A comparison of the level of satisfaction for patients who had a face-to-face consultation versus a consultation carried out by telephone in a 2-week wait bowel clinic was performed using an adapted version of Grogan et al's (2000) validated patient satisfaction questionnaire. The authors asked 10 questions to assess patient satisfaction in three major areas:
- The level of care and information provided
- The patient's experience with the health professional
- The time available for the consultation.
The face-to-face group scored their experience as being more positive on all 10 survey questions compared with telephone patients. This difference was particularly marked for questions concerning the patient's experience with, and opinion of, the health professional. Age was a confounding factor in our study, and there was some evidence that negatively phrased questions were sometimes misunderstood.
The results suggest that telephone consultations may present a challenge to patient satisfaction. However, the study had systematic methodological limitations that may have confounded these results and contributed to the observed pattern. The authors make some suggestions for how to rectify such limitations in future studies.
Introduction
The use of telephone consultations as an alternative to face-to-face consultations is a potentially cost-effective measure that can benefit patients and health workers (Car and Sheikh, 2003; Akobeng et al, 2015). For patients, they can reduce travel time and travel costs (Car and Sheikh, 2003). However, there are potential concerns about the clarity and effectiveness of communication over the telephone, particularly with elderly patients (Foster et al, 1999; Atherton et al, 2018). More research is required about the patient experience in different clinical situations to assess the effectiveness of a telephone consultation in a range of contexts.
The authors' objective was to compare patient satisfaction in the context of a 2-week wait bowel clinic consultation, carried out either during a face-to-face meeting or via a telephone call.
Methods
The study was carried out between July and December 2018 at the General Surgery Outpatients Department at the authors' district general hospital. At face-to-face consultations, all patients were handed a questionnaire immediately afterwards and asked to complete it. The first 50 individuals to complete the questionnaire were taken as the face-to-face sample. To obtain a comparison sample, 50 patients who had undergone a telephone consultation in the previous 6 weeks were selected randomly.
The questionnaire consisted of 10 statements (S1 to S10) with available responses graded from ‘strongly agree’ to ‘strongly disagree’. Six questions were phrased ‘positively’, meaning that ‘strongly agree’ was an indicator of high satisfaction. Four questions were phrased ‘negatively’, meaning that ‘strongly agree’ was an indicator of high dissatisfaction.
Statistical analysis
For each statement, the responses were scored on a scale of 1 to 5, with 1 indicating ‘strongly disagree’ and 5 representing ‘strongly agree’. Scores for each type of consultation were added up to get total score for the 50 patients, and for each statement the authors tested for a difference in medians using the Mann-Whitney U-test.
An ‘overall positivity score’ was calculated by obtaining a total score for the responses to all 10 questions for each patient, after rescaling negatively phrased statements appropriately. For example, for positively phrased statements (eg ‘I was very satisfied with the overall care received during my consultation’) a response of ‘strongly agree’ scored 5; for negatively phrased statements (eg ‘I was not given enough information by the health professional today’) ‘strongly agree’ scored 1. The overall positivity scores for all 50 patients in each consultation category were compared using a Mann-Whitney U-test.
Results
Age
The average age of the patients in the study was 68.5 years (SD ± 11.6). Patients in the sample from the face-to-face consultations were significantly older than those in the telephone consultation category (face-to-face: mean± SD 71.4±14.6; telephone: 66.1±7.7; Mann-Whitney U-test: U=636.5, P<0.001).
Level of care and information provided
Statements 1 and 6 asked the patients about their satisfaction with the level of care (S1) and the information (S6) provided. For both statements, average satisfaction was slightly higher in the face-to-face group than the telephone group, but the difference was not significantly different for either statement considered in isolation (Mann Whitney U-test: N=50,50; Statement 1: U=1050, P=0.17; Statement 2: U=1121, P=0.37)
Satisfaction with the health professional
Four statements (S2, S5, S7, S8, S9) concerned the level of patient satisfaction with the health professional. For example, statement 7 was ‘I felt that the health professional was skilled and knowledgeable about my condition’; Statement 5 was ‘The health professional had a genuine interest in me as a person’. For both these statements, patient satisfaction was significantly higher in face-to-face patients compared with the telephone group (Mann Whitney U-test, statement 5: U=826, P=0.004; statement 7: U=751, P<0.001). For the other three statements, patient satisfaction was higher for face-to-face consultations compared with the telephone group, but this was not significant (Mann-Whitney U: S2, S8, S9: All U>1000, all P>0.05).
Time pressure
Two statements (S9, S10) related to time pressure. Statement 9 was ‘The health professional made me feel I was wasting his/her time’ and statement 10 ‘I felt rushed during my consultation’. Face-to-face patients had higher levels of satisfaction on both these statements, but the difference was not significant (Mann-Whitney U-test: both U>1000, both P>0.05).
Overall satisfaction across all questions
Overall, the average satisfaction scores among both face-to-face and telephone patients were high: among face-to-face patients mean (± SD) satisfaction was 4.7 (± 0.32) out of 5, while among telephone patients it was 4.5 (± 0.16) out of 5. Nevertheless, the difference between the two groups was highly significant (Mann-Whitney U-test comparing mean scores of each of 50 patients in face-to-face and telephone categories respectively: U=779.4, P<0.001). Face-to-face patients responded more positively (or less negatively) than the telephone patient group to all 10 statements.
Discussion
Overall, face-to-face consultations scored significantly higher in reported patient satisfaction compared with the telephone consultations. This difference in reported satisfaction was particularly pronounced for questions that explored the patient experience with, and regard for, the health professional.
At face value, the findings appear to suggest that patients are less satisfied with telephone consultations. However, there are important methodological issues and confounding factors that may have contributed to the observed pattern of patient responses. First, patients in the telephone group were contacted and surveyed several weeks after their consultations, whereas those in the face-to-face group were handed a form to complete immediately after their consultations. There is widespread evidence that time delays can alter subject responses in questionnaire surveys (Schwarz, 2007). Thus, it is possible that the lower satisfaction scores among the telephone consultation group were due to the retrospective nature of the questionnaire.
Second, the two patient categories differed in the means of delivering the survey, as well as in the way the consultation was carried out. The authors discovered that it was inherently difficult to conduct a survey that offered options on a 5-point scale over the telephone. Patients would often not wait to hear the full range of options before choosing their answer; and there was frequently a mismatch between the option selected by the patient and their own verbal descriptions of how satisfied they were.
This problem could be remedied by undertaking the survey of face-to-face patients by telephone after the event, or by sending patients a paper survey to complete at home after the consultation. One health organisation (BJC Healthcare, St Louis MO), which conducted a parallel study to compare mailed survey responses with telephone surveys, found numerous small differences in patient satisfaction, and more positive responses overall in the telephone group (Burroughs et al, 2001). Burroughs et al (2001) argued that data compiled using different survey methods can lead to erroneous conclusions.
Third, there was a significant difference in age between the two consultation categories, not least because advanced age (over 80 years) was a criterion for inclusion in the face-to-face group. If older patients tend to report higher levels of satisfaction this factor could have contributed to the study findings.
Finally, there was evidence that negatively phrased questions were sometimes misunderstood. For example, all patients agreed or strongly agreed with the statement ‘I was satisfied with the way I was treated by the health professional’, yet when the same statement was written in negative form (‘I was dissatisfied with the way I was treated by the health professional’) two of the patients strongly agreed with the negative statement.
To conclude, while this study could indicate that patients are more satisfied with face-to-face consultations, this result could be an artefact of the methodological differences in the way that patient satisfaction was delivered and recorded following the different consultation methods. Future studies that rectify these limitations are required before stronger conclusions can be drawn about patient satisfaction when evaluating the merits of telephone versus in-person consultation methods.