Patient preference is a central principle in healthcare. Both patient views and satisfaction are recognised as important as expectations of standards of care rise.^{Reference Baker, Shergil, Higginson and Orrell1} Studies on patient satisfaction with care have shown that the therapeutic relationship between patient and doctor and the interpersonal relationship with staff are important to patients.^{Reference Lange, Baum, Wollinger, Renner, U'ren and Schwarzer2}

The evolution of patient-centred care means that patient involvement is increasingly integral to health services research and development, demonstrated by a rapidly growing literature base of patient views. However, there is still a dearth of literature examining patient involvement for improving professional performance in medicine.^{Reference Lalani, Baines, Bryce, Marshall, Mead and Barasi3} The literature that does exist largely focuses on communication skills during consultations. This scarcity means that we cannot yet state whether patient feedback can affect performance and what the influential factors are.^{Reference Baines, Regan de Bere, Stevens, Read, Marshall and Lalani4}

We know that judgements are made on the basis of initial perceptions;^{Reference Priebe, Conneely, McCabe and Bird5–Reference Priebe, Palumbo, Ahmed, Strappelli, Gavrilovic and Bremner7} these perceptions are based on easily identifiable features such as gender or age, and on traits judged to be important by each individual, such as standing within society. Gledhill et al found that psychiatric in-patients prefer psychiatrists to wear smart attire and to call them by their first name, although this research was conducted in 1997.^{Reference Gledhill, Warner and King8} However, the smart attire may also lead to patients viewing their psychiatrist as less friendly and approachable.

Patient preference regarding a doctor's gender is an obvious and better explored example of consideration of patients’ attitudes. It has been found that significant gender preference is low but trends for same-sex doctors are seen in specific scenarios, including choosing a primary care doctor.^{Reference Nolen, Xavier Moore, Rodgers, Wang and Walter9}

A study undertaken in The Netherlands in 1993 by Kerssens et al used a general household survey to investigate gender preference for 13 different medical specialties and explored possible reasons for any preferences arising. They found that gender preference was stronger in specialties more likely to be engaged in intimate and psychosocial health problems, such as general practitioners (GPs) and gynaecologists. They found that individuals who indicated a preference for a female physician did so on the basis that they found it easier to talk to a female and felt more comfortable being examined by a female and the same reasons were cited by those indicating a preference for a male doctor. For women, 81% had no gender preference for psychiatrists, 4% preferred a male and 15% a female psychiatrist. For men, 91% had no preference, with 3% preferring a female and 6% a male psychiatrist. This was a population, not a patient, survey.^{Reference Kerssens, Bensing and Andela10}

More recently it has been suggested that gender is likely to continue to influence the doctor–patient relationship more in psychiatry than in most other specialties. This may be due to the many entrenched social perceptions and stereotypes that we are still too unaware of.^{Reference Rajapakse11} It has also been found that female psychiatrists are still at an advantage when it comes to developing a working relationship with their patients.^{Reference Djurkov and Sertsou12}

Patients are also likely to have strong views on how important various behaviours and skills of clinicians are. When examining communication, there is clear evidence that modifiable human behaviours can have positive or negative effects in consultations. Yet even when specifically examining empathy, Derksen et al found that, although widely promoted as a fundamental skill in clinical practice, evidence is scarce for the effect of greater empathy.^{Reference Derksen, Bensing and Lagro-Janssen13} A commonly identified negative characteristic of healthcare professionals is paternalism. The desire for an equal power dynamic is one theme that frequently arises in studies examining the patient–medical professional relationship.^{Reference Baines and Regan de Bere14}

Evidence suggests that patients attending out-patient psychiatric services are generally satisfied with the care they receive from their psychiatrists.^{Reference Baker, Shergil, Higginson and Orrell1,Reference Djurkov and Sertsou12} There is some evidence exploring patient satisfaction pertaining to particular qualities in their psychiatrists, such as whether they are attentive, caring in demeanour, knowledgeable about an individual's illness and able to explain conditions well.^{Reference Jabbar, Casey, Schelten and Kelly15–Reference Channa and Siddiqi17}

There is little literature on any aspect of how the patients’ role is integrated.^{Reference Baines, Regan de Bere, Stevens, Read, Marshall and Lalani4} Even when patient involvement is promoted, many assumptions are made as to the scope, such as how, when and on what they can give feedback. Indeed, it has been seen that there is sometimes a misalignment between patient priorities and changes put into effect.^{Reference Baines, Donovan, Regan de Bere, Archer and Jones18} For example, as part of the revalidation cycle in the UK's National Health Service (NHS), doctors are mandated to submit and evaluate patient feedback. This has been found to have a positive influence overall although its exact purpose and use remain a point of contention for many.^{Reference Lalani, Baines, Bryce, Marshall, Mead and Barasi3}

It is also important to question why patient involvement in the development of professional performance has been lacking. Recent analyses have found that negative attitudes of doctors may in fact be a key barrier preventing systems development, thus hindering performance improvement.^{Reference Lalani, Baines, Bryce, Marshall, Mead and Barasi3} It is still important to generate the evidence, as clinical outcomes are likely to be affected.

There is also some indication that a therapist's perception of the patient's priorities can be incorrect. When there is a developing relationship, this failure can strongly affect the patient's confidence in their therapist.^{Reference Johansson and Eklund19} However, there appears to be no research to date specifically investigating patients’ preferences for the sociocultural characteristics of their psychiatrists.

It can take up to 17 years for research to translate into practice in the UK health service; by developing and improving patient involvement we may be able to improve this implementation process and decrease the time frame.^{Reference Morris, Wooding and Grant20}

Results

We received 132 returns of the questionnaire across all sites (76 from the East Cornwall CMHT, 28 from the East Cornwall complex care and dementia team and 28 from the East London CMHT). Participants were aged over 18 years, treated in secondary mental healthcare and were diagnosed with a severe and enduring mental illness.

The sociocultural characteristics important to patients

Participants cared more about the age and gender of their psychiatrist than their religion, background and marital status, but the majority of participants were not concerned about any of these factors (Fig. 1). With regard to age, 28% of the total sample expressed a preference regarding the age of their psychiatrist: 16% preferred a psychiatrist under 40 years old, 73% a psychiatrist 40–55 years and 11% a psychiatrist over 55 years. A larger proportion of the total sample (61%) expressed a preference regarding the level of experience of their psychiatrist, with 79% of them stating a preference for a psychiatrist who had been qualified for some time.

Fig. 1 Participants’ rating of the importance of their psychiatrist's sociocultural characteristics.

Behaviours most important to patients

When asked to rank the three most important qualities/behaviours from the list of ten, there were four clear preferences (Fig. 2):

1. (a) the psychiatrist explains things to me (more than two-thirds had this in their top three rankings)

2. (b) the psychiatrist is dedicated to my personal treatment

3. (c) the psychiatrist is up to date with medical knowledge

4. (d) the psychiatrist is friendly and polite.

Fig. 2 Participants’ ranking of the top three (out of ten) preferred qualities/behaviours shown by their psychiatrist.

Additional results regarding gender preference

In total 73 women completed the questionnaire; 73% expressed no preference regarding the gender of their psychiatrist (Fig. 3). A similar percentage was observed among the 59 men who completed the questionnaire: 75% expressed no preference with regard to the gender of their psychiatrist. There was no significant difference between genders at the 5% level on statistical analysis (chi-squared test of independence, 5% confidence value).

Fig. 3 Female participants’ preference for the gender of their psychiatrist.