Influence of appropriate emergency department utilization and verbal communication on physicians’ (dis)satisfaction with doctor–patient interactions with special consideration of migrational backgrounds

Emergency departments (EDs) provide immediate medical assistance to seriously ill or injured patients, or patients classified as emergencies by specially trained staff using the resources of a hospital. This includes patient evaluation, stabilization, diagnosis, and indication of subsequent treatment, as well as planning and organization of all further measures. EDs are characterized by their constant availability and a low access threshold. In Germany, the services of EDs can be accessed 24/7 and without any further barriers. In the years prior to the COVID‑19 pandemic, the utilization of EDs has increased steadily at both a national and international level, including the visits by many individuals who had no objective indication for emergency medical treatment [1, 2]. The increased utilization of EDs can lead to overwork and frustration of staff as well as long waiting times for patients due to limited capacity and insufficient structural conditions. In addition, many emergency departments are not adequately equipped to handle the increasing number of patients, neither financially nor in terms of personnel [3].

Health care research studies on the disproportionately high utilization of EDs focus on sociodemographic factors such as gender, age, and migration background (MiB). The utilization behavior of immigrants may differ in type and extent compared to people without migration background or experience. Apparently, these differences can be attributed, among other things, to the individual’s health status, perceived needs, language barriers, sociocultural differences, and traumatic experiences [4].

Medical staff in EDs are particularly exposed to work-related forms of stress due to high treatment needs, time pressure, and the organizational structure of the German healthcare system, in which EDs act as an interface between primary and secondary care.

The diversity of patients’ complaints and needs as well as the actual or perceived urgency of many problems make the job of ED physicians challenging. Patients who visit EDs expect to receive immediate and appropriate care. To date, very few studies have examined physicians’ satisfaction with the doctor–patient relationship in the context of EDs. Babitsch et al. (2008), for example, addressed how ED physicians perceived the relationships between doctor and patient and examined the possible role of the patients’ gender and ethnicity in this [5]. In their review of literature, Cooper et al. (2006) found that the patients’ ethnicity and especially problems associated with communication and language comprehension accounted for differences in the quality of doctor–patient relationships [6]. In their literature review, Ahmed et al. (2017) highlighted that when caring for patients with a migration background, physicians reported more misunderstandings and were more insecure regarding their ability to communicate effectively. As a result, they changed their style of communication and spoke in a more directive way, which may have had a negative impact on joint decision-making [7]. Due to differences in patient populations and patient access to medical resources, it can be assumed that a translation to other countries and patient populations is very limited.

To date there are very few studies from German-speaking countries focusing on medical staff in EDs and their satisfaction with doctor–patient relationships. Thus, the aim of the present study was to address the following questions: how do sociodemographic factors, in particular a migration background, influence the appropriate utilization of EDs? How does the quality of verbal communication influence physicians’ satisfaction with doctor–patient interactions (DPI)?

As part of a non-interventional cross-sectional study [8], factors influencing patients’ utilization of hospital emergency departments (EDs) were assessed and analyzed with a focus on how satisfied physicians were with the doctor–patient interactions (DPIs). We collected data from three sources: 1) standardized questionnaire-based interviews with patients, 2) short questionnaires for attending physicians concerning the DPI, 3) evaluation of the patient’s medical report from the ED.

A total of 4176 patients were invited to participate in the study during the above-mentioned study period. 2339 patients complied (response rate: 56%). Due to missing or unclear information on their possible migration status, 12 patients were excluded later from the study, ultimately allowing the use of data from 2327 patients. The response rate of the corresponding short questionnaires for physicians was 63.3% (i.e., 1473 short questionnaires out of the total of 2327 participating patients). Data from 1356 patients were eventually included in this analysis. We only considered those patients for whom we had both a completed questionnaire according to the standardized guideline interview and the corresponding questionnaire for physicians answering the question about their satisfaction with the DPI.

Medical personnel in EDs are strained by particularly high demands due to high treatment needs, time pressure, and the organizational structure of the German healthcare system, in which EDs act as an interface between primary and secondary care. To date, very few studies have examined how satisfied ED physicians are with the care they provide [9, 10] and other influencing factors. Babitsch et al. (2008) examined how a migration background of patients seeking help affects the satisfaction of ED physicians with the treatment. Their logistic regression analysis showed that the likelihood of physicians being satisfied was significantly lower when they treated patients of Turkish origin than when they treated patients of German origin. The main reasons for their dissatisfaction were communication problems due to patients’ low command of German as well as a perceived lack of urgency for emergency treatment [5]. Our study also demonstrated that most patients perceived their complaints to be more urgent than the ED physicians who treated them. The highest level of agreement was found among patients without migration background. To date, qualitative studies on the reasons patients decide to visit an ED and on their decision-making process are lacking. In order to evaluate whether their visit to the ED is appropriate or not, health-care professionals rely on the perceived severity and urgency of medical problems, while patients focus more on their possibility to access health-care services and on the context in which the medical problem occurred [11].

When a patient’s perceived urgency differed strongly from the physician’s assessment, the ED physicians we interviewed were significantly less likely to consider the doctor–patient interaction “satisfactory” (model 2 of our logistic regression). A native language other than German and a (self-assessed) insufficient knowledge of German also proved to be negative influencing factors. It is a task an ED’s and its medical staff’s task to recognize emergency situations and illnesses that require inpatient treatment or immediate therapy and to initiate or organize diagnostics and treatment. The medical staff are aware that psychosocial factors, relationship and other conflicts, and various nonsomatic causes can also trigger complaints and lead patients to the ED. The observed discrepancy in perceived urgency demonstrates the clash of different “emergency” concepts, which can lead to dissatisfaction.

The “correct” or “appropriate” utilization of EDs is a complex issue. Depending on the definition, the proportion of inappropriate or nonurgent utilization of emergency services in meta-analyses of international studies ranges from 5 to 90% (median 32.1%) [12]. In addition to country-specific influencing factors, this considerable range can be attributed to different definitions of “appropriateness” and dissimilar study populations. Appropriate utilization can be viewed and defined from two different perspectives—from the perspective of providers of health-care services and from the perspective of patients. For our index assessing the appropriate utilization of EDs, we have attempted to combine both perspectives.

The data we collected in detail by means of personal interviews provide information on various characteristics of the study population. This information complements the medical and administrative data summarized in the medical records of the ED.

In this study, we paid special attention to a possible migration background of patients as well as their knowledge and command of German.

In our study, in addition to the three variables “inpatient admission,” “patient’s indication of severity of pain,” and “physician’s recommendation to visit an ED,” we added “patients’ perceived urgency” to our index to assess whether the utilization of the ED was appropriate. According to our index calculations, ED utilization was more often appropriate among patients without a migration background.

Previous studies have also analyzed various characteristics of inappropriate ED utilization, such as general living conditions, psychological and cognitive characteristics, the outpatient medical care situation, and the respective health-related behavior. With regard to outpatient primary care, both poorer local accessibility (“convenience”) and poorer assessment of treatment options of GP practices compared to EDs appeared to be decisive factors [13]. It is important to bear in mind that most patients consider themselves to be in acute need of treatment, which in turn suggests that there is a mismatch between an individual’s health literacy and his or her actual medical indication [14, 15]. In this context, measures to improve patients’ health literacy would be beneficial. Eichler et al. (2009) showed that low health literacy is associated with higher health expenditures per person per year [16]. A study by Zhang et al. (2020) in EDs in Australia found that older people in general, older immigrants, new immigrants, and people without tertiary education or English language skills had a significantly lower health literacy than the general population [17].

The DPI is influenced by a variety of factors. A successful DPI is important for both, treatment success and staff satisfaction. Prolonged feelings of frustration and anger need to be avoided. We found that immigrants of the so-called first generation had significantly lower chances of receiving a positive DPI assessment by physicians than patients without a migration background (model 1 of our logistic regression). Patients who spoke German “well” or “very well” according to their own assessment had a higher chance that their DPI was considered “satisfactory.” On the other hand, non-German-speaking patients were less satisfied with ED services. The provision of a (qualified) interpreter improved the satisfaction of these patients [18]. Language barriers are the main obstacles for good communication with immigrants in EDs, which can negatively affect patients and lead to poor therapeutic compliance, feelings of anxiety, and a desire for a “different” kind of care [19].