Journal of Clinical Epidemiology 65 (2012) 10e15

REVIEW ARTICLE

An overview of 19 instruments assessing the doctor-patient relationship:

different models or concepts are used
Rhona M. Eveleigh*, Esther Muskens, Hiske van Ravesteijn, Inge van Dijk, Eric van Rijswijk,
Peter Lucassen
Department of Primary and Community Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
Accepted 25 May 2011

Abstract
Objectives: The doctorepatient relationship has been linked to patient satisfaction, treatment adherence, and treatment outcome. Many
different instruments have been developed to assess this relationship. The large variety makes it difficult to compare results of different
studies and choose an instrument for future research. This review aims to provide an overview of the existing instruments assessing the
doctorepatient relationship.
Study Design and Setting: We performed a systematic search in PubMed, PsychInfo, EMBASE, and Web of Science for question-
naires measuring the doctorepatient relationship. We appraised each instrument ascertaining the questionnaires focused on the doctore
patient relationship. We compared the content and psychometric characteristics of the instruments.
Results: We found 19 instruments assessing the doctorepatient relationship. The instruments assess a variety of dimensions and use
diverse conceptual models for the doctorepatient relationship. The instruments found also vary in terms to which they have been psycho-
metrically tested.
Conclusion: We have provided an overview of 19 instruments assessing the doctorepatient relationship. The selection of an instrument
for future research should be based on the model or conceptual basis of the doctorepatient relationship that is most applicable to the study
objectives and the health care field in which it will be applied. Ó 2012 Elsevier Inc. All rights reserved.
Keywords: Doctorepatient relationship; Therapeutic alliance; Trust; Questionnaire; Instruments; Review

1. Introduction physicians with a more formal style [5]. In particular, pa-

tient satisfaction, treatment adherence, and treatment out-
The relationship between doctors and patients is an im-
come have been found to be associated with the
portant factor in the effectiveness of treatment. In 1927,
doctorepatient relationship [3,6,7]
Peabody [1] proposed that ‘‘the practice of medicine in
A conceptualization of the relationship between the pa-
its broadest sense includes the whole relationship of physi-
tient and the physician in medical care has not yet been
cian with his [or her] patient’’. Later, the importance of the clearly articulated. Firstly, Hall et al. [8] considered trust
doctorepatient relationship was described by Balint [2] in
as the global attribute of treatment relationships: encompass-
1955 as ‘‘the doctor as a drug.’’ In psychotherapy, the qual-
ing subsidiary features, such as satisfaction, communication,
ity of the treatment relationship is found to shape patient
competency, and privacy. A second concept, frequently used
outcomes more strongly than the specific techniques ap-
in psychotherapy, is the therapeutic or working alliance: the
plied [3]. In primary care, ‘‘knowing the patient is at least
collaborative and affective bond between therapist and
as important as knowing the disease’’ [4], and physicians
patient [6,9]. According to Bordin [9], a good therapeutic
with a warm and friendly style are more effective than
working alliance consists of the following three elements:
agreement on goals, an assignment of tasks, and the develop-
ment of an affective bond between therapist and patient.
* Corresponding author. 117 Department of Family and Community Thirdly, empathy has been described as the key feature in
Medicine, Radboud University Nijmegen Medical Centre, PO Box 9101,
6500 HB Nijmegen, The Netherlands. Tel.: þ31-24-3668005; fax: þ31- all relationships [10,11]. Ridd et al. [12] derived, in their
24-3541862. metasynthesis, a conceptual framework including all these
E-mail address: R.Eveleigh@ELG.UMCN.NL (R.M. Eveleigh). elements. They characterized the patients’ perspective on
0895-4356/$ - see front matter Ó 2012 Elsevier Inc. All rights reserved.
doi: 10.1016/j.jclinepi.2011.05.011
 R.M. Eveleigh et al. / Journal of Clinical Epidemiology 65 (2012) 10e15
What is new?
Key finding:
 Our search for instruments assessing the doctore
patient relationship revealed 19 instruments, assess-
ing various aspects of the doctorepatient relation-
ship. The instruments found also vary in terms to
which they have been psychometrically tested.
What this adds to what was known?
 To our knowledge there is no (recent) overview
of instruments assessing the doctorepatient
relationship.
What is the implication, what should change now?
 The relationship between the doctor and the patient
has been proven to be important for (mental) health
outcome. Therefore, it is also an important aspect of
medical scientific and clinical research, conse-
quently measuring this relationship will add to the
validity and reliability of research. In this review,
we sought not to find the best instrument but to pro-
vide an overview giving relevant information to re-
searchers to decide on the best instrument for the
specific aim of their study.
the depth of the doctorepatient relationship, as a product of
longitudinal care and consultation experiences, by four
main elements: knowledge, trust, loyalty, and regard. Each
having two sides, the patients’ opinion of the doctor and the
patients’ perception of the doctor’s opinion about them.
Although many different instruments have been devel-
oped to assess this relationship, the importance of assessing
the relationship in scientific research is undervalued. An
example of its value is the study by van Os et al. [13] who
showed that the correct application of the depression guide-
line by general practitioners only improved the patient’s
well-being when patients valued their relation with their gen-
eral practitioner positively. The large variety in instruments
makes it difficult to compare results of different studies
and to choose which instrument to use in future research.
To be able to choose the adequate instrument, a decision
on which aspects of the doctorepatient relationship should
be measured must be made in advance. In this study, we
choose to focus solely on the doctorepatient relationship,
combined by the four elements knowledge, trust, loyalty,
and regard [12]. Other aspects of the doctorepatient interac-
tion, such as communication and satisfaction will not be
reviewed here. Communication assessment instruments
have recently been reviewed extensively by Boon and
Stewart [14]. The communicative style of health care pro-
viders is known to have a strong influence on the apprecia-
tion of the doctorepatient relationship [15]. Nevertheless,
11
the ways in which the concepts of doctorepatient communi-
cation and relationship are measured are different. Commu-
nication questionnaires report on the behavior of the health
care provider, that is, communication techniques, both ver-
bal and nonverbal. Satisfaction questionnaires report the ful-
fillment of one’s wishes, expectations, or needs, thus making
a judgment on past actions. In contrast, relationship ques-
tionnaires assess the emotions or sentiment elicited by the
contact between the health care provider and the patient.
To our knowledge there is no (recent) overview of in-
struments assessing the doctorepatient relationship. This
review aims to provide information and topics for deciding
about the selection of a specific questionnaire from the in-
struments available. We performed a systematic review and
compared the psychometric characteristics of the instru-
ments present.
2. Methods
2.1. Search strategy
In December 2009, we systematically searched for ques-
tionnaires measuring the doctorepatient relationship. Our
inclusion criteria were the following: 1) article about a ques-
tionnaire or survey; 2) questionnaire measuring the relation-
ship between a health care provider and the patient; 3) with
the relationship as the main theme of the questionnaire, not
with satisfaction or communication as the main theme.
We searched in four databases: PubMed, PsychINFO,
EMBASE, and Web of Science. For PubMed our search con-
sisted of the All Fields and MeSH terms for the ‘‘doctore
patient relationship,’’ ‘‘therapeutic and working alliance,’’
‘‘instrument or questionnaire,’’ and ‘‘psychometrics’’ com-
bined with the Boolean operator AND (the complete search
string for PubMed is shown in Appendix 1 [see Appendix on
the journal’s Web site at www.jclinepi.com]). The search
was limited to research on ‘‘Humans’’ and ‘‘Adults’’ and to
the exclusion of letters, editorials, and news items. We adap-
ted the search for the other databases as required. There was
no language restriction.
2.2. Selection of publications
For inclusion we screened titles and abstracts. When ti-
tle and abstract did not reveal sufficient information for in-
clusion or exclusion, the investigators read the full-text
publication. Two investigators (R.E. and E.M.) indepen-
dently included publications from the list of retrieved pub-
lications. Disagreements about inclusion or exclusion were
resolved by consulting a third investigator (H.v.R.). Inter-
investigator agreement on inclusion and exclusion was
calculated as kappa; we considered kappa 0.6e0.8 as good
and kappa 0.8e1.0 as excellent agreement [16]. After
inclusion, we checked the references for additional publi-
cations. We excluded duplicate citations. No quality ap-
praisal was applied because the aim of this study was to
12 R.M. Eveleigh et al. / Journal of Clinical Epidemiology 65 (2012) 10e15

make a complete overview of the currently existing 3. Results

instruments.
2.3. Selection of instruments
After the initial search we allocated the instruments de-
scribed in the included studies. All instruments were then
judged, by three investigators (R.E., E.M., and H.v.R.), to
consider if they indeed assessed the doctorepatient rela-
tionship. This was done by scoring each item of the instru-
ment separately as assessing relationship (R), satisfaction
(S ), communication (C ), or miscellaneous (examples
shown in Table 1). We considered an instrument to assess
the doctorepatient relationship if more than half of the
items were scored with an ‘‘R.’’ Instruments mainly assess-
ing satisfaction or communication were excluded. To be
able to provide a comprehensive and up-to-date overview
of the existing doctorepatient relationship questionnaires,
we decided to report only on the most recent version or
modification of an instrument that has been validated; thus
combining publications on the same (revised) instruments.
We did not exclude instruments on the basis of the rater be-
cause we believe that the patient, the doctor, and the ob-
server all can rate the doctorepatient relationship in their
own way. Although the relationship between a doctor and
a patient could be influenced by the general trust in all doc-
tors, we only included instruments assessing the relation-
ship with a health care provider.
2.4. Description of instruments
Three investigators (R.E., E.M., and H.v.R.) extracted
and registered the data from the included studies on stan-
dard forms and compared the registration forms. We were
not blinded for information on authors and journal because
we were already well acquainted with some of the material.
In addition to the data found in the included studies, we
performed a literature search per instrument to find all pub-
lished work per instrument. We collected information con-
cerning the content and the psychometric characteristics of
the instruments.
3.1. Systematic search
Our database search retrieved 288 publications and after
removing the duplicates, 237 publications remained to be
screened. Two researchers screened independently by title
and abstract, resulting in the exclusion of 221 publications.
The interinvestigator agreement was ‘‘good’’ with a kappa
of 0.75 (95% confidence interval: 0.63e0.86). Reviewing
the included publications (n 5 43) we found a total of 35
instruments as some publications reported on the same
instrument. Fifteen instruments were excluded; five instru-
ments were former versions of another instrument, nine did
not meet our inclusion criteria after appraisal (less then half
of the items scored R), and one was unavailable (Projective
Test of Dual Communication and Interaction [17]). A flow-
chart is provided in Fig. 1.
In total, we identified and included 19 instruments as-
sessing the doctorepatient relationship in this study
[18e47]. An overview of these instruments is shown in
Appendix 2 (see Appendix on the journal’s Web site at
www.jclinepi.com). An overview of the psychometric prop-
erties of each instrument can be found in Appendix 3. Fig. 2
shows the item appraisal of the instruments.
3.2. Content of the instruments
Of the 19 instruments found, eight instruments focus on
the mental health field. Four of these eight instruments have
been developed in psychotherapy (Working Alliance Inven-
tory [revised short version] [WAI-SR], Agnew Relationship
Measure [ARM], California Psychotherapy Alliance Scales
[CALPAS], and Vanderbilt Therapeutic Alliance Scale
[VTAS]). Nine instruments have been used in the primary
or general health care field (Kim Alliance Scale, Stanford
Trust in Physician scale [STP], Helping Alliance question-
naire-Revised [HAq-R], patient–physician relationship
questionnaire, Patient–Doctor Relationship Questionnaire
[PDRQ-9], Wake Forest (Physician) Trust Scale [WFT],
Health Care Relationship [HCR] Trust Scale, Consultation
and Relational Empathy [CARE] Measure, and Difficult
Doctor–Patient Relationship Questionnaire [DDPRQ-10]).

Table 1. Examples of item appraisal

Relationship
‘‘I trust my physician’’
‘‘.supported me so that it was
easier to deal with my
illness.’’
‘‘I feel I can count on my doctor’’
‘‘I feel involved in my health
care’’
‘‘Making you feel at ease.’’
Communication
‘‘.discusses options
and choices.’’
‘‘How often does your doctor ask
how family members are
coping with your illness?’’
‘‘.gave an illustrative picture
of illness.’’
‘‘.made the interaction very
formal’’
‘‘.pays full attention to what
you are trying to tell’’
Satisfaction Miscellaneous
‘‘.content with my ‘‘the patient self observes behaviors’’
doctors treatment.’’
‘‘How thorough is your doctor?’’ ‘‘how self-destructive is this
patient?’’
‘‘.cleanliness of the
waiting room.’’
‘‘.ability to get an urgent
appointment.’’
‘‘.medical skills are not as
good as they should be’’
 R.M. Eveleigh et al. / Journal of Clinical Epidemiology 65 (2012) 10e15
Fig. 1. Selection of instruments.
Other instruments (n 5 2) focus on a specific health care
field, that is, palliative oncology (Human Connection scale)
and mandated community treatment (Dual-Role Relation-
ships Inventory revised version [DRI-R]).
All instruments state the dimensions aimed to measure
or have undergone a factor analysis. A great diversity be-
tween the dimensions of the instruments is presented. The
dimension most often mentioned is some form of alliance,
containing descriptions as bond, goals, tasks, and collabora-
tion. Other instruments frequently mention dimensions
as ‘‘trust,’’ ‘‘empathy,’’ and ‘‘relational communication.’’
The DDPRQ-10 measures inverse dimensions because this
is a physician-rated instrument developed to describe the
relationship with the difficult patient.
Almost all instruments are patient rated (n 5 16), only the
VTAS, the RCOS-O, and the DDPRQ-10 are not. The VTAS
Fig. 2. Appraisal of instruments.
13
and RCOS-O are observer rated, the DDPRQ-10 is physician
rated. Some instruments have, besides the patient-rated ver-
sions, also a physician- or observer-rated version.
Some instruments have been revised various times. The
WAI-SR has been frequently revised and shortened. Six in-
struments have one version and have (not yet) been revised.
These have seldom been used in research articles or are yet
to be used by others than the creators of the instrument. As
shown in Appendix 3, six instruments are based on versions
of (one or more) other instruments.
3.3. Psychometric properties of the instruments
Some instruments have not been completely tested psy-
chometrically; others have undergone psychometrical tests
vigorously.
Most instruments have a known internal consistency
(Cronbach’s alpha) and some kind of validity tested. Four-
teen instruments have a Cronbach’s alpha of 0.90 or higher.
Four questionnaires have an alpha between 0.60 and 0.79,
of which three subscales, indicating an acceptable internal
consistency. The questionnaire with the highest overall in-
ternal consistency (a 5 0.95) is the DRI-I and has 30 items.
The questionnaire with the highest internal consistency on
one of the subscales is the STAR, which has a Cronbach’s
alpha of 0.98 on the subscale ‘‘positive collaboration.’’
Testeretest reliability is mentioned for seven instru-
ments; the interrater reliability in only four.
4. Discussion
Our search for instruments assessing the doctorepatient
relationship revealed 19 instruments, assessing various as-
pects of the doctorepatient relationship. The instruments
found also vary in terms to which they have been psycho-
metrically tested.
4.1. Variety of dimensions
The variety of aspects assessed by the instruments illus-
trates the diversity of conceptual models used for the doctore
patient relationship. The factors or dimensions might vary
in such a way that they are not commensurable.
Some of the instruments are developed for use in medi-
cal health care disciplines. These instruments are frequently
based on dimensions as trust (e.g., STP, WFT, and HCR)
and empathy (e.g., 4-PAS and CARE). In comparison, in-
struments originating from the psychotherapy field focus
on the working or therapeutic alliance: the interaction or re-
lationship between the therapist and the patient. The patient
version of the older 36-item version of the WAI and the
HAq-I have been found to measure the patient’s view of
the relationship equivalently [48]. Stiles et al. [49] found
that the core alliance scales of the ARM (Bonds, Tasks,
and Goals) are correlated with the WAI scales, supporting
the assumption that the ARM and the WAI measure some
14 R.M. Eveleigh et al. / Journal of Clinical Epidemiology 65 (2012) 10e15
of the same core constructs. Also, the CALPAS, the Penn
(precursor of the HAq), the Vanderbilt, and the WAI have
all been found to measure the same construct [50].
The relationship with a physician could be envisioned to
differ in comparison to the relationship with a psychothera-
pist, thus explaining the different dimensions assessed.
However, the instruments originally developed in psycho-
therapy have also been used and validated in medical health
care fields. Thus, the doctorepatient relationship must have
commonalities with the therapistepatient relationship. This
can be illustrated by comparing the different dimensions
and factors with the four constructs of the doctorepatient
relationship by Ridd (knowledge, trust, loyalty, and regard).
All the dimensions mentioned fit well within this concep-
tual framework.
4.2. Psychometric properties of the instruments
This overview illustrates the complexness of psychomet-
ric testing of questionnaires. Internal consistency was
mostly tested; in all but one instrument, Cronbach’s alpha
had been calculated. Other psychometric properties, for ex-
ample, testeretest reliability and interrater reliability were
not commonly tested; thus making a comparison between
the instruments on psychometric grounds almost impossible.
4.3. Use of instruments
All instruments are designed for the use in clinical re-
search and not clinical practice. The importance of the
use of these instruments in clinical research is unambigu-
ous. The relationship between the doctor and the patient
has been proven to be important for (mental) health out-
come [3,5]. Therefore, it also is an important aspect of
medical scientific and clinical research, consequently mea-
suring this relationship will add to the validity and reliabil-
ity of research. If, and how, doctorepatient relationship
questionnaires could be of use in clinical practice is un-
clear. They might be able to give insight to doctors and
therapists in their own relationship with their patient.
5. Strengths and weaknesses of the study
To our knowledge, we are the first to provide an overview
of the doctorepatient relationship assessment instruments.
Two independent researchers screened the publications for
inclusion, with good interinvestigator agreement (kappa
0.75), implying that our inclusion and exclusion criteria were
clear, which adds rigor to our study. The instrument appraisal
was done by three researchers, reaching consensus by dis-
cussion. This strenuous task was done over the course of
a couple of weeks to remain thorough and decisive. Although
beforehand we had decided on the appraisal method, this
procedure is at risk being arbitrary. Some items of the ques-
tionnaires might have been classified differently by other
researchers.
6. Conclusion
In this review we sought not to find the best instrument
but to provide an overview giving relevant information to
researchers to decide on the best instrument for the specific
aim of their study. The growing interest in this field has re-
sulted in a large number of doctorepatient relationship as-
sessment instruments. We recommend that future efforts be
aimed at using, refining, and combining existing instru-
ments, instead of developing new instruments.
Researchers using a doctorepatient relationship ques-
tionnaire should be aware of what they are measuring. The
suitability of an instrument will depend on the scope of the
future research. The selection of an instrument should be
based on the model or conceptual basis of the doctorepatient
relationship that is most applicable to the study objectives
and the health care field in which it will be applied. In the pri-
mary care setting, a research instrument is preferably concise
and easy to use. The PDRQ is brief (nine items) and has an
excellent overall internal consistency.
Appendix
Supplementary material
Supplementary material can be found, in the online ver-
sion, at 10.1016/j.jclinepi.2011.05.011.
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