AIDS PATIENT CARE and STDsVolume 16, Number 1, 2002Mary Ann Liebert, Inc.

Physician-Patient Relationships, Patient Satisfaction, and Antiretroviral Medication Adherence Among

HIV-Infected Adults Attending a Public Health Clinic

KATHLEEN JOHNSTON ROBERTS, Ph.D.

ABSTRACT

The goal of this project was to explore the connections between human immunodeficiencyvirus (HIV)-positive patients adherence to antiretroviral medication treatment regimens andtheir beliefs about and satisfaction with their primary care physicians. In-depth interviewswere conducted with 28 HIV-positive patients. Results showed that most patients were ex-tremely satisfied with their current primary care physicians. When patients were dissatisfiedwith their care, it was often because there was a mismatch between the patient’s expectationsof care and the physician’s consultation style. Results also showed that good quality physi-cian-patient relationships tended to promote adherence while lesser quality relationships im-peded it. Findings suggest that strengthening and promoting the bonds between physiciansand HIV/acquired immunodeficiency syndrome (AIDS) patients should be an absolute pri-ority, at both the interpersonal level of physician-patient interactions but also at the organi-zational level.

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INTRODUCTION

MEDICAL ADVANCES during the late 1990’shave changed the landscape of human

immunodeficiency virus/acquired immunedeficiency syndrome (HIV/AIDS) care quitedramatically. While an HIV diagnosis used tobe considered a virtual death sentence,HIV/AIDS is now considered to be much moreof a chronic, manageable disease. Antiretrovi-ral drug “cocktails,” while include protease in-hibitors and other anti-HIV drugs, have beenfound to reduce the amount of virus in manypatients’ blood to undetectable levels.1 Whileresearchers and clinicians do not use the word“cure” to describe the latest treatment regi-

mens, it is clear that the regimens help manyindividuals live longer and healthier lives.2–4

However, current antiretroviral regimens arecomplex, with numerous proscriptions regard-ing the timing of doses as well as patients’ in-take of food and water. If patients do not takeantiretroviral medications essentially as pre-scribed, if doses are missed or taken improp-erly, resistance selection is expected, leading toclinical failure.2,5 Moreover, resistant HIV maybe transmitted.6 Hence, adherence to antiretro-viral regimens is imperative, not only for thehealth of individual patients, but also for thehealth of the public as a whole.

Decades of social and behavioral researchsuggest that physician-patient relationship

Department of Sociology, University of California, Los Angeles, Los Angeles, California.

variables are closely associated with patient ad-herence. As summarized by O’Brien, et al.7 pa-tient “satisfaction, communication, and con-sultation style are all factors in the doctor-patient relationship that directly affect patientadherence.”7 Patients who are dissatisfied withthe their medical care are less likely than otherpatients to comply to treatment recommenda-tions.8–10 If patients do not feel in control oftheir illnesses and “left out” of treatment deci-sion-making, nonadherence is likely to oc-cur.11,12

In contrast, a collaborative relationship be-tween physician and patient, one in which pa-tients play an active role in treatment decision-making, is positively related to both patientsatisfaction and adherence.10,13–15 The greater apatient’s sense of control over the disease, themore likely he/she is to adhere to treatmentrecommendations.16

Studies suggest that HIV/AIDS patients’ lev-els of satisfaction with their physicians are generally high.17,18 For example, Kochen andcolleagues17 assessed levels of provider satis-faction among patients with HIV/AIDS in Ger-many. Results showed that 84% of 394 patientswere satisfied with their general practitioners.Factors related to both the physician and thepatient can influence HIV-positive patients’levels of satisfaction with their health care.19,20

Sullivan and colleagues20 found that HIV-pos-itive patients who perceived their primary carephysicians to be empathetic and knowledge-able with respect to HIV were more likely thanother patients to be satisfied with their medicalcare. Katz and colleagues19 found that HIV-positive men who had fee-for-service insurancewere more satisfied with the interpersonal re-lations with their physicians compared withmen who had managed care.

No studies to date have explored the poten-tial links between HIV/AIDS patients’ satis-faction with their physicians and their beliefsabout and practices of adherence to antiretro-viral treatment regimens. This is surprisinggiven the necessity of patient adherence to an-tiretroviral medications and the link betweenpatient satisfaction and adherence. This studyhelps to fill this gap in the literature by ex-ploring the connections between HIV-positivepatients’ adherence to antiretroviral medica-

tion treatment regimens and their beliefs aboutand satisfaction with their primary care physi-cians.

METHODS

In-depth, face-to-face interviews were con-ducted with 28 HIV-positive patients. Inter-views lasted approximately 60 minutes andwere audiotaped. All patients were askedabout what, if anything, is difficult about tak-ing antiretroviral medications, and what, ifanything, helps them take their medications asdirected. The interview questions were open-ended and the content, as well as the flow ofconversation, changed with each subject, tomatch what the interviewee knew and felt.21

Written informed consent was obtained priorto the start of each interview. Each participantwas paid $20.00 in cash for their time and forthe transportation costs associated with travel-ing to the interview site. Fieldnotes were writ-ten at the conclusion of each interview and alltapes were transcribed.

Sample recruitment

Participants were recruited from the Univer-sity of California, San Francisco AIDS Programof San Francisco General Hospital (SFGH). Thiswell-regarded, urban, public health clinicserves primarily low-income individuals fromdiverse racial/ethnic backgrounds. Recruit-ment occurred between June 1997 and January1998. Participants were recruited through fly-ers handed out and posted on bulletin boardsin the waiting room. To be eligible for partici-pation, patients had to be 18 years of age, beable to speak English, and have a primary carephysician. Also, only persons who self-re-ported that they were HIV positive and hadbeen taking an antiretroviral cocktail regimenthat included a protease inhibitor for at least 3months were eligible to participate.

Analysis

Following the suggestions of Strauss andCorbin,22 multiple readings of the transcriptswere performed to identify major ideas orthemes that emerged from the participants’ de-

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scriptions of their situations. Important and fre-quently mentioned ideas were grouped intocoding categories and Ethnograph (a softwareprogram for computer-based text search andretrieval) was used to help manage the dataduring the coding process.

Adequacy and plausibility of data

Informal respondent validation and peer re-view were employed to ensure the adequacyand plausibility of the data.23,24 First, through-out the interviews, the interviewer asked sub-jects if she was understanding what they weresaying, thus providing respondents with theopportunity to correct any misunderstandingsthat may have arisen, and adding additionaldata to the project that were used to enrich theanalyses and bolster the credibility of the find-ings. Also, the interviewer often “checked” in-formation gleaned from one respondent withanother. Next, peer review was accomplishedby having the method of analysis and resultscritiqued by two independent medical sociolo-gists and one physician who cared for HIV-pos-itive patients. All of these individuals were sat-isfied with the accuracy of the findings.

RESULTS

Sample demographics

Fifteen men and 13 women respondentswere recruited. The average age of respondentswas 40, although ages ranged from 19 to 54.About half (46%) of respondents were Cau-casian, 36% were African American, 14% wereHispanic, and 4% were of other racial/ethnicbackgrounds. More than half (54%) of respon-dents had completed at least some college ed-ucation while the rest had completed highschool or less education. Forty-three percent ofrespondents earned less than $5,000.00 peryear, 39% earned between $5,001.00 and$10,000.00 per year, 14% earned more than$10,001.00 per year, and 4% did not know theirannual income.

The majority (68%) of patients had MediCalinsurance, 18% had both MediCal andMediCare, 4% had private health insurance,and 11% had no insurance. The year of HIV di-

agnosis for patients ranged from 1984 to 1996;the modal year of diagnosis was 1989 (n 5 5).Eleven percent of patients rated their healthstatus as “excellent,” 54% as “good,” 32% as“fair,” and 4% as “poor.” The majority (75%) ofrespondents had HIV viral loads under 5,000copies while 8% had counts between 5,001 and50,000, and only one subject had a count above100,000. Three patients did not know their vi-ral loads. Eighteen percent of patients had lessthan 100 T cells, 43% had 101–250, 32% had250–500, and 8% had 501 or more T cells.

The three most common antiretroviral med-ication regimens for patient subjects were (1)3TC, d4T, and indinavir (29%), (2) AZT, 3TC,and indinavir (14%), and (3) 3TC, d4T, and nel-finavir (11%). The remaining subjects reportedtaking various other regimens. The length oftime patients had been taking their antiretro-viral medication regimen ranged from 3 to 36months, with the average length of time being12 months.

“I love my doctor”

Most patients were extremely satisfied withtheir primary care physicians. Many patientscould find absolutely nothing negative to sayregarding their relationships with their doc-tors. Rather, patients used a variety of flatter-ing adjectives to describe their providers, in-cluding “excellent,” “good,” “compassionate,”“caring,” “knowledgeable,” and “wonderful.”The only nonflattering adjective that some pa-tients used to describe their physicians was“busy.” Given the state of health care today,and the widespread dissatisfaction that manypatients have with health care, this type of ado-ration is exceptional. Moreover, that the ado-ration occurs at a busy clinic located at a pub-lic health, urban hospital that serves primarilylow-income, minority patients makes the situ-ation all the more notable.

Many patient respondents talked about “lov-ing” their physician, and considering theirphysician to be “a friend.” As patient 6 stated,“We have a close bond and she’s great. I lovemy doctor. Oh, man, she’s just—she’s verydown-to-earth and caring and sensitive andyou can talk to her basically about anything.”Likewise, patient 20 stated, “He’s just there for

PATIENT SATISFACTION AND ADHERENCE 45

me. I like him a lot . . . I think it was a meetingof the minds . . . I think . . . we really becamepatient and doctor, as well as friends.” Re-garding this “friendship” component of manyphysician-patient relationships, some patientsstated that they had done activities with theirphysician that were outside the scope of a typ-ical physician-patient relationship, such as at-tending a basketball game, getting a ride homefrom the clinic, or exchanging gifts during theholidays.

It may be that patients’ high levels of satis-faction with their physicians are because of aphysician “halo effect.” That is, given thatSFGH is one of the premier AIDS clinics in theworld, perhaps the physicians who work thereare more motivated and interested in caring forHIV/AIDS patients than are physicians whopractice elsewhere. This “devotion” may havecontributed to the overall good quality of thephysician-patient relationships found at theclinic.

Friend or mechanic?

It is important to note, however, that therewas a range of variation regarding the types ofrelationships patients established with theirphysicians. As noted above, some patients con-sidered their physician to be their friend. Theytalked to their doctor about all aspects of theirlives—their emotions, their living situations,and their medications. For example, patient 22stated:

I have . . . one of the best doctors there is in SanFrancisco. . . . He’s like the greatest and I love him.He has this great sense of humor, you know? Andhe keeps me smiling and he keeps my hopes up. . . .He never rushes me out. . . . He always takes thetime. We can sit there and he wants to know howI’m doing. Not just with the medications, not justwith AIDS, but personal. With my family, what’sgoing on around me.

In contrast, other patients, while still beingsatisfied with the relationship that they hadwith their physician, described a very differ-ent sort of relationship, one that was more“professional” and “business-like.” As pa-tient 06 explained, “We’re not on a first namebasis. He calls me by my last name and I callhim ‘doctor’. . . . That’s just the way he is . . .

the way he operates. He’s professional.” Pa-tient 15 also had a more professional rela-tionship with his physician. He made an analogy between his AIDS physician and amechanic:

Subject: It’s kind of like a real professional kind ofrelationship . . . I mean, it’s like having a car, youknow? You get it around 60 or something, it startsjiggling or something like that, whatever. It’s a re-ally cool car. You want to keep it, but you’re notsure what’s wrong with it. So, you take it to some-body who really knows cars. Now, he can sit thereand look at it, say “Well, it looks fine to me. . . .”[Or, he] fixes it, says “It was this, and don’t run overpotholes anymore. . . .” Interviewer: Mmm hmm.And so, your doctor is kind of an expert of AIDS—Subject: Yeah. Kind of like that and on me. On mybody . . . how my body works.

Hence, this patient considered his physicianto be a competent professional who “knewbodies” just as mechanics “knew cars.” This pa-tient was not interested in being friends withhis physician; rather, he wanted a professionalwho knew how to fix problems as they arosewith his HIV disease.

Physician as “anchor”

Regardless of the particular type of relation-ship respondents had developed with theirown providers, many individuals maintainedthat good physician-patient relationships wereparticularly important for HIV/AIDS patients.As patient 10 stated, “The [HIV/AIDS] patientis in an unusual world, a very strange placethat has very few windows. And, one of thewindows that they do have would be the physi-cian.” Likewise, patient 16 stated:

Having a relationship with my doctor— It’s veryimportant because it gives me a sense of closeness,you know, and a connection, where I can feel asthough I can talk to her about anything that’s go-ing on with me, and that’s really important for me,you know, because having this disease is very scary.It’s very scary.

These comments suggest that AIDS physi-cians serve as a sort of anchor for patients—they help them deal with a disease that, untilrecently, was considered to be a death sentencefor most patients.

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Less than optimal physician-patient relationships

There were a few instances in the data of pre-vious physician-patient relationships that pa-tients considered to be less than optimal. Thesetended to occur when there was an uneasy fitbetween what the patient wanted/expectedfrom his/her physician and what the physicianactually provided. For example, if a patientwanted their physician to be a “friend” (e.g.,ask about nonmedical components of life suchas lovers, friends, pets, etc., during office vis-its), and the physician failed to do so (becausetheir consultation style was more business-likeor they were rushed or whatever), conflictand/or dissatisfaction often were the result.Some patients recalled switching physicians inthe past because of a mismatch between theirexpectations and the physician’s style. As pa-tient 4 explained:

Subject: I had to change the doctor. Interviewer: You changed doctors? Tell me aboutthat. Subject: So maybe 2 years ago, I don’t know exactly,but my doctor, my other one, he was really good,but I needed the part that—the heart part. Interviewer: The “heart part?”Subject: Yeah . . . just prescribing, but no, you know,“How are you today?” He was very mechanic.

Hence, this patient preferred a more affectiverelationship (the “heart part”)—a business-like,mechanical encounter did not meet his needs.Similarly, if a patient wished to be an activeparticipant in the consultation, and the physi-cian preferred to operate in a “doctor knowsbest” manner, the resulting physician-patientrelationship was often uneasy.

Adherence and physician-patient relationships

Many patients talked directly and sponta-neously about the connection between thequality of the relationship they developed witha physician and their adherence to the anti-retroviral medications. The basic theme was “Ifyou don’t trust your doctor, you won’t trust(and take) your meds.” An excerpt from patient23’s interview provides illustration:

Subject: If you’re not having a good relationshipwith the doctor, you’re not gonna have a good re-lationship with the medications, either, I mean, I

don’t think so. If you’re not trusting your doctor,you’re not gonna trust the medications. Interviewer: So do you think if you don’t have agood relationship with your doctor, maybe you’renot going to take your meds?Subject: Yeah, cuz you wouldn’t trust your doctor. . . . Some people feel that way. I’ve talked to otherwomen [who] won’t take their medications, and Ithink it’s because they don’t have a good relation-ship with their doctor. There’s no trust there.

Other patients revealed that trusting theirphysician, and having their physician believein the antiretroviral medications, helped themalso believe in the medications. Hence, trustingone’s doctor was indirectly related to good ad-herence. The trust component of physician-pa-tient relationships was seen to be especially vi-tal by some patients. Patient 8 said, “I’d hate tobe an AIDS patient and not trust doctors.” Like-wise, patient 12 stated, “My doctor . . . [says]there’s a [antiretroviral] combination . . . shethinks it’s good, which I think its’s good . . . itkeeps me up.” Patient 06 also maintained, “Ifhe says this [antiretroviral medications] wouldbe good for me, I trust that it’ll be good for me.”

Physician-patient interactions also were re-lated to patient adherence. In some cases, pa-tients suggested that a good relationship withtheir doctor allowed them to open up and dis-close information about their adherence to theantiretroviral regimens. For example, patient09 stated that his physician asked him aboutmissing doses at just about every office visit.His physician’s gentle, caring way of probingwas respected by the patient:

Subject: He’s just checking, I guess. Make sure I’msticking to my routine. Interviewer: Does it help you at all, stay on the rou-tine, that he asks you?Subject: Yeah, you know . . . some docs gonna ask inone way, you won’t want to do shit for them. And,some doctors ask another way and you do everythingthey ask you to do. So, he has that quality, I guess,to ask you a certain way and probe at you a certainway, and you know, yeah, I’m doing all right.

Had his physician not had this “quality,” hadhe been more threatening or judgmental, thispatient may not have felt as free to open up andtalk about his adherence.

Sometimes simply getting reassurance froma physician and/or having them help trou-

PATIENT SATISFACTION AND ADHERENCE 47

bleshoot problems was enough for a patient tocontinue adhering to an antiretroviral regimen.For example, patient 14 revealed that he had hadmany disturbing side effects from his medica-tions. These side effects had made him considerstopping his regimen. The following is his ver-sion of what occurred when he told his physi-cian about wanting to quit his medications:

It was horrible . . . I had a big stomach, all the wayout, bloated all the time . . . I was suffering and Iwalked in, and told her [my physician] . . . “I’m go-ing to throw all these pills in the garbage. . . . “ Shegoes, “What? You are going to do no such thing.”

Subsequently, the physician changed hismedication regimen to alleviate his side effects.To date, the patient has not “thrown his pillsin the trash can.”

Alternatively, having an uneasy physician-patient relationship sometimes had a negativeimpact on patients’ adherence. For example,patient 10 explained:

I’ve had . . . some very questionable experiences. Myfirst physician . . . went on maternity leave. . . . I wasput off on somebody who really didn’t seem to wantto. I don’t know what the issue or what his under-standing of a patient relationship was, but he madeit very clear that if you have a problem, we’ll dealwith it in the future. . . . And that was extraordinar-ily frustrating, annoying. You questioned the facility,you questioned the integrity of the doctor and every-thing. And, you want to stop taking your medicines.You don’t want to perform what’s asked of you.

This patient also revealed that he had hadsome problems with his antiretroviral medica-tion during the time he was seeing this physi-cian. He subsequently stopped taking the med-icine and called his physician. The physiciansaid that he would see him at “his next ap-pointment.” The next appointment was a cou-ple months away, and patient 10 developed vi-ral resistance during that time period. Thisinstance of nonadherence possibly could havebeen avoided had this physician been more ac-cessible to his patient.

DISCUSSION

In this project, most patients were extremelypleased with their physicians and recognized

the value of a good quality physician-patientrelationship. These findings give a very differ-ent picture of relationships in AIDS care thanwas common at the beginning of the epidemic.During the 1980s and early 1990s, most all re-search regarding such relationships inHIV/AIDS care focused on such issues as fearof HIV exposure or the perceived challenges ofproviding care to certain groups of patients(e.g., injection drug users or gay men).25,26 Al-though the purpose of this project was not toinvestigate such issues, that they did notemerge at all from the data is important. In-stead, that patients used terms such as “friend-ship” and “love” to describe their relationshipswith their physicians is significant.

There are several possible explanations forthe overall good quality of physician-patientrelationships found in this project. First, the ad-vent of antiretroviral medications has led todramatic decreases in AIDS deaths and ill-nesses.2–4 This has contributed to a change inthe social construction of AIDS. Specifically, inrecent years, AIDS has lost some of its stigma.AIDS, in many Americans’ minds, is no longerthe “death sentence” it used to be. AIDS is be-coming thought of as more of a chronic diseaseand less of a lethal one. This “normalizing” ofAIDS has perhaps carried over into physician-patient relationships in HIV/AIDS care. Be-cause fear and distrust are perhaps not as cen-tral of concerns, more room is left to focus onthe good, nurturing aspects of the relation-ships.

Another possible explanation is that the pa-tients in this study were especially satisfiedwith their physicians because they knew thatsuch physicians were “AIDS experts.” Patientsmay have felt “lucky” to be able to be treatedat a premier AIDS clinic by doctors who areamong “the best of the best.” Also, because thephysicians interviewed in this project special-ized in HIV/AIDS, it may be that they wereparticularly adept at providing care to their pa-tients.

Conversely, it may be that patients were lessthan forthcoming about their true feelings to-ward their physicians. Because patients wereinterviewed only once for the project, there wasnot a lot of time to build a long-term relation-ship between interviewer and interviewees.

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Perhaps patients may have been more willingto disclose “true” accounts of their relation-ships with their providers under different cir-cumstances, such as during a series of inter-views over a prolonged period. Likewise, adifferent vision of physician-patient relation-ships may have emerged with the use of par-ticipant observation. Future studies could in-vestigate these possibilities.

Next, findings from this study suggest thatthere is a relationship between patients’ levelsof satisfaction with their physicians and theiradherence to antiretroviral treatment regimens.Namely, good-quality physician-patient rela-tionships tend to promote adherence whilelesser quality relationships may impede it. Un-derscoring the importance of the physician-pa-tient relationship, patients in this project re-peatedly talked about the need for trust in theirphysicians, stating that if they did not trusttheir provider they would not trust (and take)their antiretroviral medications. These resultssuggest that it is crucial for patients withHIV/AIDS to feel at ease with their primarycare physicians, as the adherence practices ofpatients who have uneasy relationships withtheir physicians may be less than ideal. Impor-tantly, when HIV-positive patients do not feelcomfortable with their physicians, they mayfail to disclose the truth about their adherence,if and when they are asked.

The policy implications from these resultsare clear: strengthening and promoting thebonds between physicians and patients withHIV/AIDS should be an absolute priority, atboth the interpersonal level of physician-pa-tient interactions but also at the organizationallevel. At the organizational level, HIV/AIDSclinics should establish policies that allow pa-tients to see the same provider over time, ratherthan seeing a different health care professionaleach time they visit the clinic, on a drop-in ba-sis. HIV/AIDS clinics should also strive tolengthen the time of office visits as much aspossible, thus giving patients and physiciansthe time necessary to communicate with eachother about adherence issues. HIV/AIDS clin-ics also should establish and/or simplify pro-cedures that allow patients to switch primarycare physicians as the need arises. When aphysician-patient relationship is not satisfac-

tory, patients should be able to switch easilyand swiftly to another physician that betterserves their needs. While continuity of care iscertainly important in this domain, so is the es-tablishment of a mutually satisfactory andcomfortable relationship between doctor andpatient.

Because of the small sample size and ex-ploratory nature of the study, results from thisstudy should not be generalized to other lo-cales. Future studies should examine the beliefsof patients with HIV/AIDS, levels of healthcare satisfaction, and adherence practices in avariety of geographical locations, includingthose places that have fewer HIV/AIDS casesthan San Francisco. Also, because not all pa-tients with HIV/AIDS receive treatment fromHIV/AIDS specialists, it is important to com-pare and contrast patients’ levels of satisfactionwith physicians who specialize in caring forthose with this HIV/AIDS versus those who re-ceive care from non-HIV/AIDS experts.

In conclusion, as the medical treatments forHIV/AIDS become increasingly effective andsophisticated, it is important to remember thatphysician-patient relationships still play a pri-mary role in HIV-positive individuals’ livesand can have a substantial effect on their wellbeing. Technological and pharmacologic ad-vances have not replaced the “heart part” ofHIV/AIDS care.

ACKNOWLEGMENTS

This research was supported by funds fromthe Universitywide AIDS Research Program,University of California, grant No. D97-SF-001.

REFERENCES

1. St. Louis ME, Wasserheit JN, Gayle HD. Janus con-siders the HIV pandemic: Harnessing recent advancesto enhance AIDS prevention. Am J Publ Hlth1997;87:10–12.

2. Ungvarski PJ. Update on HIV infection. Am J of Nurs1997;97:44–52.

3. Palella FJ, Jr, Delaney KM, Moorman AC, et al. De-clining morbidity and mortality among patients withadvanced human immunodeficiency virus infection.HIV Outpatient Study Investigators. N Engl J Med1998;338:853–860.

PATIENT SATISFACTION AND ADHERENCE 49

4. Carpenter CC, Fischl MA, Hammer SM, et al. Anti-retroviral therapy for HIV infection in 1998: Updatedrecommendations of the International AIDS Society-USA Panel. JAMA 1998;280:78–86.

5. Volberding P. New treatment options and their im-plications for behavioral research. Presented at theWinter Lecture Series at the Center for AIDS Preven-tion Studies. San Francisco, CA: 1996.

6. Hecht FM, Grant RM, Petropoulos CJ, et al. Sexualtransmission of an HIV-1 variant resistant to multiplereverse-transcriptase and protease inhibitors. N EnglJ Med 1998;339:307–311.

7. O’Brien MK, Petrie K, Raeburn J. Adherence to Med-ication Regimens: Updating a Complex Medical Is-sue. Med Care Rev 1992;49:435–454.

8. DiMatteo MR, DiNicola DD. Achieving Patient Com-pliance: The Psychology of the Medical Practitioner’sRole. New York: Pergamon Press, 1982.

9. Gerber K, Nehemkis A. Compliance: The Dilemma ofthe Chronically Ill. New York: Springer PublishingCompany, 1986.

10. Ley P. Communicating with Patients: Improving Sat-isfaction and Compliance. London: Croom Helm,1988.

11. Schwartz LS. A Biopsychosocial Approach to theManagement of the Diabetic Patient. Prim Care1988;15:409–421.

12. Adelman HS, Taylor L. Children’s reluctance regard-ing treatment: Incompetence, reluctance, or an ap-propriate response. School Psych Rev 1986;15:91–99.

13. Hall J, Roter DL, Katz NR. Meta-analysis of correlatesof provider behavior in medical encounters. Med Care1988;26:657–675.

14. Francis V, Korsch BM, Morris MJ. Gaps in doctor-pa-tient communication: Patients’ responses to medicaladvice. N Engl J Med 1969;280:535–540.

15. Heszen-Klemens I, Lapinska E. Doctor-patient inter-actions, patients’ health behaviors, and effects of treat-ment. Soc Sci Med 1984;1:9–18.

16. Kaplan SH, Greenfield S, Ware JE. Impact of doctor-patient relationship on the outcomes of chronic dis-ease. In: Stewart M, Roter D, eds. Communicatingwith Medical Patients. Newbury Park, CA: Sage Pub-lications, 1989, pp. 228–245.

17. Kochen MM, Hasford JC, Jäger H, et al. How do pa-tients with HIV perceive their general practitioners?BMJ 1991;303:1365–1368.

18. Langner SR, Hutelmyer C. Patient satisfaction withoutpatient human immunodeficiency virus care asdelivered by nurse practitioners and physicians.Holistic Nurs Pract 1995;10:54–60.

19. Katz MH, Marx R, Douglas JM Jr, et al. Insurance typeand satisfaction with medical care among HIV-in-fected men. J Acquir Immuno Synd Hum Retrovirol1997;14:35–43.

20. Sullivan LM, Stein MD, Savetsky JB, Samet JH. Thedoctor-patient relationship and HIV-infected pa-tients’ satisfaction with primary care physicians. J GenIntern Med 2000;15:462–469.

21. Rubin HJ, Rubin IS. Qualitative Interviewing: The Artof Hearing Data. Thousand Oaks, CA: Sage Publica-tions, 1995.

22. Strauss A, Corbin J. Basics of Qualitative Research:Grounded Theory Procedures and Techniques. New-bury Park, CA: Sage Publications, 1990.

23. Lincoln YS, Guba EG. Naturalistic Inquiry. NewburyPark: Sage Publications, 1985.

24. Miles MB, Huberman AM. Qualitative Data Analysis.Thousand Oaks, CA: Sage Publications, 1994.

25. Eakin J, Taylor K. The Psychosocial Impact of AIDSon Health Care Providers: An International Bibliog-raphy and Review of the Literature. Toronto, Ontario,Canada: Physician Behavior Research Unit, Depart-ment of Behavioral Science, 1990.

26. Gerbert B, Bleecker B, Maguire BT, Caspers N. Physi-cians and AIDS: Sexual risk assessment and willing-ness to treat HIV-infected patients. J Gen Intl Med1992;7:657–664.

Address reprint requests to:Kathleen Johnston Roberts, Ph.D. UCLA Department of Sociology 2201 Hershey Hall, Box 951551 Los Angeles, CA 90095-1551

E-mail: kathleen-j-roberts@yahoo.com

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