Journal of General Internal Medicine

, Volume 17, Issue 11, pp 817–824

Unmet expectations for care and the patient-physician relationship

  • Robert A. Bell
  • Richard L. Kravitz
  • David Thom
  • Edward Krupat
  • Rahman Azari
Original Articles


OBJECTIVE: To profile patients likely to have unmet expectations for care, examine the effects of such expectations, and investigate how physicians’ responses to patients’ requests affect the development of unfulfilled expectations.

DESIGN: Patient and physician questionnaires were administered before and after outpatient visits. A follow-up telephone survey was administered 2 weeks post visit.

SETTING: The offices of 45 family practice, internal medicine, and cardiology physicians.

PATIENTS: Nine hundred nine adults reporting a health problem or concern.

MEASUREMENTS AND MAIN RESULTS: Before their visits, patients rated their general health and trust in the index physician. After the visit, patients reported upon 8 types of unmet expectations and any request they made. Two weeks thereafter, patients rated their visit satisfaction, improvement, and intention to adhere to the physician’s advice. They also reported any postvisit health system contacts. Overall, 11.6% of patients reported ≥1 unmet expectation. Visits in which a patient held an unmet expectation were rated by physicians as less satisfying and more effortful. At follow-up, patients who perceived an unmet expectation for care also reported less satisfaction with their visits, less improvement, and weaker intentions to adhere. Patients with an unmet expectation related to clinical resource allocation had more postvisit health system contacts. Unmet expectations were typically reported by a patient whose request for a resource was not fulfilled.

CONCLUSIONS: Unmet expectations adversely affect patients and physicians alike. Physicians’ nonfulfillment of patients’ requests plays a significant role in patients’ beliefs that their physicians did not meet their expectations for care.

Key words

unmet expectations residual expectations patient satisfaction adherence physician-patient communication 


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  1. 1.
    Joos SK, Hickam DH, Borders LM. Patients’ desires and satisfaction in general medicine clinics. Public Health Rep. 1993;108:751–9.PubMedGoogle Scholar
  2. 2.
    Kravitz RL, Callahan EJ, Paterniti D, Antonius D, Dunham M, Lewis CE. Prevalence and sources of patients’ unmet expectations for care. Ann Intern Med. 1996;125:730–37.PubMedGoogle Scholar
  3. 3.
    Linder-Pelz SU. Toward a theory of patient satisfaction. Soc Sci Med. 1982;16:577–82.CrossRefPubMedGoogle Scholar
  4. 4.
    Kravitz RL. Patients’ expectations for medical care: an expanded formulation based on review of the literature. Med Care Res Rev. 1996;53:3–27.PubMedGoogle Scholar
  5. 5.
    Lazare A. The interview as a clinical negotiation. In: Lipkin M, Putnam SM, Lazare A. The Medical Interview: Clinical Care, Education, and Research. New York: Springer-Verlag; 1995.Google Scholar
  6. 6.
    Kroenke K. Patient expectations for care: how hidden is the agenda? Mayo Clin Proc. 1998;73:191–3.PubMedGoogle Scholar
  7. 7.
    Beckman HG, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101:692–6.PubMedGoogle Scholar
  8. 8.
    Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: have we improved. JAMA. 1999;281:283–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients’ unvoiced agendas in general practice consultations: qualitative study. BMJ. 2000;320:1246–50.CrossRefPubMedGoogle Scholar
  10. 10.
    Brody DS, Miller SM, Lerman CE, Smith DG, Lazaro CG, Blum MJ. The relationship between patients’ satisfaction with their physicians and perceptions about interventions they desired and received. Med Care. 1989;27:1027–35.CrossRefPubMedGoogle Scholar
  11. 11.
    Marple RL, Kroenke K, Lucey CR, Wilder J, Lucas CA. Concerns and expectations in patients presenting with physical complaints. Arch Intern Med. 1997;157:1482–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Himmel W, Lippert-Urbanke E, Kochen MM. Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice. Scand J Prim Health Care. 1997;15:118–22.PubMedCrossRefGoogle Scholar
  13. 13.
    Froehlich GW, Welch HG. Meeting walk-in patients’ expectations for testing: effects on satisfaction. J Gen Intern Med. 1996;11:470–4.CrossRefPubMedGoogle Scholar
  14. 14.
    Kravitz RL, Cope DW, Bhrany V, Leake B. Internal medicine patients’ expectations for care during office visits. J Gen Intern Med. 1994;9:75–81.CrossRefPubMedGoogle Scholar
  15. 15.
    Kravitz RL, Callahan EJ, Azari R, Antonius D, Lewis CE. Assessing patients’ expectations in ambulatory medical practice. J Gen Intern Med. 1997;12:67–72.CrossRefPubMedGoogle Scholar
  16. 16.
    Williams S, Weinman J, Dale J, Newman S. Patient expectations: what do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction. Fam Pract. 1995;12:193–201.CrossRefPubMedGoogle Scholar
  17. 17.
    Miller RH, Williams PC, Napolitana G, Schmied J. Malpractice: a case-control study of claimants. J Gen Intern Med. 1990;5:244–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Hickson GB, Clayton EW, Entman SJ. Obstetricians’ prior malpractice experience and patients’ satisfaction with care. JAMA. 1994;272:1583–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Marquis MS, Davies AR, Ware JE. Patient satisfaction and change in medical care provider: a longitudinal study. Med Care. 1983;21:821–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Ware JE, Davies AR. Behavioral consequences of consumer dissatisfaction with medical care. Eval Program Plann. 1983;6:291–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Becker MH, Maiman LA. Strategies for enhancing patient compliance. J Community Health. 1980;6:113–25.CrossRefPubMedGoogle Scholar
  22. 22.
    Zemencuk JK, Feightner JW, Hayward RA, Skarupski KA, Katz SJ. Patients’ desires and expectations for medical care in primary care clinics. J Gen Intern Med. 1998;13:273–6.CrossRefPubMedGoogle Scholar
  23. 23.
    Kravitz RL, Bell RA, Franz C. A taxonomy of requests by patients (TORP): a new system for understanding the clinical negotiation in office practice. J Fam Pract. 1999;48:872–8.PubMedGoogle Scholar
  24. 24.
    Uhlmann RF, Carter WB, Inui TS. Fulfillment of patient requests in a general medicine clinic. Am J Public Health. 1984;74:257–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Thompson AGH, Sunol R. Expectations as determinants of patient satisfaction: concepts, theory and evidence. Int J Qual Health Care. 1995;7:127–41.CrossRefPubMedGoogle Scholar
  26. 26.
    Standard definitions: final dispositions of case codes and outcome rates for surveys. The American Association for Public Opinion Research; 2000. Available at: html. Accessed on September 25, 2002.Google Scholar
  27. 27.
    Kravitz RL, Bell RA, Franz CE, et al. Characterizing patient requests and physician responses in office practice. Health Serv Res. 2002;37:217–38.PubMedGoogle Scholar
  28. 28.
    Ware JE Jr, Hays RD, Methods for measuring patient satisfaction with specific medical encounters. Med Care. 1988;26:393–402.CrossRefPubMedGoogle Scholar
  29. 29.
    Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika. 1951;16:297–334.CrossRefGoogle Scholar
  30. 30.
    Ware JE. SF-36 Health Survey. In: Maruish ME, ed. The Use of Psychological Testing for Treatment Planning and Outcomes Assessment, 2nd Ed. Mahwah, NJ: Lawrence Erlbaum; 1999;1227–46.Google Scholar
  31. 31.
    Anderson LA, Dedrick RF. Development of the Trust in Physician scale: a measure to assess interpersonal trust in patient-physician relationships. Psychol Rep. 1990;67:1091–100.PubMedGoogle Scholar
  32. 32.
    Safran DG, Kosinski M, Tarlov AR, et al. E. The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care. 1998;36:728–39.CrossRefPubMedGoogle Scholar
  33. 33.
    Thom DH, Campbell B. Patient-physician trust: an exploratory study. J Fam Pract. 1997;44:169–76.PubMedGoogle Scholar
  34. 34.
    Shelton PJ. Measuring and Improving Patient Satisfaction. Gaithersburg, Md: Aspen Publishers; 2000.Google Scholar
  35. 35.
    DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol. 1993;12:92–102.CrossRefGoogle Scholar
  36. 36.
    Sherbourne CD, Hays RD, Ordway L, DiMatteo MR, Kravitz RL. Antecedents of adherence to medical recommendations: results from the Medical Outcomes Study. J Behav Med. 1992;15:447–68.CrossRefPubMedGoogle Scholar
  37. 37.
    Gerteis M, Edgman-Levitan S, Daley J, Delbanco T., eds. Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care. San Francisco: Jossey-Bass Inc.; 1993.Google Scholar
  38. 38.
    Cleary PD, McNeil PJ. Patient satisfaction as in indicator of quality care. Inquiry. 1988;25:25–36.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2002

Authors and Affiliations

  • Robert A. Bell
    • 1
  • Richard L. Kravitz
    • 2
  • David Thom
    • 3
  • Edward Krupat
    • 4
  • Rahman Azari
    • 5
  1. 1.Received from the Department of CommunicationUniversity of California-DavisDavis
  2. 2.U.C. Davis Center for Health Services Research in Primary CareUniversity of California-Davis Medical CenterSacramento
  3. 3.the Division of Family and Community MedicineStanford University Medical SchoolPalo Alto
  4. 4.Massachusetts College of Pharmacy and Health SciencesBoston
  5. 5.the Department of Statistics, and the U.C.D. Center for Health Services Research in Primary CareUniversity of California-DavisDavis

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