest. Patients possess high confidence in physicians but also demonstrate higher expectations for ideal physician performance and higher expectations for improvement along five dimensions of humanistic care and five dimensions of access to care. The ability to align expectations of patients and physicians, and meet commonly held objectives, will be increasingly important in assuring the future health of this critically important societal relationship. ship in their society and that it far exceeds in importance spiritual relationships, financial relationships and coworker relationships.5 This relation- Author Affiliations, Financial Disclosures, and Investigators are listed at the end of this article. Corresponding Author and Reprints: Mike Magee, MD, Director, Pfizer Medical Humanities Initiative, 235 East 42nd St. New York, NY 10017 1 RELATIONSHIP-BASED HEALTH CARE Table 1. Relative Importance of Relationships This relationship is extremely/very important to you? United States United Kingdom Canada Family 95 92 94 Doctor 78 63 76 Spiritual Advisor 56 21 32 Co-Worker 51 63 46 Financial Advisor 43 36 35 Pharmacist 48 26 44 Germany 91 72 10 64 35 34 South Africa 95 80 69 68 60 54 Japan 71 55 27 40 19 39 Question: Indicate how important the following relationship is to you. (% extremely or very important, 4 or 5 on a scale of 5) ship was previously defined by more than 90% of United States patients and physicians surveyed nationwide as three things: (1) compassion, (2) understanding, and (3) partnership.6 Additional studies revealed remarkable evolution of the relationship over a two-decade period in the United States including the initial emancipation of the patient, their empowerment through patient education, and active patient engagement in the shaping of our current health delivery system toward patientphysician partnerships, team approaches and joint risk sharing.7 Since the forces that are believed to have fueled this fundamental reshaping of one of American society’s most fundamental stabilizing relationships are global in nature, it was reasonable to hypothesize that the patient-physician relationship is actively evolving in other countries as well. This study was designed to simultaneously survey physicians and patients’ perceptions of their relationships with each other in six countries on four different continents. METHODS The following results are based on 3,707 interviews with doctors and patients conducted in the United States, United Kingdom, Canada, Germany, South Africa and Japan. In order to qualify for the study, doctors in each country had to be general practitioners, practicing for five or more years. Patients had to be at least 21 years of age. Interviews in the United States, United Kingdom, Germany, South 2 Africa and Japan were conducted between July 22 and August 30, 2002. Interviews in Canada were conducted between September 26 and October 13, 2002. Patients in each country were contacted via telephone using a random digit dialing (RDD) methodology that ensures that individuals with listed, as well as unlisted telephone numbers are included in the study. 2,506 interviews were conducted with patients: 500 in the United States (response rate, 60%), 400 each in the United Kingdom (response rate, 73%), Germany, South Africa and Japan, and 406 in Canada. 1,201 interviews were conducted with doctors; 200 each in the United States, Canada, Germany, South Africa and Japan, and 201 in the United Kingdom. Table 2. Physicians Critical Role as Health Information Resource Source = Origin of health information Trust = Trust in information based on source Action = Willingness to follow recommendations and advice based on source United States Source Trust Action Doctor 67 82 98 Pharmacist 27 65 90 Family 42 42 82 Internet 36 21 52 Media 22 11 48 Government 10 20 58 United Kingdom Canada Source Trust Action Source Trust Action 67 76 91 58 81 95 51 61 84 28 69 92 69 52 78 36 38 77 42 17 41 30 17 47 36 15 37 20 15 49 19 17 39 10 21 54 Germany Source Trust Action Doctor 81 78 93 Pharmacist 37 50 70 Family 68 52 69 Internet 46 22 29 Media 46 16 29 Government 7 14 22 South Africa Japan Source Trust Action Source Trust Action 53 77 91 66 55 73 43 65 86 14 34 63 42 43 72 52 36 63 25 27 40 22 19 36 23 21 33 48 21 53 5 11 25 9 21 47 Questions: Source: When looking for health information, which of the following do you regularly turn to? Trust: If you were to receive health information from the following source, how much would you trust that information? (% great deal or very much, 4 or 5 on a scale of 5) Action: If you were to receive health information from each of the following sources, how likely would you be to follow recommendations or advised based treatment based on that information? (% very likely or somewhat likely, 3 or 4 on a scale of 4) RELATIONSHIP-BASED HEALTH CARE Table 3. Confidence in Physicians % Above Other Leaders (Great Deal/Fair Amount of Confidence) United United South States Kingdom Canada Germany Africa Japan Religious +23 +44 +36 +49 +23 +21 Government +39 +53 +52 +50 +52 +23 Hospitals +17 +16 +16 +19 +33 +14 Corporations +56 +52 +56 +48 +42 +24 Financial +35 +38 +35 +34 +28 +27 Question: Thinking about some of the institutions and people with whom you interact, please tell how much confidence you have in the following (% a great deal or a fair amount, 4 or 5 on a scale of 5) Table 4. Patient Description of Patient-Physician Relationship % Describing Relationship With Their "Regular Doctor" as . . . United United South States Kingdom Canada Germany Africa Japan Authoritarian 17 20 13 13 16 12 Mutual Partner 41 41 44 40 55 49 Advisor 37 37 41 45 29 36 Question: Which of the following best describes your current relationship with your regular doctor: Authoritarian: Your doctor is an authority figure and in charge of interaction with you. Mutual Partner: Your doctor is a mutual partner or collaborator, sharing interaction with you nearly equally. Advisor: Your doctor is merely an advisor and you are in charge of interaction. Table 5. Patient Description of Future Patient-Physician Relationship % Describing Best Relationship for Future as . . . United United South States Kingdom Canada Germany Africa Japan Authoritarian 4 6 5 5 7 3 Mutual Partner 41 35 31 30 51 42 Mutual Team Partnership 54 58 60 64 42 55 Question: Thinking about the future of doctor/patient relationships which of the following descriptions of a doctor/patient relationship do you feel would be best in the future: A compliance oriented relationship where the doctor directs the interaction and determines treatment, and you only have a small part in making decisions. A mutual partnership where you and your doctor spend nearly an equal amount of time discussing diagnosis and possible treatments. A mutual team partnership where you and a team of health care professionals including your doctor discuss diagnosis and possible treatments and reach conclusions through collaboration. The margin of error for patients in the United States is +4.4%. The margin of error for patients in the United Kingdom, Canada, Germany, South Africa and Japan is +4.9%. The margin of error for doctors in each country is +6.9%. FINDINGS Importance of Relations In all countries studied, the patient- physician relationship ranked second in importance only to family relationships (Table 1). The percentage gap between number one and number two rankings varied as follows: South Africa (15%), United States (17%), Japan (16%), Canada (18%), Germany (19%) and United Kingdom (29%). (Table 1) In all countries studied, the physician was viewed by patients as the dominant source of health information. In addition, patients had far greater trust in the accuracy of information coming from physicians versus other sources (including pharmacist, family, Internet, media and government) and were far more likely to change their health behavior based on information from a physician compared to information from other sources (Table 2). Confidence levels in physicians (% having a great deal or fair amount of confidence) compared to government, hospitals, corporations and financial leaders far exceeded all others in all countries studied (Table 3). Most patients had a "regular doctor" including Germany (88%), United States (84%), Canada (84%), United Kingdom (80%), South Africa (80%), and Japan (73%). Of those who had regular doctors, large majorities agreed strongly or somewhat that "my doctor puts my interests above everything else" (Japan 92%, South Africa 83%, United States 80%, Canada 78%, Germany 73%, United Kingdom 72%). The Relationship In defining the current patientphysician relationship, patients in all countries agree that authoritarian, paternalistic relationships are relatively uncommon today. (United Kingdom 20%, United States 17%, South Africa 16%, Canada 13%, Germany 13%, Japan 12%). Most countries believe the dominant form of patient-physician relationship today is a mutual partnership with 50/50 joint decision making between patient and physician. Nearly as many patients in the United States, United Kingdom, Canada and Germany believe the current form is 3 RELATIONSHIP-BASED HEALTH CARE Table 6. Health Consumer Empowerment – Role of Physician in Decision Making In Making Risk-Related Decisions,Which Do You Prefer? United United States Kingdom Canada Germany Doctor takes total responsibility 5 6 6 3 Doctor provides options and tells you what to do 26 36 29 33 Doctor provides options and leaves decision to you 69 57 63 64 Not sure 0 1 2 0 South Africa 10 Japan 4 38 36 51 1 60 0 Question: In making risk related decisions, which of the following do you prefer: A doctor who takes total responsibility for making such a decision and tells you the course of treatments to follow without discussing alternatives. A doctor who informs you of the alternative treatments and risks, and tells you the treatment he or she will follow unless you disagree. A doctor who informs you of the alternative treatments and risks, tells you his or her recommendation and leaves it up to you to decide. an advisor model where physicians act as consultants to patients who in turn make their own decisions independently (Table 4). When asked to define the best relationship for the future, authoritarian relationships decline significantly (3% to 7%). Mutual partnerships emphasizing one on one joint decision making and mutual team partnerships, a patient in a 50/50 partnership with a doctor lead team that provides both clinical care and educational support are the preferred patient visions for the future (Table 5). Patient Empowerment Compared to ten years ago, large majorities of patients agree that patients ask more questions (United States 91%, South Africa 91%, Canada 90%, United Kingdom 89%, Germany 89%, Japan 74%). Most believe that patients make more choices and active- ly evaluate benefit and risk more than did patients ten years ago. (United States 87%, Canada 84%, South Africa 82%, United Kingdom 79%, Germany 78%, Japan 70%). Most agree as well that patients take better care of their own health (Japan 90%, Germany 76%, South Africa 70%, United Kingdom 68%, Canada 67%, United States 65%). In making risk-related decisions, patients worldwide prefer doctors who Table 7. Patient and Physician Ratings of Ideal Physician Performance % Who Agree the Ideal Physician Provides (Pt = Patient, Phys = Physician): United United States Kingdom Canada Germany Pt Phys Pt Phys Pt Phys Pt Phys Humanistic Compassion 94 100 85 100 86 94 73 93 Trust 97 98 93 100 97 100 91 100 Understanding 96 100 92 100 94 96 91 99 Patience 94 98 89 99 95 99 91 99 Listening 97 99 94 93 94 98 91 99 Average 96 99 91 98 93 97 87 98 Access To Doctor 91 98 87 99 93 99 89 97 Time With Doctor 90 95 87 78 79 91 87 87 Appointment Scheduling 89 92 91 51 88 78 84 71 Treatment Choice 96 90 93 70 93 91 95 72 Choice of Specialist 92 86 89 82 89 85 86 84 Average 92 92 89 76 88 89 88 82 South Africa Pt Phys Japan Pt Phys 73 73 70 67 96 76 95 91 89 84 96 91 91 96 89 80 66 84 98 98 96 91 90 95 66 88 89 94 92 86 89 93 86 92 78 88 84 61 57 55 57 63 83 80 21 65 76 65 Question: Access Domain: How important would you say it is for doctors to have this in order to establish the best possible relationship with patients? (% extremely or very important, 4 or 5 on a scale of 5). Humanistic Domain: Please indicate which of these words or phrases describe the best possible doctor under ideal circumstances (% affirmative). 4 RELATIONSHIP-BASED HEALTH CARE Table 8. Patient and Physician Ratings of Current Physicians Performance % Agree the Current Physician Possesses (Pt = Patient, Phys = Physician): United United States Kingdom Canada Germany Pt Phys Pt Phys Pt Phys Pt Phys Humanistic Compassion 73 84 58 93 71 90 51 74 Trust 87 84 77 98 89 97 76 92 Understanding 77 88 65 97 80 93 71 86 Patience 70 64 55 75 74 63 58 64 Listening 77 92 64 78 68 89 79 92 Average 77 84 64 88 76 86 67 82 Access To Doctor 60 67 47 78 60 55 70 79 Time With Doctor 66 83 54 49 58 69 63 73 Appointment Scheduling 63 84 42 48 53 64 75 78 Treatment Choice 73 87 54 68 64 84 65 81 Choice of Specialist 70 83 49 67 63 66 60 87 Average 66 81 49 62 60 68 67 80 South Africa Pt Phys Japan Pt Phys 57 62 63 56 79 63 70 86 76 55 92 76 56 69 52 44 45 53 71 67 57 62 73 66 55 76 74 76 78 72 65 82 68 85 89 78 47 33 38 42 36 39 61 57 22 72 58 54 Question: Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative). Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5). provide options and leave decisions to the patient versus doctors who provide options and tell the patient what to do or doctors who take total responsibility (Table 6). Patients’ confidence in managing their own health is very high in all countries except Japan. Patients are completely (5 on a scale of 5) or very confident (4 on a scale of 5) in self management in the following numbers: United States 76%, South Africa 72%, Canada 69%, United Kingdom 66%, Germany 63%, Japan 15%. 57% of Japanese patients are somewhat confident (3 on a scale of 5) and 23% are not very confident (2 on a scale of 5) in Table 9. Average Opportunity Ratings: Patient and Physician Perceptions of Opportunity for Improved Physician Performance (Difference Between Average Ideal and Actual) United United Ger- South States Kingdom Canada many Africa Japan Humanistic Domain: Average of 5 dimensions: Patient Opportunity Rating 19 27 17 20 13 31 Physician Opportunity Rating 15 10 11 16 15 29 Perception Gap 4 17 6 4 2 2 Access Domain: Average of 5 dimensions: Patient Opportunity Rating 26 40 28 21 14 24 Physician Opportunity Rating 11 14 21 2 10 11 Perception Gap 15 26 7 19 4 13 Note: Opportunity Rating = Ideal Rating - Current Rating self-management. Physician confidence in patient selfmanagement is lower than patient scoring in five of the six countries including the United States (-12%), South Africa (-32%), Canada (-11%), United Kingdom (-26%), and Germany (-20%). Japanese physicians are more confident in patient self-management than are their patients with 49% believing all or most patients (4 or 5 on a scale of 5) know what to do when it comes to taking care of their general health, and 39% believing some but not most (3 on a scale of 5) patients know what to do. A majority of patients in five of the six countries agree that patients should take the most responsibility for health care overall in the future including United Kingdom (71%), South Africa (63%), Japan (61%), United States (55%) and Germany (52%). Less than half of the Canadian patients agree (43%). Performance Ratings Patients and physicians were asked to 5 RELATIONSHIP-BASED HEALTH CARE evaluate the ideal physicians’ performance in five humanistic domains and five access domains. They were then asked to rate current physician performance in each of these areas. The gaps between ideal and reality or the opportunity rating were then calculated by simple subtraction and highlight patients and physicians’ perceptions of opportunity for improvement in physician performance in each of these dimensions. Humanistic domains included compassion, trust, understanding, patience, partnering and listening. Access domains included access to doctor, time spent with doctor, ease of appointment scheduling, access to varied treatment options and access to specialists. Ideal physician ratings are displayed in Table 7. They reflect the patients and physicians’ perspectives of what should be possible in physician performance under ideal circumstances in each country. Displayed are five humanistic and five access dimensions as well as average scores in each domain. In general all cohorts are more optimistic regarding possibilities for humanistic performance than for access performance with ideal humanistic scores exceeding ideal access scores by an average 4 points by patients and 14 points by physicians respectively. In all countries studied physician’s average humanistic scores in the ideal exceed patients. In contrast, physicians’ average ideal access scores fall below expectations in the ideal set by patients in the United Kingdom (13 points), and in Germany (6 points). Current ratings of physicians are displayed in Table 8. They reflect the patients and physicians’ perspectives of what current performance of physicians is in each country. When compared to ideal ratings the difference demonstrates perceived opportunities for improvement in physician performance toward the ideal. The level of opportunity is affected by both the level of expectation as expressed in the ideal score and the measure of today’s reality reflected in the current score. In all countries studied current physicians performance as an average of all dimensions of both humanistic and access domains are scored higher by physicians than by patients by an average 12 points in the aggregate. Patients and physicians in the United States, United Kingdom, Canada and Japan score current humanistic performance higher than current access performance. Table 9 displays Opportunity Ratings (the difference between ideal and current ratings) for improved physician performance in humanistic and access domains by country. Patients perceive the greatest opportunities for humanistic advances in the United Kingdom and Japan and the greatest opportunities for access advances in the United Kingdom, Canada and the United States. Patient and physician perceptions of opportunity for improvement are relatively well aligned in the United States, Canada, South Africa and Japan. The greatest variance in patient and physician point of view exists in the United Kingdom in both the humanistic domain (17% difference) and access domain (26% difference), and in Germany in the access domain (19% difference). COUNTRY PROFILES United States In the United States, the patient-physician relationship is viewed by 78% of patients as extremely or very important. This compares to 95% for family relations, 56% for spiritual relations, 51% for co-worker relations and 43% for financial relations. United States patients’ confidence in physicians exceeds other societal leaders from government (+39%), industry (+56%), financial sector (+35%), religious community (+23%) and hospital industry Table 10. United States: Physician Current Performance and Opportunity Ratings (Parenthesis) Current Humanistic Rating Compassion Trust Understanding Patience Patients (Opportunity Rating) 73(11) 87(10) 77(19) 70(24) Physicians (Opportunity Rating) 84(16) 84(14) 88(12) 64(34) Perception Gap 11(5) 3(4) 11(7) 6(10) Current Access Access to Time Spent Appointment Access to Rating Doctor With Doctor Scheduling Treatment Patients (Opportunity Rating) 60(31) 66(24) 66(23) 73(23) Physicians (Opportunity Rating) 67(31) 83(10) 84(8) 87(3) Perception Gap 7(0) 17(14) 22(15) 14(20) Question: Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative). Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5). Note: Opportunity Rating = the difference between Ideal Physician Score and Current Physician Score. 6 Listening 77(20) 92(7) 15(13) Access to Specialists 70(22) 83(3) 13(19) RELATIONSHIP-BASED HEALTH CARE Table 11. United Kingdom: Physician Current Performance and Opportunity Ratings Current Humanistic Rating Compassion Trust Understanding Patients (Opportunity Rating) 58(27) 77(16) 65(27) Physicians (Opportunity Rating) 93(7) 98(2) 97(3) Perception Gap 35(20) 21(14) 32(24) Current Access Access to Time Spent Appointment Rating Doctor With Doctor Scheduling Patients (Opportunity Rating) 47(40) 54(33) 47(49) Physicians (Opportunity Rating) 78(21) 49(29) 48(3) Perception Gap 31(19) 6(4) 6(46) (Parenthesis) Patience 55(34) 75(24) 20(10) Listening 64(30) 78(15) 13(15) Access to Treatment 54(39) 68(2) 14(37) Access to Specialists 49(40) 67(15) 18(25) Question: Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative). Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5). Note: Opportunity Rating = the difference between Ideal Physician Score and Current Physician Score. (+17%). 48% of United States patients agree strongly that "my doctor puts my interests above everything else", while 32% agree somewhat with this statement. Physicians are the leading source of health information (67%), the most trusted source of health information (82%) and the most likely source to instigate positive health behavioral change (98%). Patients in the United States are highly evolved as health consumers. 76% of patients are completely or very comfortable in managing their own general health while 40% of physicians are completely or very comfortable with patient’s self management and 39% of physicians are somewhat confident in patient self management. Patients (69%) and physicians (63%) agree in the majority that in making risk-related decisions with patients, the doctor should provide options and leave the decision to the patient rather than tell the patient what to do. A minority of United States patients (17%) and physicians (19%) see themselves in an authoritarian doctor-driven patient-physician relationship. The majority of physicians (73%) and patients (41%) identify a mutual partnership with joint decision making as their current model. A significant number of patients (37%) identify their relationship as a more independent advisor model, where physician provides information and patients make independent decisions. In viewing the preferred model relationship for the future 93% of physicians and 95% of patients favor partnership models over authoritarian ones and 52% of physicians and 54% of patients support the movement toward team-based approaches. United States patients and physicians share in common high expectations for ideal physician performance (Table 7). Average ideal physician humanistic ratings of five humanistic dimensions are 96% by patients and 99% by physicians. Average ideal physician access ratings of five access dimensions are 92% by patients and 92% by physician. Patients and physicians share as well common expectations for improvement including 19% (patients) and 15% (physicians) upgrades in average humanistic performance and to a lesser degree in average access performance at 26% (patients) and 11% (physicians) (Table 9). In rating current performance in individual dimensions in the humanistic domain, ratings are lowest by patients and physicians for patience (patients – 70% with a 24% opportunity for improvement, and physicians – 64% with a 34% opportunity for improvement). Scores in current performance in access dimensions are moderately high by patients (66% to 73%) and somewhat higher by physicians (67% to 87%) with patients seeing greater opportunity for improvement than do physicians in four of the five dimensions (Table 10). United Kingdom In the United Kingdom the patientphysician relationship is viewed by 63% of patients as extremely or very important. This compares to 92% for family relations. Co-worker relations (63%) score relatively high in the United Kingdom compared to other countries and far exceed spiritual relations (21%) and financial relations (36%). Confidence in physicians by patients in the United Kingdom is high compared to other leaders far exceeding government (+39%), corporations (+56%), financial community (+34%), religious community (+23%), and hospitals (+17%). 33% of United Kingdom patients agree strongly that "my doctor puts my interests above everything else," while 40% agree somewhat with this statement. Physicians at 67% are the second leading source of health information (next to families 69%), but are the most trusted (76%) and most likely to insti7 RELATIONSHIP-BASED HEALTH CARE Table 12. Canada: Physician Current Performance and Opportunity Ratings (Parenthesis) Current Humanistic Rating Compassion Trust Understanding Patience Patients (Opportunity Rating) 71(15) 89(8) 80(14) 74(21) Physicians (Opportunity Rating) 90(4) 97(3) 93(3) 63(36) Perception Gap 19(11) 8(5) 13(11) 11(15) Current Access Access to Time Spent Appointment Access to Rating Doctor With Doctor Scheduling Treatment Patients (Opportunity Rating) 60(33) 58(21) 53(35) 64(29) Physicians (Opportunity Rating) 55(44) 69(22) 64(14) 84(7) Perception Gap 5(11) 11(1) 11(21) 20(22) Listening 68(26) 89(9) 21(17) Access to Specialists 63(26) 66(19) 3(7) Question: Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative). Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5). Note: Opportunity Rating = the difference between Ideal Physician Score and Current Physician Score. gate positive health behavioral change (91%). Patients in the United Kingdom are well evolved as health consumers with 70% completely or very confident in managing their own health and 22% somewhat confident. Only 28% of physicians in the United Kingdom are completely or very confident in patients taking the right actions to manage their own health with 41% of physicians somewhat confident and 24% of physicians not very confident. This is in spite of the fact that 91% of physicians and 71% of patients in the United Kingdom agree that patients currently do take the most responsibility for their own health. While the majority of patients (57%) and physicians (50%) believe that in making risk-related decisions with patients they prefer a doctor who provides options and leaves the decision to the patient, a significant number of patients (36%) and physicians (50%) prefer a doctor who provides options and tells the patient what to do. A minority of United Kingdom patients (20%) and physicians (10%) see themselves in an authoritarian doctor driven patient-physician relationship. The majority of physicians (76%) and patients (41%) identify a mutual partnership with joint decision making as their current model. A significant number of patients (37%) identify 8 their relationship as an independent advisor model, where physician provides information and patient makes independent decisions. In viewing the preferred model relationship for the future, 93% of patients and 92% of physicians favor partnership models to authoritarian ones. In addition patients (58%) support movement toward team-based approaches to a greater degree than do physicians (35%). United Kingdom patients and physicians demonstrate moderate variance in their expectations for ideal physician performance (Table 7). While physicians rate ideal performance for the humanistic domains at 98%, patients place their expectation at 91%. Conversely patients rate the ideal physician performance in access domains at 89% while physicians expectation of access in the ideal is rated at only 76%. Patients and physicians in the United Kingdom diverge as well in their expectations for improvement. Patients foresee an average 27% potential for improvement in the humanistic domain and 40% potential for improvement in the access domain while physicians see only the opportunity for a 10% and a 14% improvements in humanistic and access domains respectively (Table 9). In rating current humanistic performance, physician scores are high in three dimensions and moderate in two while patients scores are moderate in three and low in two. In addition, patients see greater potential for improvement than do physicians with opportunity ratings exceeding those of physicians by 20% for compassion and 24% for understanding. Access dimensions are scored low by patients and moderate to low by physicians. Most notable is a striking difference in opinion on opportunity for improvement in access with patients opportunity ratings exceeding physicians by 46% in appointment scheduling, 37% in access to treatments and 25% in access to specialists (Table 11). Canada In Canada, the patient-physician relationship is viewed by 74% of patients as extremely or very important. This compares with 94% for family relations, 46% for co-worker relations, 35% for financial relations and 32% for spiritual relations. Confidence in physicians by patients in Canada is high compared to other leaders far exceeding leaders in government (+52%), corporations (+56%), financial community (+35%), religious community (+36%) and hospitals (+16%). 41% of Canadian patients agree strongly that "my doctor puts my interests above everything else," while RELATIONSHIP-BASED HEALTH CARE Table 13. Germany: Physician Current Performance and Opportunity Ratings (Parenthesis) Current Humanistic Rating Compassion Trust Understanding Patience Patients (Opportunity Rating) 51(22) 76(15) 71(20) 58(33) Physicians (Opportunity Rating) 74(19) 92(8) 86(13) 64(35) Perception Gap 23(3) 16(7) 15(7) 6(2) Current Access Access to Time Spent Appointment Access to Rating Doctor With Doctor Scheduling Treatment Patients (Opportunity Rating) 70(19) 63(24) 75(9) 65(30) Physicians (Opportunity Rating) 79(18) 73(14) 78(-7) 81(-9) Perception Gap 9(1) 10(10) 3(16) 16(39) Listening 79(12) 92(7) 13(5) Access to Specialists 60(26) 87(-3) 27(31) Question: Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative). Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5). Note: Opportunity Rating = the difference between Ideal Physician Score and Current Physician Score. 37% agree somewhat with this statement. Physicians at 58% are the leading source of health information with families rating second at 36%. Physicians are also the most trusted source of information (81%) and the source most likely to instigate positive health behavioral change (95%). Patients in Canada are significantly evolved as health consumers with 79% either completely or very confident that they take the right actions in managing their own health compared to 34% of Canadian physicians who believe the same to be true. 58% of physicians and 43% of patients agree that patients currently take the most responsibility for their health. A majority of physicians (69%) and patients (63%) prefer a doctor who provides options and leaves decisions to the patients in making risk-related decisions. Less than one third of doctors (31%) and patients (29%) prefer a doctor who provides options and tells the patients what to do under these circumstances. A minority of Canadian patients (13%) and physicians (10%) see themselves in an authoritarian doctor-driven patient-physician relationship. The majority of physicians (70%) and patients (44%) identify a mutual partnership with joint decision making as their current model. A significant number of patients (41%) identify their relationship as an independent advisor model, where physician provides information and patient makes independent decisions. In viewing the preferred model relationship for the future, 91% of patients and 94% of physicians support partnership models over authoritarian ones. In addition, 60% of patients and 52% of physicians support movement to team-based approaches. Canadian patients and physicians show little variance in their expectations for ideal physician performance on humanistic scales (patients 93%, physicians 97%) or access scales (patients 88%, physicians 89%) (Table 7). Canadian patients and physicians also see similar room for improvement in both humanistic (patients 17%, physicians 11%) and access (patients 28%, physicians 21%) scales (Table 9). In rating current performance in individual dimensions in the humanistic domain, ratings by patients are moderate and ratings by physicians are high except for patience (63%). In patience, patients and physicians see significant room for improvement (21% and 36%). In current access ratings patients grades are low as are physicians except for access to treat- ments where physicians rate 84% while patients rate 64%. Patients and physicians agree generally in high opportunity potential (19% to 44%) in access to doctor, time spent with doctor and access to specialists. However visions for improvement in appointment scheduling and access to treatments vary by 21% and 22% respectively with patients more optimistic than physicians (Table 12). Germany In Germany the patient-physician relationship is viewed as extremely or very important by 72% of patients. This compares with 91% for family relations, 35% for financial relations, 64% for coworker relations, and 10% for spiritual relations. Confidence in physicians by patients in Germany is high compared to other leaders far exceeding leaders in government (+50%), corporations (+48%), financial community (+34%), religious community (+49%), and hospitals (+19%). 33% of German patients agree strongly that "my doctor puts my interests above everything else," while 40% agree somewhat with this statement. German physicians at 81% are the leading source of health information with families rated second at 68%. Physicians are also the most trusted source of information (78%), 9 RELATIONSHIP-BASED HEALTH CARE Table 14. South Africa: Physician Current Performance and Opportunity Ratings (Parenthesis) Current Humanistic Rating Compassion Trust Understanding Patience Patients (Opportunity Rating) 57(16) 62(11) 63(7) 56(11) Physicians (Opportunity Rating) 70(25) 86(5) 76(13) 55(29) Perception Gap 23(9) 24(6) 13(6) 1(18) Current Access Access to Time Spent Appointment Access to Rating Doctor With Doctor Scheduling Treatment Patients (Opportunity Rating) 55(11) 76(12) 74(15) 76(18) Physicians (Opportunity Rating) 65(24) 82(11) 68(18) 85(7) Perception Gap 10(13) 6(1) 6(3) 9(11) Listening 79(17) 92(4) 13(13) Access to Specialists 78(14) 89(-11) 11(25) Question: Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative). Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5). Note: Opportunity Rating = the difference between Ideal Physician Score and Current Physician Score. and the source most likely to instigate positive health behavioral changes (93%). Patients in Germany are well evolved as health consumers with 73% of German patients completely or very confident that they take the right actions in managing their own health. Approximately one-quarter of German patients (26%) are only somewhat or not very confident in patient selfmanagement of general health. A majority of patients (64%) and a minority of physicians (44%) prefer a doctor who provides options and leaves decisions to patients when confronting a risk-related decision. In contrast, a majority of physicians (53%) and a minority of patients (33%) prefer a doctor who provides options and tells patients what to do under similar circumstances. A minority of German physicians (14%) and patients (13%) see themselves currently in an authoritarian doctor-driven patientphysician relationship. A majority of physicians (66%) and a minority of patients (40%) identify a mutual partnership with joint decision making as their current model. A majority of patients (45%) and a minority of physicians (16%) identify their relationship as an independent advisor 10 model where physician provides information and patient makes independent decisions. In viewing the preferred model relationship for the future, 20% of German physicians choose an authoritarian model in contrast to 5% of German patients. The majority of physicians (80%) and patients (94%) prefer partnership models over authoritarian ones. In addition, 64% of patients and 53% of patients support movement toward team-based approaches. German patients and physicians show mild variance in their expectations for ideal physician performance on humanistic scales (patients 87%, physicians 98%) and access scales (patients 88%, physicians 82%) (Table 7s). Patients and physicians show mild variance in room for future improvement in average humanistic performance (patients 20%, physicians 16%) and moderate variance in room for improvement in average access performance (patients 21%, physicians 2%) (Table 9). In rating current performance in individual dimensions in the humanistic domain, physicians and patients scores are moderate to low. Greatest variation between patients and physician scoring occurs in compassion (23% difference). Opportunity ratings in the humanistic domain show patients and physicians well aligned. In rating current performance in individual dimensions in the access domain, scoring by physicians is moderate and by patients moderate to low. Greatest variance exists in access to treatment (16% difference) and access to specialists (27% difference). In addition, physicians are significantly more pessimistic in their opportunity ratings which differ from patient ratings by 31% for access to specialists, 39% for access to treatments and 16% for appointment scheduling (Table 13). South Africa In South Africa, the patient-physician relationship is viewed by 80% of patients as extremely or very important. This compares with 95% for family relations, 68% for co-worker relations, 60% for financial relations and 69% for spiritual relations. Confidence in physicians by South African patients is high compared to other leaders far exceeding leaders in government (+52%), corporations (+42%), financial community (+28%), religious community (+23%), and hospitals (+33%). 56% of South African patients agree strongly that "my doctor puts my interests above everything else," while 27% agree somewhat with this statement. RELATIONSHIP-BASED HEALTH CARE Table 15. Japan: Physician Current Performance and Opportunity Ratings (Parenthesis) Current Humanistic Rating Compassion Trust Understanding Patience Patients (Opportunity Rating) 56(35) 69(27) 52(37) 44(36) Physicians (Opportunity Rating) 71(27) 67(31) 57(39) 62(29) Perception Gap 15(8) 2(4) 5(2) 18(7) Current Access Access to Time Spent Appointment Access to Rating Doctor With Doctor Scheduling Treatment Patients (Opportunity Rating) 47(37) 33(28) 38(19) 42(13) Physicians (Opportunity Rating) 61(22) 57(23) 22(-1) 72(-7) Perception Gap 14(15) 24(5) 16(20) 31(20) Listening 45(21) 73(17) 28(4) Access to Specialists 36(21) 58(18) 22(3) Question: Humanistic Domain: Do each of the following words or phrases describe most doctors? (% affirmative). Access Domain: How satisfied would you say you are in this area? (% extremely or very satisfied, 4 or 5 on a scale of 5). Note: Opportunity Rating = the difference between Ideal Physician Score and Current Physician Score. Physicians at 53% are the leading source of health information with families (42%) and pharmacists (43%) on a second tier. Physicians are also the most trusted source (77%) and the source most likely to instigate positive behavioral change (91%). Patients in South Africa are significantly evolved as health consumers with 76% completely or very confident that they take the right actions in managing their own health compared to 24% of South African physicians who share this belief. 68% of physicians are somewhat or not very confident in South African patient self-management. A majority of patients (51%) and a minority of physicians (44%) prefer a doctor who provides options and leaves decisions to patients when faced with risk related decisions, while a majority of physicians (54%) and minority of patients (38%) prefer a doctor who provides options and tells the patient what to do under similar circumstances. A minority of South African patients (16%) and physicians (10%) see themselves in an authoritarian doctor-driven patient-physician relationship. The majority of physicians (79%) and patients (55%) identify their relationship as a mutual partnership marked by joint decision making. A minority of doctors (11%) and patients (29%) identify their relationship as an independent advisor model with doctors providing information and patients making decisions independently. In viewing the preferred model relationship for the future, 93% of patients and 96% of physicians support partnership models over authoritarian ones. In addition 42% of patients and 57% of physicians support movement toward team-based approaches. South African patients and physicians show moderate variance in their expectations for ideal physician performance on average humanistic scales (patients 76%, physicians 91%) but little variance in their expectations for ideal access performance (patients 86%, physicians 88%) (Table 7). South African patients and physicians largely agree on average opportunity ratings both in humanistic performance (patients 13%, physicians 15%) and in access performance (patients 14%, physicians 10%) (Table 9). In rating current performance in the individual dimensions in the humanistic domain, patients and physicians scores are highly variable. The greatest variance between patients and physicians is in compassion and trust (physicians rate these 23% and 24% higher respectively than do patients). Physicians see greater opportunity for improvement in patience (18% differ- ence) than do patients. In current access ratings, scoring by patients and physicians is moderate to low with mild variability between the two groups. Patients and physicians see similar opportunities for improvement in access dimension except in access to specialists where patients see a 25% greater opportunity for improvement than do physicians (Table 14). Japan In Japan, the patient-physician relationship is viewed by 55% of patients as extremely or very important compared with 71% for family relations, 40% for co-worker relations, 19% for financial relations and 27% for spiritual relations. Confidence in physicians in Japan exceeds other leaders in government (+23%), corporations (+24%), financial industry (+27%), religious community (+21%) and hospitals (+14%). 39% of Japanese patients agree strongly that "my doctor puts my interests above everything else," while 53% agree somewhat with this statement. Physicians are identified as the leading source of health information (66%) with family second (52%). Physicians are also the most trusted resource (55%) and most likely to instigate positive behavioral change (73%). Patients in Japan are less evolved as health consumers than in other nations 11 RELATIONSHIP-BASED HEALTH CARE studied with only 28% completely or very confident that they take the right actions in managing their own health. Japanese physicians are generally in agreement with 22% completely or very confident in patient self-management. The vast majority of patients (58%) and physicians (57%) are somewhat confident of patients self management or not very confident (patients 10%), physicians (17%). Patients (60%) and physicians (57%) in Japan prefer a doctor who provides options and leaves decisions to patients when faced with risk related decisions. A smaller but significant number of patients (36%) and physicians (39%) prefer a doctor who provides options and tells the patient what to do under these circumstances. A minority of patients (12%) and physicians (4%) currently see themselves in authoritarian doctor driven patient-physician relations. A majority of patients (49%) and a large majority of physicians (84%) currently define their relationship as a mutual partnership marked by joint decision making. A large minority of patients (36%) and a small minority of physicians (11%) see their relationship as an independent advisor role with physicians providing information and patients making independent decisions. In viewing the preferred model for the future, the majority of patients (97%) and physicians (92%) prefer partnership models over authoritarian ones. In addition 55% of patients and 58% of physicians foresee movement toward team-based approaches. Japanese patients and physicians show little variation in their expectations for ideal physician performance on average humanistic scales (patients 84%, physicians 95%) and on average access scales (patients 63%, physicians 65%) (Table 7). Expectations for ideal access are significantly lower in Japan than in any other country studied. Japanese patients and physicians are in close agreement and see large areas for improvement in average physician humanistic performance (patients 12 31%, physicians 29%). Expectations for gains in access performance are more modest (patients 24%, physicians 11%) (Table 9). In rating current performance in individual dimensions in the humanistic domain, Japanese patients and physicians provide low scores with little variability between patient and physician assessment except in listening where physicians rating exceeds patients by 28%. Yet patients and physicians are optimistic for the future, seeing high opportunity for improvement across all dimensions with little variability between patient and physician perception. Low scores dominate as well in the current access dimensions with patients scoring time spent with doctor, access to treatments and access to specialists 24%, 31%, and 22% lower than do physicians respectively. Patients and physicians have similar opportunity ratings in access to doctors, time spent with doctor and access to specialists, but doctors see less opportunity than do patients for improvements in appointment scheduling and access to treatments by 20% and 20% respectively (Table 15). Discussion Democracies are relationship based societies infused by two integrated themes: individualism, marked by both rights and responsibilities and community, marked by principles of civility, respect for law and active expressions of citizenship. Stability and progress rely on highly functional and enduring relationships capable of capturing learnings and transmitting them intergenerationally and securing an environment that is durable, forward looking and optimistic8. Enduring relationships are recognizable as real and formative rather than superficial in so far as individuals who actively care for each other, give meaning to each other as participants in something larger than their own limited self interest. Enduring relationships are committed, that is they resist separation and unite individuals who pro- vide each other with real time feedback designed to strengthen their bonds through mutual self improvement. Such feedback requires a supportive societal environment marked by facilitated partner contact and open access to information. Societal support of such relationships represents an investment in social capital or the creation of new resources unable to be realized by individuals working independently in a non-cooperative fashion.2 3 4 8 In the six countries surveyed the patient-physician relationship is highly valued by citizens, second only in importance to family relationships. Prior studies have defined this relationship in over 90% of patients and physicians as possessing three key elements: compassion, understanding and partnership.5 While the deeply personal nature of the engagement in part explains its power in each of these societies, it does not fully define its purpose or value to those societies. On one level this relationship delivers what we would quite literally expect and that is individual evaluation and treatment of medical conditions and the provision of increasingly preventive oriented information and council through remarkably decentralized and pervasive grassroots networks.9 A secondary benefit that is somewhat less visible is a byproduct of this partnership and that is the reinforcement of the integrity of the family unit as relatives and loved ones are intentionally included and immersed in meeting the challenges of medical conditions or planning prevention for the patient in order to secure a brighter family future10. A third function, largely taken for granted, is the capacity of these relationships, exercised some 750 million times a year in the United States alone, in the aggregate, to absorb, process and manage the daily fears and worries of a populace in a constructive, well controlled and hopeful manner11. Finally, as a fourth role, transmitted progressively from individual, to family, to community and to society, is the creation of general confidence and trust on the macro RELATIONSHIP-BASED HEALTH CARE level that our day to day world is relatively safe, somewhat protected and generally hopeful and therefore worth the daily investment of our human, social and financial capital.2 3 4 8 12 To accomplish these four highly integrated objectives, the patient-physician relationship has been aggressively redefining itself over the past two decades. The emancipation of patients embodied in the realization and acceptance of personal responsibility for one’s own health management gained credence as part of the civil rights movement in the 1980’s1. Fueled by the Internet, general support from a widening array of caregivers and an enlightened self interest, patients correctly identified education as the lever that would empower them to move with their physician toward new partnership and team approaches and away from passive dependence on authoritarian based models13. Now facing the challenges of aging with the emergence of four- and five-generation families, an expansion of scientific understanding and new discoveries, an increasing emphasis on health prevention as a responsibility not only to oneself and one’s family, but also to one’s community and society, a more enlightened understanding of the impact of state policies and approaches on this most fundamental and dynamic societal relationship is emerging. While this study clearly reveals that the evolution of the patient-physician relationship is a worldwide phenomenon, the speed, readiness, and stresses felt vary somewhat from culture to culture. The comparative studies reveal variability in the alignment of expectations of patients and physicians in the ideal, and in their current reality in both humanistic performance of physicians and access performance of physicians. To fully realize the potential of the patient-physician relationship to deliver the care, reinforce cooperative networks, and act as a societal stabilizer, the relationship must manage service on the micro level in a manner that accumulates social capital to advantage communities and societies on a macro level. This requires at a minimum social policy that draws physicians and patients closer together rather than farther apart giving them the opportunity to participate and advocate for each other. It requires as well a relatively wellaligned vision by both patient and physician of what is excellence (ideal performance) and what is the current opportunity for improvement (the difference between ideal and actual performance). Patient expectations are affected by their level of emancipation and empowerment as health consumers which in turn is a function of the level of educational and emotional support provided by physicians and other caregivers to the patient14. Physician aspirations are affected by their general support for patient emancipation, empowerment, and team approaches tempered by their perceptions of what is realistic in light of the available resources and the level of function or dysfunction of their health delivery system15. In general, a highly dysfunctional system would be expected to prevent a physician from providing the access and advocacy he would ideally choose to provide in support of the patient. Over time, such obstacles would be expected to artificially depress what the physician would consider to be ideally acceptable leading him to accept a lower goal as the best he can do under the circumstances. Given more time, a performance ideal that would initially be unacceptable gradually and grudgingly becomes acceptable. In contrast, the patient, newly empowered and progressively more educated (with or without the physician) to what is in fact ideally possible, would be expected to react negatively to the physician whose "ideal" has gradually descended to what is "possible". The empowered health consumers’ expectation of the physician and of this fundamental relationship is extraordinarily high. Met with an unresponsive physician, patients are left to logically acknowledge the presence of one of two realities. Either my physician doesn’t care about me or my physician is powerless to advocate for me. Either way, the common result is to draw the patient away from the relationship as he/she acknowledges "I now must fend for myself," and to draw the physician away from the relationship mired in helplessness and hopelessness. The net effect is that patients and physicians who are natural allies, are gradually repositioned as adversaries. The physician is redefined as a protector or agent of the state and the patient redefined as an endless consumer of valuable resources without regard to cost. Under such circumstances, a health care system may appear to be delivering care, albeit with high levels of dissatisfaction on the part of both patients and physicians, while in fact it is receiving only a partial return on its investment. In contrast, designing health care systems that set well aligned and high ideals for performance, and that set and realistically resource well aligned and reasonable expectations for improvement, assure not only more cooperative and appreciated care delivery by all concerned, but also a fuller return on investment in public support and accumulated social capital12. SUMMARY The patient-physician relationship is a critical underpinning of stable societies, second only in importance to family relationships in all countries studied. Over the past two decades this relationship has been fundamentally transformed from an authoritarian and paternalistic physician control model to a mutual partnership with team support of both clinical and patient education missions. The emancipation, empowerment and active engagement of health consumers has reinforced high expectations for physician performance in both humanistic, access, and advocacy dimensions. Physicians ability to align with and aspire to meet these expectations in support of patients continued evolution will large13 RELATIONSHIP-BASED HEALTH CARE ly define the physician’s future effectiveness as a health care leader, the future viability of this most critical relationship, and its ability to deliver on a micro level movement toward prevention and wellness and on a macro level expansion of social capital and general societal well being. The profile comparisons of six countries on four continents, each with a different approach to health care system design and financing, demonstrate significantly different levels of patient-physician alignment in the scoring of ideal and actual performance of physicians on five dimensions of humanism, and five dimensions of access. These scorings would benefit from future tracking. While it is not possible to assign cause and effect, the relationship between the structural design, financing, and incentives of the health delivery system and the positioning of patients and physicians/caregivers as partners or adversaries, and the resultant impact on the patient-physician relationship and public support for its investment in health care infrastructure warrants further study. Author Affiliations: Senior Fellow in the Humanities, World Medical Association; Director, Pfizer Medical Humanities Initiative; Honorary Master Scholar, New York University School of Medicine; Professor of Surgery, Jefferson Medical College. Financial Disclosures: Dr. Magee is employed as Director of the Pfizer Medical Humanities Initiative. Funding/Support: This study was supported by an unrestricted grant from Pfizer Inc, New York, NY. REFERENCES 1. Nash, D. Connecting with the New Health Care Consumer. New York, NY: McGraw-Hill; 2001. 2. Coleman, J. 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