Introduction:

The relationship between patient and doctor is referred to as therapeutic relationship. This relationship is a key factor for effective and significant therapy. [1]

The significance of therapeutic relationship is that, it is the interaction for development a strong bond between a health care provider and recipient of care in which feelings, thoughts and ideas of patients have been allowed to be shared, heard, understood and valued. Due to patient-clinician relationship, there is small but significant effect on healthcare outcome and the ratio of this outcome is approximately 23% to 66%. This value shows that doctor-patient relationship has some beneficial effect on health care quality of patients.[2]

A theory was developed that will be helpful to find out the quality of the client–therapist relationship which can be explained by attachment theory  According to the attachment theory, although treatment therapy and the helping alliance is a collaborative process but the attachment process is also necessary in which patients and therapist bring effective therapeutic relation. Indeed, the interaction between patient and therapist is important for health care concerned. The recent course of events suggests that the relational aspect of therapy is necessary. [3]

The therapeutic relationship determines the patient satisfaction level with doctor and extent of provider communication and association between clinician and patient which has effect on patient’s health outcome. But there are some major deficiencies in communication during visiting to any health care professional’s i-e poor communication, less well-equipped facilities or negligence. Due to poor communication, result is lower satisfaction level that lead to poor health outcomes on patients.[4]

The barriers of communication not only restrict personal relationship, but it also obstructs professional association and seriously compromise negotiation efforts. Information depth, body language, facial expression and perceptual structure can considerably affect on the quality of health and attachment between patients and clinician. This is necessary for the physician to avoid communication hazards and improves the basic communication skills that can helpful to make stronger bond for the patient and doctor.[5] 

Some fundamental changes are required in our health care system to bring effective impact on health of patients and relationship among patient-clinician. The first change is communication, which is basic component for wellbeing of every individual. Similarly as primary care practitioner  adopt some advanced changes they will influence on the mental health, medical self management, behavioral and health outcomes  of the patients.[6]

For receiving effective health care goals, two OPD are compared i.e. physiotherapy OPD and orthopedic OPD. Physical therapists are medical professionalizes who diagnose, prognosis, treat and evaluate the outcome of patient’s health related to physiotherapy. However, instead of relying on exercise regimens, orthopedic surgeons treat the patients through operation to restore the function. After surgery from orthopedic most patients recognize the significant role of physiotherapy for improvement quality of life  and according to them they have received  better treatment protocol as compare to orthopedic surgeons.[7]

According to patient’s perceptions of quality of care, standard practices are compared by physiotherapy-led orthopedic triage. In this triage patients referred from orthopedic surgeons to physiotherapist. Patients reported that they have acknowledged good quality of care in both physiotherapy and orthopedic OPD, but the patients in the physiotherapy-led orthopedic triage describe higher quality of care in physiotherapy OPD as compared

to the orthopedic OPD .[8]

Gap:

In previously available literature no such study has been conducted to find the comparison between physiotherapy and orthopedic OPD on the base of therapeutic relationship.

Rationale:

Physical therapy profession is one of the effective health care professions and plays a vital role for the betterment and improvement in quality of life of patients. This study will helps in generating awareness about therapeutic relationship based difference among physiotherapy and orthopedic OPD. With the help of this study outcome, measure can be taken to enhance this relationship so that quality of care can be enhanced.

Objective:

To determine the therapeutic relationship of patient-doctor in physiotherapy and orthopedic OPD in Lahore

Operational deffinition:

DPQR-9:

DPQR-9 is a brief and useful measurement tool to find out the doctor-patient relationship according to the patient’s perspective. [9]

It is nine (9) items questionnaire designed to evaluate the therapeutic relationship and can be used for public health.

 It has good psychometric properties as reliability co-efficient of DPRQ-9 (Cronbach's α) is 0.94. Total range is 10-45, with 45 as highest possible score and 9 as lowest score. If the score will anywhere below 35 it means that you and your Primary care practitioner(PCP) are not particularly well matched.[10]

Literature review:

Rachel Kornhaber et al conducted a systemic review to evaluate the therapeutic relationship between care recipient and care provider. Through electronic database, they concluded that doctor-patient relationship is associated with supporting behavior which improves quality of life that will enhance patient’s satisfaction level. On the other hand, increased physiological stress and feelings of dehumanization are related with negative clinician patient relationship.[11]

Shauna et al, conducted a cross section study. The purpose of this study is to find out the benefits of mindfulness between health care professionals and patients. Patients are divided into two groups; one group received considerable attention due to regular appointment from their practitioner and other group getting less attention from their care giver due to indiscretion. The result was revealed, those group who received forceful attention from care giver they ultimately enhance patient-profession relationship. [12]

A descriptive co relational study by Bakker et al, to examine relationship between perception of engagement with health care provider and health status and promote the attachment with clinician. By using health care provider scale, they concluded that patients who were more engaged and have significant attachment with their care provider they have greater devotion to clinician advice. Conversely, Patients who do not have any appointment to their practitioner they appreciably less engaged and eventually have poor health status due to their avoidance behavior.[13]

 A retrospective cohort study by Kristin R Archer et al, in 8 December 2009. The intend of this study is to explore the variability in orthopedic surgeons and physical therapist, to assessment the need for physical therapist in patients with lower extremity trauma. Through the chi-square analysis, the conclusion is, surgeon referred the patients to physical therapist for therapy which will be better for her condition and range of motion will also be improved. [14]

 Songhai DM et al had a descriptive study. The aim of this study is to improve therapeutic relationship between care recipient and care provider by compassionate care. On the base of questionnaire that held in hospital, result is revealed that sympathy will improve by communication with therapist that will lead to better patient-clinician relationship. Lack of association of patients will cause poor understanding with physician.[15]

Kristen Adams et al conducted a systemic review study, in 1 October 2013, in which they describe physician responses to patients which associated with physician-patient relationship and care outcomes. A code book was developed in which responses are categorized into three types toward, away and neutral. The result is neutral and toward responses were associated with patient closure to gain the empathy and sympathy and build strong bond with physician for betterment of health condition.[16]

 Davenport TE et al examined the information content of diagnosis to physical therapist with respect of patient’s characteristics, physician and orthopedic surgeons by randomized retrospective study. By using of referral diagnosis categorize, the conclusion of this study is that the practice of evidence based physical therapist has autonomy and they have responsibility to conduct differential diagnosis of pathology.[17]

Holmes GM et al, conducted a cross sectional study, in 5 October 2005. The purpose of this study is, to indentify factors associated with orthopedic surgeons that referred the patients to the physical therapist for musculoskeletal condition. After controlling for diagnosis, they concluded that physical therapist has strong characteristics for treatment of referred patients and it may be high quality indicative to assess musculoskeletal condition.[18]

 The endeavor of this study was to describe the predictor’s referral rates to physical therapy from general practice. By obtaining the questionnaire from general physicians, they analyst that increasing health care treatment and declaration for need of treatment, are large indication and possible benefits for physiotherapy therefore they have high referral rate.[19]

A study was designed to compare the clinical diagnostic accuracy (MRI) referral rates in physical therapist and orthopedic surgeons. On the base of radiological profile of each patient, they concluded that there is significantly greater rate of diagnostic accuracy (MRI) recommendations from orthopedic surgeons then physiotherapy which have disadvantages on health and also high cost for patients.[20]

Hypothesis:

Null hypothesis (Ho): There is no significant difference in physiotherapy and orthopedic OPD on the basis of therapeutic relationship.

Alternative hypothesis (HI): There is significant difference in physiotherapy and orthopedic OPD on the basis of therapeutic relationship.

Materials & methods:

Study design:

This was a comparative cross-sectional study.

Study population:

Male and female patients visiting physiotherapy and orthopedic OPD

Study setting:

Data from the physiotherapists of following hospitals was collected.

• Punjab social security hospital
• Chaudhry Muhammad Akram Teaching & Research Hospital
• General hospital Lahore
• Sharif Medical and Dental college
• Lahore medical and Dental college

Study duration:

The total duration of this study was six months.

Sample size:

According to this formula the minimum sample size calculated was 148

This sample has been calculated by considering following parameters.  

Where

Z_1-α/2 (Z score for level of significance in two-sided test) = 1.96

 Z_1-β (Z score for power of the test) = 1.28 (90% power)

Proportion in group 1 (P₁) = 23%

Proportion in group 2 (P₂) = 66%

Sampling Method:

Convenient sampling technique

Ethical Issues:

Ethical issues were kept under consideration. That did not affect the patient ethics, cultures and values. Patient’s demographic data was kept safe and not be shared to other persons. During data collection, every step was taken to ensure confidentiality of patients. Researcher followed all ethics of medical field.

Eligibility Criteria:

 Inclusion Criteria:

Both male and female subjects visiting orthopedic and physiotherapy OPDs with musculoskeletal problems were included.

Exclusion Criteria:

People excluded who have tumors, coagulation disorder, neoplastic disorder, infections. Noncompliant patients to exercise program, cardiovascular disease patients and pregnant women were excluded

Data Collection Procedure:

This comparative cross-sectional study was conducted in Azra Naheed Medical College, superior university Lahore to find out the difference between physiotherapy and orthopedic OPD on the base of therapeutic relationship. The aim and purpose of the study is to improve therapeutic relationship between patients and Doctor. An informed consent was taken from the university’s higher management. Total sample size was 148 in both physiotherapy and orthopedic OPD. Data was collected from the patients with the help of questionnaire which have nine (9) items questions i-e Doctor-patient relationship questionnaire (DPRQ-9) who’s reliability coefficient (Cronbach's α) is 0.94. The grading system of (DPRQ-9) for therapeutic relationship is (1-not at all appropriate), (2- somewhat appropriate), (3- appropriate), (4- mostly appropriate), (5- totally appropriate).

Total range is 10-45, with 45 as highest possible score and 9 as lowest score. It was clear that most participants felt pretty good about their primary care practitioner’s (PCP). If the score will anywhere below 35 it means that you and your PCP are not particularly well matched. Ethical approval was taken from Naheed Medical College, Superior University Lahore. People with Musculoskeletal disorders are included and other diseases like tumors, infection and pregnant women etc are excluded. Data was collected both private and government hospitals physiotherapy and orthopedic OPD. Informed consent was taken from each person participating in research. It was completely explained to every participant. They were asked for their informed participation. All participants were conscious and willing to participate in study. All collected data was entered in computer program SPSS version 16 and calculated through this software. Independent sample T-test was used to compare therapeutic relationship of patients with concerned health care professionals. P values were identified as statistically significant if ≤ 0.05.

 

Result:

Minimum	Maximum	Mean	Std. Deviation
12.00	72.00	37.32	14.17

Table 1: Age of the subjects

Minimum age is 12.00 and maximum age is 72.00 mean age value is 37.32.

Variables		Physiotherapy OPD n=75	Orthopedic OPD n=73	P-Value
Age		37.77 ±15.45	36.74 ±12.44	0.66
Setting	Government n=39	16	23	0.27
		19.3%	35.4%
	Private n=109	67	42
		80.7%	64.6%
Gender	Male n=78	46	32	0.45
		55.4%	49.2%
	Female n=70	37	33
		44.6%	50.8%

Table 2:  Socio-demographic Comparison

A total of 148 participated in the study out of them 75 were from physiotherapy OPD and 73 were from Orthopedic OPD. The mean age of participants in physiotherapy OPD was 37.77 ±15.45 and in Orthopedic OPD was 36.74 ±12.44. 55% participants in physiotherapy OPD were male and 45% were females whereas among participant from Orthopedic OPD 49% were male and 51% were female. (P-value 0.45) Participants in both groups were also comparable in terms of their work setting (p=0.27) (TABLE 1 & 2)

A total of 9 variables related to therapeutic relationship were asked from participants in both groups. This variable contains information about experience of participants regarding nature of health care provider, time spending, trust wordiness, attitude, dedication, agreement, level of comfort, contentment, and accessibility and the results showed that in all 9 categories there was significant difference between the therapeutic relationship in both groups  (Table 3)

 

 

Outpatient Department	Not at all appropriate	Somewhat appropriate	Appropriate	Mostly appropriate	Totally appropriate	P-Value
My primary care practitioner (PCP) helps me.
Physiotherapy n=75	0	1	17	36	29	<0.05
	0.0%	1.2%	20.5%	43.4%	34.9%
Orthopedic n=73	1	8	15	23	18
	1.5%	12.8%	23.4%	35.5%	27.8%
Total n=148	1	9	32	59	47
	.7%	6.2%	21.0%	39.8%	31.3%
My PCP has enough time for me.
Physiotherapy n=75	0	2	22	30	29	<0.05
	0.0%	2.4%	26.5%	36.1%	34.9%
Orthopedic n=73	1	4	25	15	20
	1.5%	6.9%	38.3%	23.1%	30.2%
Total n=148	1	6	47	45	49
	.7%	4.8%	31.8%	30.4%	33.3%
I trust my PCP.
Physiotherapy n=75	0	5	20	34	24	<0.05
	0%	6.0%	24.1%	40.6%	28.3%
Orthopedic n=73	0	10	20	20	15
	0%	26.2%	30.8%	30.0%	23.1%
Total n=148	0	22	40	54	39
	0%	10.9%	27.4%	36.8%	26.9%
My PCP understands me.
Physiotherapy n=75	1	3	25	29	25	<0.05
	1.2%	3.6%	30.1%	34.9%	30.1%
Orthopedic n=73	0	10	29	13	13
	0.0%	26.2%	44.6%	20.6%	20.6%
Total n=148	1	13	54	42	38
	.7%	8.5%	36.5%	28.4%	25.9%
My PCP is dedicated to help me.
Physiotherapy n=75	0	5	18	39	21	<0.05
	0.0%	6.0%	21.7%	47.0%	25.3%
Orthopedic n=73	1	17	19	16	12
	1.5%	26.2%	29.5%	24.6%	18.2%
Total n=148	1	22	37	55	33
	.7%	14.9%	25.4%	37.2%	22.9%
My PCP and I agree on the nature of my medical Symptoms
Physiotherapy n=75	1	3	24	29	26	<0.05
	1.2%	3.6%	28.9%	34.9%	31.3%
Orthopedic n=73	2	10	28	14	11
	3.1%	15.0%	53.8%	21.5%	16.5%
Total n=148	3	13	59	43	37
	2.0%	8.8%	39.9%	29.1%	25.2%
I can talk to my PCP.
Physiotherapy n=75	0	5	25	33	20	<0.05
	0.0%	6.0%	30.1%	39.8%	24.1%
Orthopedic n=73	2	10	28	14	11
	3.1%	20.0%	53.8%	21.5%	16.5%
Total n=148	2	18	60	47	31
	1.4%	12.2%	40.5%	31.8%	20.2%
I feel content with my PCP’s treatment
Physiotherapy n=75	0	2	23	30	28	<0.05
	0.0%	2.4%	27.7%	36.1%	33.7%
Orthopedic n=73	1	9	26	13	16
	1.5%	13.5%	40.0%	20.0%	24.0%
Total n=148	1	11	49	43	44
	.7%	7.2%	33.1%	29.1%	29.9%
I find my PCP easily accessible.
Physiotherapy n=75	0	1	22	35	25	<0.05
	0.0%	1.2%	26.5%	42.2%	30.1%
Orthopedic n=73	3	8	24	14	16
	4.6%	12.2%	36.1%	21.5%	24.5%
Total n=148	3	9	46	49	41
	2.0%	6.5%	31.8%	33.1%	27.6%
* P-value significant at or less than 0.05

Table 3:  Distribution of Responses regarding Therapeutic Relationship

Therapeutic Relationship	Physiotherapy OPD n=75	Orthopedic OPD n=73	P-value
My primary care practitioner (PCP) helps me.	4.12±0.77	3.09±1.01	<0.05
My PCP has enough time for me.	4.04±0.85	3.15±0.83	<0.05
I trust my PCP.	4.01±0.86	3±0.77	<0.05
My PCP understands me.	3.89±0.92	3.08±0.83	<0.05
My PCP is dedicated to help me.	3.92±0.84	3.08±0.91	<0.05
My PCP and I agree on the nature of my medical Symptoms	3.92±0.93	2.98±0.78	<0.05
I can talk to my PCP.	3.82±0.87	2.98±0.78	<0.05
I feel content with my PCP’s treatment	4.01±0.85	2.78±0.78	<0.05
I find my PCP easily accessible.	4.01±0.79	2.86±0.86	<0.05

Table 4: Comparison of therapeutic relationship in each variable

Therapeutic Relationship	Physiotherapy OPD n=75	Orthopedic OPD n=73	P-value
DPQR-9 Score	35.61±4.61	29.08±4.21	<0.05
* P-value significant at or less than 0.05

Table 5: Comparison of Therapeutic Relationship among Physiotherapy OPD & Orthopedic OPD

 

Table 5 is comparing the score of DPQR-9 among both groups. The score in physiotherapy group was 35.61±4.61 and in Orthopedic OPD group was 29.08±4.21. P value calculated through independent sample t test is showing the there is significant difference in therapeutic relationship among both groups

Conclusion:
The therapeutic relationship of patient and primary care practitioner in orthopedic was not well matched. On the other hand, therapeutic relationship in patient with PCP in physiotherapy OPD was well matched. There was significant difference in therapeutic relationship among both groups and Physiotherapy OPD showed better relationship with patients as compared to orthopedic OPD.

Discussion:
There are many types of human relationship or interpersonal relationship which brings people close to each other physically and emotionally. Doctor and patient relationship is significantly most important connection. The relationship between primary care practitioner and client is essential to establishing a successful outcome by promoting willingness for the client to share and engage with the counselor. [21]

In 2016 an Effective doctor-patient communication is a central clinical function in building a therapeutic doctor-patient relationship, which brings positive health care outcomes on patients. This is important in the delivery of high-quality health care. Much patient dissatisfaction and many complaints are due to breakdown in the doctor-patient relationship. However, many doctors tend to overvalue their ability in communication [22]

Another research in 2014 corroborated that once the therapeutic relationship is formed, an individual in therapy become more willing toward doctor to open up emotionally and provides further details about his or her associated symptoms. This will be helpful for the therapist to better understand the affected person’s point of view, feelings, and motives, then the therapist is able to provide the most appropriate and effective interventions for improvement of patients health. [23]

According to this study there was significant difference in therapeutic relationship among both groups’ physiotherapy and orthopedic.

In 2016 it was proved that patients referred from orthopedic surgeons to physiotherapist then, these patients describe high quality of care in physiotherapy OPD. [24]

Another study in 2005 was proved that the patients from orthopedic OPD have greater rate of clinical diagnostic accuracy like MRI and X-ray which is costly for patients. [25]

Results show that, patient Doctor Relationship score in physiotherapy group was 35.61±4.61 and in Orthopedic group was 29.08±4.21, which show that there was significant difference in therapeutic relationship among both groups.

For buildup of good therapeutic relationship between care provider and client among both physiotherapy and orthopedic OPD’s, there were some components which necessary for betterment of interaction i.e. trust, respect, interest, and empathy. To effectively show empathy a doctor must be able to understand verbal and nonverbal cues by patients. This professional interaction is caring and supportive relationships which promote the patient’s well being. [26]

 Therapeutic interpersonal relationships are the primary component of all health care interactions that facilitate the development of positive clinician–patient experiences and also have better outcome on patient’s health.[27]

According to results, in physiotherapy OPD time spending was 4.04±0.85 and in orthopedic OPD time given from physician was 3.15±0.83. Trust worthiness in orthopedic OPD was   3±0.77 and PCP trust toward patients in physiotherapy was 4.01±0.86. Patients’ understanding in physiotherapy was 3.89±0.92 and in orthopedic OPD was 3.08±0.83. Agreement on medical symptoms in physiotherapy were 3.92±0.93 and agreement on nature of medical symptoms in orthopedic was 2.98±0.78.

The contentment of patients to primary care practitioner or doctor in physiotherapy OPD was 4.01±0.85 and in orthopedic OPD patient’s satisfaction and contentment was 2.78±0.78, which shows that, there was significant difference in patient contentment among both groups.

As rate of contentment were   low in orthopedic due to some patients complain, that was not perform proper functional work and inject intra articular steroids injection which have side effects on patients although, these joint injections are fairly safe and can provide long-term benefits but side effects from the steroid injection include menstrual irregularities, skin flushing, muscular fatigue, and gastrointestinal upset. Local side effects may include soreness at the site of injection, bruising, changes in skin pigmentation and infection. Therefore, some patients do not respond to treatment even with medications. Some orthopedics does not communicate with patients daily however it’s good for them. [28]

Related to patient’s contentment, physiotherapist performs rehabilitation exercise of patients daily once or at least after one day which is comfortable for patient’s mobility and also improves patient’s   range of motion and does not have any side effects. Therefore, patients have daily communication with their doctor and telling about their improvement. Patient reports of positive physician relational communication because they appointed with doctor daily and patient reports satisfaction was also good. [29]

The accessibility of doctor in orthopedic was 2.86±0.86 and in physiotherapy was 4.01±0.79.

This is very important for recovery of patients, as patients need to know that someone is paying attention to them and available for them.[11]

 In orthopedic OPD, often physician not available at time for  patients they might attend surgeries and patients are waited for doctor which have negative impression on patients because patients demand doctor will available at the spot for them. Therefore, for the improvement of patient satisfaction is to spend more time with each patient, not increased time for wait.[30]

In this study a reliable and valid questionnaire is used to determine the therapeutic relationship between patient and doctor. Doctor-Patient Relationship Questionnaire (DPRQ-9) is a reliable co-efficient scale used to compare the agreement between two different types of groups i.e. physiotherapy and orthopedic.

A study proved in 2015 in which (DPRQ-9) questionnaire is used. This study showed that P value was > 0.5 in the factor analysis. But in our study P.value is < 0.5 that is statistically significant which shows that there were significant differences in pervious study and our study. [31]

In another study in 2010 which declared that Physical therapists and orthopedic surgeons both work in health care settings, treating patients with physical conditions that cause discomfort or difficulty moving. Although orthopedic surgeons can perform operations, inject steroids injections and some surgeons recommended steroids medications which have adverse effect on patient’s health. However, instead of relying on exercise orthopedic surgeons perform operations to restore function to patients. On other hand physical therapists, use a variety of techniques to help patients gain or regain physical mobility, including massage techniques, stretching and exercise regimens, or the use of adaptive equipment in patient homes or workplaces.[32]

It is necessary for a good relationship between physiotherapist and orthopedic surgeon. Although, orthopedic surgeon and the physiotherapist are partner, because some time the therapists find small minute details of the problem which are missed from orthopedic surgeon. They provide valued instruction and evaluation of minute details of injury.

On the base of our study result, different elements are identified that can be utilized in future research. Examination for associations of patient–doctor relationship can be done by making use of these elements. Results show that, there was significant difference in therapeutic relationship among both groups. The relationship of patient and primary care practitioner in orthopedic OPD are not well matched. Conversely in physiotherapy OPD Doctor-Patient relationships are well matched and showed better relationship with doctor as compare to orthopedic OPD.

limitations/ recommendations:

• Time duration for this study was short, limited population was selected
• Only orthopedic OPD was selected but other OPDs can also be selected for comparison with physiotherapy OPD on the base of therapeutic relationship,
• Resources were also limited, and it was a low-cost study

Declaration:

We acknowledge the support of our parents and teachers.

Both authors made similar contributions to the study. The research received no financial assistance or funding. There are no conflicts of interest or any ethical issues. Informed consent was taken from all participants and data were collected pro forma.

Anonymity was protected through out.

On behalf of all authors, the corresponding author states that there is no conflict of interest.