Family Practice
© Oxford University Press 2001
Vol. 18, No. 1
Printed in Great Britain
Loyalty to the regular care provider:
patients’ and physicians’ views
Danièle Roberge, Marie-Dominique Beaulieua, Slim Haddada,
Ronald Lebeaua and Raynald Pineaulta
Roberge D, Beaulieu M-D, Haddad S, Lebeau R and Pineault R. Loyalty to the regular care
provider: patients’ and physicians’ views. Family Practice 2001; 18: 53–59.
Background. Changes in the organization of primary care practices are likely to have repercussions on the manner in which patients and physicians perceive loyalty to a regular source of
care. A better understanding of their views will contribute to conceptual reflections on this
poorly documented topic and, where needed, will reinforce efforts to adapt services to patient
expectations.
Objectives. The aims of this study are to document and compare the views that patients and
GPs have of loyalty to the regular care provider.
Methods. This exploratory study uses the focus group technique. In 1997, we set up three
groups of patients and three groups of physicians practising in Montreal. A total of 23 patients
and 14 physicians participated in the study. The meetings investigated the participants’ points
of view on various aspects of the notion of loyalty. Analysis was based on transcripts of the
meetings. The emerging themes were identified and the viewpoints were coded independently
and then revised (when necessary) in order to obtain a consensus.
Results. Patients and physicians have a relatively congruent vision of the notion of loyalty. This
tendency to use the regular source of care over time appears to be rooted in a formal or informal
contract between patients and their physicians and implies a sustained partnership and a strong
interpersonal relationship. The relationship established is neither exclusive nor permanent.
Patients periodically reconsider it by evaluating their physician’s technical and interpersonal
skills.
Conclusions. This study highlights the dynamic and multidimensional nature of the notion of
loyalty. It shows that patients clearly identify with a particular physician rather than a clinic. The
results challenge the prevailing methods of assessing longitudinality of care.
Keywords. General practice, longitudinality, loyalty, patients’ and physicians’ views.
doctor–patient relationships that are known to have
many benefits.1
The notion of loyalty has scarcely been addressed in
the literature on continuity of care. It is related to the
concept of ‘longitudinality’ which refers to consistency
in the relationship between a patient and a physician over
time and which is translated by the consumer behaviour
of using the regular source of care for all health needs.2
The majority of studies dealing with consistency of the
doctor–patient relationship have focused on measuring
profiles of utilization of the regular source of care based
on information contained in administrative databases.
Most often, these data sources do not allow for reconstituting the utilization profiles for all health needs and
they are even less revealing about the reasons why individuals do or do not decide to consult their regular source
Introduction
The restructuring of primary care services in most
western countries is likely to have repercussions on the
manner in which consumers and physicians view loyalty
to a regular source of care. Some fear, for instance,
that organizational models that favour group practices
encourage interchangeability and jeopardize long-term
Received 2 February 2000; Revised 6 July 2000; Accepted
5 September 2000.
Centre de recherche, Hôpital Charles LeMoyne, 3120,
boulevard Taschereau, Greenfield Park and aCentre Hospitalier Universitaire de Montréal, Université de Montréal,
Montréal, PQ, Canada.
53
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Family Practice—an international journal
of care and about the dynamics of the doctor–patient
relationship. Yet these aspects are seen as major determinants of consistent use.1,3 They can be understood
better through qualitative approaches.
To date, there is little documentation on patients’ and
physicians’ views on what characterizes a long-term
doctor–patient relationship. A few studies have focused
on finding out why patients have discontinued a relationship with their doctor.4–6 Others have attempted to document physicians’ views of the benefits of a long-term
doctor–patient relationship.7,8
To our knowledge, no study has focused specifically on
the notion of loyalty nor has there been any attempt
to understand the dimensions of the dynamics of the
relationship that are favourable to a long-term link between physicians and their patients. The research conducted to date has not allowed for a clear understanding
of the concept of loyalty and its complexities, and the
points of view of the main actors involved have hardly
been documented.
The goal of this study is to define the notion of loyalty
to the attending physician. More specifically, its goal is
to document and compare the vision that patients and
physicians in the Montreal region have of loyalty to the
regular care provider.
icians (five women and nine men) participated in the
focus groups.
The patients were recruited through advertisements in
the Montreal daily newspapers and in neighbourhood
weeklies. A total of 23 people participated in the meetings. There were approximately eight people in each
group, with an average age of 43 years (range: 27–72).
The majority of the participants were women (16/23).
Participants were paid $25 for their time and travel
expenses.
Methods
Data analysis
The analysis was based on the transcripts of the meetings. Following a first reading of all of the verbatims,
exchanges or expressions that were likely to reflect the
views of one or more participants concerning loyalty
were identified independently by two members of the
team. This material was then submitted to the project
researchers so that each one could proceed to identify
emerging themes. Subsequent meetings allowed for the
pooling of common themes and, when necessary, the
researchers sought to reach a consensus. Lastly, each expression was listed under the theme to which it referred.
The validation of these thematic classifications was
carried out independently by two of the team members
on approximately one-third of all the verbatims.
The study uses the focus group technique. This is the
preferred method for an exploratory approach where
the study involves collecting a variety of opinions on a
subject with little existing documentation.9
Participants and recruitment strategy
Three groups of physicians and three groups of patients
were created. In order to obtain a wide range of opinions
on the issue, we strove for a certain level of heterogeneity
in terms of age and sex of participants, and practice
settings for physicians in each of the groups. It should be
noted that the population in Québec is predominantly
French-speaking. There is a system of universal health
care coverage and consumers are free to choose their
GP. The majority of physicians work in group practice.
Health care funding is public, but 85% of the care
is delivered in a fee-for-service ‘private’ manner.
Approximately 14% of the care is delivered in salaried,
community health clinics, and the remaining 1% in
family medicine units in teaching hospitals.
The first focus group was composed of physicians who
serve in key positions in various medical organizations
and associations that are grappling with issues of continuity. This meeting enabled the researchers to validate
the content of the interview plan for running the focus
groups, to document the participants’ views on the notion
of loyalty and to compile a list of GPs in various practice
settings for recruitment purposes. A total of 14 phys-
Procedure
An experienced moderator led the patient groups and a
member of the research team led the physician groups.
The participants’ comments were recorded. The meetings, which lasted an average of 1.5 hours, followed a predetermined interview plan (see Appendix). The notion
of loyalty was investigated by questioning the participants about the different manners in which one could
be loyal to a physician, whether or not this behaviour
was unequivocal (loyalty to one or several physicians)
and the temporal nature of this phenomenon (a lifelong
behaviour or one that changes over time). The focus
groups were conducted in French and all the participants
were French-speaking (francophone), reflecting the
language spoken by the majority of people in Québec.
Results
The content analysis suggests that the material could
be grouped into the following three main themes: (i) the
various aspects of the notion of loyalty; (ii) the main
behaviours associated with loyalty; and (iii) the roles
that physicians and patients play in maintaining a longterm doctor–patient relationship.
The notion of loyalty
Using a Venne diagram, Figure 1 illustrates the dominant ideas raised by patients and physicians concerning their view of loyalty. The ideas appearing at the
Loyalty to the regular provider
FIGURE 1
55
Patients’ and physicians’ views of loyalty
intersection of the circles are common to both groups of
participants.
It is interesting to note that, overall, patients and physicians have a relatively congruent vision of what loyalty
means. First of all, loyalty is seen as a patient behaviour,
one which is set forth in the form of contract, agreement
or commitment between the two parties. This aspect is
clearly illustrated by the words of a patient first, and then
by those of a physician.
“I see a strong association between the word loyalty
and the word commitment.”
“I think that this contract is established tacitly.
When someone comes to see us and then returns,
there is some sort of a request for availability; if you
agree to see the patient and you are happy that he
comes back to see you, you make a commitment to
be available.”
In addition, many patients perceive that loyalty rests
first and foremost upon confidence in their doctors.
“You have to have confidence in your doctor and
you have to see eye-to-eye with him . . . it’s that
confidence that’s going to make you decide that he’s
your doctor.”
Moreover, patients seek a certain independence in
their actions. For instance, some patients say that they
occasionally consult other professionals (e.g. alternative
medicine) without actually considering this as being disloyal to their doctor. Patients stressed that they cannot
reach their doctor every time a health need arises. This is
why the agreement established between the patient and
the doctor does not necessarily imply an exclusive tie. As
a result, it is understood and accepted by both parties
that patients occasionally will seek a second opinion or
consult other physicians when an emergency arises. The
following excerpt from a physicians’ group illustrates
this point.
“If it’s occasional [seeing another physician for a
second opinion], I’m even happy about it. From
time to time, it feels good to hear these people tell
me: ‘I saw Doctor X and he told me that my treatment is correct’, but this should not be a regular
or systematic occurrence because then there is no
loyalty.”
While the principle of non-exclusivity of the relationship is accepted, priority must be given to the regular
physician when a health need arises.
Physicians and patients view loyalty as something that
is not established for life, nor in a permanent manner.
The former recognize the existence of therapeutic
relationships corresponding to an individual’s stages
of life. Patients periodically reconsider the therapeutic
relationship in light of their evaluation of their attending
physician’s technical and interpersonal skills:
“If for some reason there is no longer a connection
between me and a given doctor or if I have treatments that are not satisfactory or that don’t appear
justified to me, then I’ll go elsewhere.”
As for physicians, regularity of contact is a more important element than the frequency of the visits may be:
“as far as I’m concerned, if he [the patient] comes
every ten years, he comes to see me regularly; it’s
regular, but not frequent. It means that over a space
of time, when he needed to see a doctor he always
came to see me.”
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The large majority of physicians acknowledge that
they cannot be available all the time. This is why some of
them consider that it is important for the patient to be
loyal to a clinic, in so far as they see that it offers advantages in terms of continuity of information. However,
the majority of the patients we met do not see things in
the same way; they identify first with their physician
rather than with a clinic. Lastly, for some patients, the
notion of loyalty signifies an obligation to which they do
not want to be subjected.
is to communicate with their physician (Fig. 2). From
the patients’ point of view, this role consists first of
collaborating with the physician, i.e. to inform him of
everything that can help him to understand and solve the
health problem (symptoms, effectiveness of treatments,
parallel or previous consultations, etc.):
Behaviours indicative of loyalty
Patients and physicians perceive two main behaviours
of loyalty to a physician: generally loyal or generally
disloyal. A person who is generally loyal to his physician
is one who decides to consult him for the majority of his
health needs, even if he occasionally consults another
professional. Among the so-called loyal patients, physicians have also identified a profile corresponding to
what could be considered as dependent behaviour. There
are patients who need their physician’s approval for
anything that has to do with their health and they want
to interact only with this doctor. According to physicians,
this behaviour leads to waits for consultations and, in
some circumstances (a serious health problem, for example), can be harmful to the health of these people. On
the contrary, a disloyal person does not seek to establish
a continuous link with his physician, and will consult
physicians and clinics indiscriminately regardless of the
nature of his health problems. Physicians refer to such
individuals as ‘shoppers’.
It is also their responsibility to ask the physician
questions in order to gain a better understanding of their
state of health. For physicians, it is important for patients
to express their expectations clearly:
Patients’ roles
According to all of the participants, the main role that
patients play in maintaining a long-term relationship
FIGURE 2
“It’s important for the patient to collaborate with
the doctor . . . it’s important to make a list, to write
down your complaints before you go to see your
doctor.”
“When a patient has clear requests, then I think that
we can also have clear answers. Someone who does
not say what services he is actually looking for . . .
well, it’s hard to figure out his needs and satisfy
him.”
Respecting appointments and a certain openness to
the doctor’s recommendations were also highlighted.
Physicians’ roles
In various respects, the participants have a common view
of the role that physicians play in maintaining a longterm relationship (Fig. 3). First of all, the physician must
make himself available. He must also give the patient
clear information and be frank with him about his health
and treatments. When many professionals are working
with the same patient, the role of the physician also consists of co-ordinating the care, especially by explaining
the results of consultations and ensuring follow-up of the
prescribed tests. The specific expectations of patients
The role of patients as expressed by both groups of participants
Loyalty to the regular provider
FIGURE 3
57
The role of physicians as expressed by both groups of participants
concerning the responsibilities of the physician also have
to do with maintaining his competence.
“I’m a diabetic, and with this disease research moves
very fast and I like it when doctors are up on the
latest developments.”
Physicians feel that it is also important for them to
respect the relationship established.
“. . . because there is a relationship, and you have to
respect that. In spite of the additional work associated with patient follow-up, if you want to have a
relationship and you want there to be some loyalty,
then you have to see your patients.”
Lastly, physicians consider that it is their job to inform
their patients in a precise manner of their availability
and how they run their office and to make them see the
importance of seeing the same physician regularly.
Discussion
To our knowledge, this study is the first to attempt to
define the phenomenon of loyalty to the regular care
provider, using the viewpoints of patients and physicians.
This exploratory study must, however, be considered
as a first look at this complex and little documented
issue. The wealth of information gathered conveys the
multidimensional and dynamic nature of the notion of
loyalty. Our results run parallel to the proposals made
by various authors to the effect that consistent use of a
regular source of care is rooted in a formal or informal
contract between the patient and his regular source
of care10 and that it implies a sustained partnership,11 a
climate of trust6 and a strong interpersonal relationship.1
Thus, from a conceptual point of view, loyalty refers to
a patient behaviour, which is influenced by various
facilitating factors including the commitment of the two
parties, patient trust in his physician and the quality of
the interpersonal relationship.
The comments gathered show that patients and physicians share a relatively congruent vision of the notion
of loyalty. They feel that the doctor–patient relationship
is neither exclusive nor is it established permanently.
Regularity of contacts and the strength of the relationship predominate. Frequency of visits seems to be
relatively less important for them.
The participants expressed clear expectations with
regard to the roles of each partner in the implementation
and pursuit of a long-term relationship. The dynamics of
the relationship seem to rest to a large extent on communication, freedom of exchanges and negotiation
between the two parties. The view of their respective
roles tends to support the importance of a model of
interaction qualified as ‘mutual participation’ where
patients and physicians provide their own information
and where patients participate in the decision-making
process.12,13
The majority of patients we met prefer their own physician as opposed to a clinic for a regular source of care.
This finding suggests that in spite of the changes in the
organization of primary care practice, often in favour of
group practice, people continue to identify clearly with
their personal physician. Yet, physicians see patient
loyalty to a clinic as a positive means of ensuring continuity of information.
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Family Practice—an international journal
Interestingly, the physicians we met report that they
place a high value on regularity of contacts with their
patients. According to them, this is favourable to maintaining the therapeutic relationship. Regularity of contacts
was not raised by the physicians as a means of stabilizing
their income. Nevertheless, it is plausible to believe that,
depending on the physicians’ place of practice, they
must find a balance between their personal objectives
(e.g. stability/improved income) and their fundamental
values. This may be the case in the walk-in clinics where
the emphasis is on accessibility and an immediate response
to needs, and continuity of care is of less importance. In
contrast, in those practice settings where physicians
have their own clientele, professional ethics may then
be perfectly congruent with personal objectives: patient
loyalty being a means both to provide better care and to
ensure income stability. The influence of organizational
context on the value that physicians place on loyalty
and on the manner in which they perceive it should be
explored.
The results of this study are of theoretical interest.
They contribute to refining the complex notion of loyalty
to the regular care provider. In addition, they have
revealed the principal structural elements of loyalty,
i.e. time and episodes of care. In fact, the behaviour of
loyalty can be studied adequately only across various
episodes of care extending over a long period of time.
Our findings highlight the limits of those studies that
have examined use of the regular source of care over
relatively short periods (usually a year), using administrative databases. These approaches do not seem to
articulate the manner in which physicians and patients
perceive loyalty.
Primary care physicians who are concerned with the
issue of maintaining long-term doctor–patient relationships and who wish to adapt their practice to patient
expectations will find the information reported here
useful. This study identifies various attributes of the
relationship that are favourable to loyalty and, possibly,
to better clinical outcomes. In particular, the study highlights the importance of mutual commitment which is
likely to facilitate the integration of prevention activities into clinical practice and patient compliance with
prescribed treatments. This, however, remains to be
verified.
The dimensions of the notion of loyalty identified in
this exploratory study should be validated using larger
samples of physicians and patients. In addition, the
cultural context may have an influence on the notion of
loyalty that emerged from this study. This, of course, is
inherent in any study of this type. It would thus be important to produce similar studies in other contexts. Lastly,
efforts are needed to conceptualize an appropriate
measure of loyalty taking into account the dynamic,
progressive and complex nature of this phenomenon.
Acknowledgements
This study was made possible by a research grant from
National Health Research and Development Program,
Canada (# 6605-4396-301).
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Appendix
Interview plan for discussion groups with physicians
Review of the research objectives: to characterize the phenomenon of loyalty, in particular to define it and to identify the criteria that could be
used to measure it.
Review of the proposed definition: loyalty refers to a patient spontaneously and regularly calling upon his attending physician to respond to his
health problems.
Discussion of the definition: participants’ views on the definition.
Discussion of the identification of behaviours or profiles: are there different ways to be loyal to an attending physician? What are the profiles of
consultation observed most frequently in daily practice?
Open discussion period.
Interview plan for discussion groups with patients
What does the term attending physician mean to you? Can a person have more than one attending physician? If yes, under what circumstances?
In your opinion, what does it mean to be loyal to your attending physician?
Are there different ways in which you can be loyal to your physician?
What might lead or prompt a person to stop seeing his/her attending physician? Or, conversely, to continue seeing him?
In certain instances, can we speak of loyalty to an institution (a clinic, etc.) rather than to a doctor? (to be explored if not mentioned: which is more
important—to see the same doctor or to seek treatment at the same clinic?)
Loyalty to your doctor: is this a behaviour that one adopts for life or does it change over time and why?