Psychometric validation of the Spanish version of the Patient-Doctor Relationship Questionnaire (PDRQ).

Abstract

Introduction. The main aim of this study was to make a Spanish adaption of the international Patient-Doctor Relationship Questionnaire (PDRQ) that assesses the quality of patient-doctor relationship in Spanish patients admitted to an Internal Medicine Service under conditions of regular clinical practice. Method. A total of 188 adult patients of 6 Internal Medicine physicians from a University Hospital in downtown Madrid were analyzed. Sociodemographic and clinical variables were collected and the PDRQ Spanish version questionnaire was administered. Results. Results showed excellent psychometric data on reliability, factorial, and construct validity. Furthermore, based on scientific literature, criteria validity was determined, considering continuity of care as external criteria. Results ratify previous data related to positive relation between quality of doctor-patient relation and continuity of care. Conclusions. The Spanish 13 item version of the PDRQ (CREM-P in Spanish) proved to be a valid instrument for assessing the quality of patient-doctor relation in adult patients, with clinical and research value. Key words: Patient-doctor relationship. Communication. Patient satisfaction. Quality of Health Care. Physicians. Psychometric. Questionnaires. Translations. Spain. Adult. Actas Esp Psiquiatr 2008;36(0):00-00.

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Método. Fueron evaluados 188 pacientes de seis mé-
dicos especialistas en Medicina Interna de un Hospital
Universitario de Madrid capital. Se recogieron informa-
ción clínica y sociodemográfica y fue administrada la
traducción española del cuestionario PDRQ.
Resultados. Los resultados indicaron niveles altos en
fiabilidad, validez factorial y validez de contenido. Asi-
mismo, a partir de los resultados obtenidos en la literatu-
ra científica se procedió al estudio de la validez criterial
utilizando como criterio externo la continuidad del cui-
dado. Los resultados refrendan datos previos sobre la re-
lación positiva entre calidad de la relación médico-pa-
ciente y continuidad del cuidado.
Conclusiones. El cuestionario final obtenido (CREM-P)
de 13 ítems se muestra como un instrumento fiable, válido
y de fácil cumplimentación, diseñado para permitir la eva-
luación tanto en contextos clínicos como de investigación.
Palabras clave:
Relación médico-paciente. Comunicación. Satisfacción del paciente. Calidad del cuidado.
Médicos. Psicométrico. Cuestionarios. Adaptaciones. España. Adultos.
INTRODUCTION
The national health care system has changed substan-
tially in recent years. These changes have affected many as-
pects of the clinical practice, not only on the structural and
organizational level but also directly on the relationship
with the patient. On May 16, 2003, Law 41/2001, November
14, or the Basic Law on the Autonomy of the Patient and
Rights and Obligations in Material of Clinical Information
and Documentation entered into force. This law stresses the
care focused on the patient as a central characteristic of
each and every one of the modifications made regarding
the 1986 General Health Law. We generally speak of the
patient-focused care as an aspect of the patient-doctor re-
lationship that takes into consideration the preferences,
problems and emotions of the patients1. At present, this is
considered to be a mechanism by which the best results of
the patient are obtained on the physical, psychological and
social level. In this sense, patient-doctor relationship quality
has been related with treatment success1,2, treatment adher-
Introduction. The main aim of this study was to make a
Spanish adaption of the international Patient-Doctor Rela-
tionship Questionnaire (PDRQ) that assesses the quality of
patient-doctor relationship in Spanish patients admitted to
an Internal Medicine Service under conditions of regular
clinical practice.
Method. A total of 188 adult patients of 6 Internal Me-
dicine physicians from a University Hospital in downtown
Madrid were analyzed. Sociodemographic and clinical varia-
bles were collected and the PDRQ Spanish version question-
naire was administered.
Results. Results showed excellent psychometric data on
reliability, factorial, and construct validity. Furthermore,
based on scientific literature, criteria validity was determined,
considering continuity of care as external criteria. Results
ratify previous data related to positive relation between
quality of doctor-patient relation and continuity of care.
Conclusions. The Spanish 13 item version of the PDRQ
(CREM-P in Spanish) proved to be a valid instrument for as-
sessing the quality of patient-doctor relation in adult pa-
tients, with clinical and research value.
Key words:
Patient-doctor relationship. Communication. Patient satisfaction. Quality of Health Care.
Physicians. Psychometric. Questionnaires. Translations. Spain. Adult.
Actas Esp Psiquiatr 2009;37(2):94-100
Validación psicométrica de la versión
española del Cuestionario de Relaciones
Médico-Paciente (CREM-P)
Introducción. El principal objetivo del presente estudio
fue la adaptación del instrumento internacional Patient-
Doctor Relationship Questionnaire (PDRQ) que evalúa la ca-
lidad de la relación médico-paciente a una muestra españo-
la de pacientes de Medicina Interna en condiciones de
práctica clínica habitual.
Originals
Psychometric validation of the Spanish
version of the Patient-Doctor
Relationship Questionnaire (PDRQ)
1Hospital Universitario 12 de Octubre
Madrid (Spain)
2Universidad Autónoma de Madrid
Madrid (Spain)
Correspondence:
Bernardo Moreno-Jiménez
Ivan Paulov, 6
Universidad Autónoma de Madrid
28049 Madrid (Spain)
E-mail:bernardo.moreno@uam.es
J. C. Mingote Adán1
B. Moreno Jiménez2
R. Rodríguez Carvajal2
M. Gálvez Herrer2
P. Ruiz López1

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ence levels3and influence of bad praxis4. Even those pa-
tients who do not give value to joint decision making,
according to the study of Thom and Campbell5, stress the
need to establish a relationship of complicity as a way of
increasing the confidence level.
The study of the patient-doctor relationship has been the
object of research of many publications of the clinical area.
However, the results of the research conducted by Haidet et
al.6show that in spite of the effort made by teaching, medi-
cal and institution professionals, the attitudes of the stu-
dents in their last years of medicine are more oriented to-
wards paternalism in the patient-doctor interaction than
that expected, even though they know that an interaction
focused on the doctor is related with less satisfaction and
confidence of the patient with the doctor figure. In the
beginning, the literature related the way difficult patients
were handled with the origin of a deficient clinical rela-
tionship7. Most of the investigations were focused on the
assessment by the medical professional of the quality of his
or her interaction with the patient. In this sense, Hahn et
al.7developed a questionnaire to evaluate the difficulties in
the patient-doctor relationship. In this research, the authors
detected a series of characteristics of the difficult patient,
such as psychiatric disorders, functional incapacity and lack
of satisfaction with the care. Later studies have focused on
the search for detection and management strategies of the
difficult patient, but always from the paternalist view of
the care8.
However, an appropriate patient-doctor relationship
with quality is characterized by a longitudinal relationship
between the doctor and patient (continuity of the care)9, an
agreement between both on the clinical problem and its
treatment1,10, mutual confidence and fluid and open com-
munications between both11.
Among the different aspects characterizing the patient-
doctor relationship, communication levels are one of those
studied most in the literature. The patients, regardless of
their social-economic status or ethnic group, generally
want to know the full details of their diagnosis and its pos-
sibility of cure12. However, several studies indicate that the
information provided by the doctors is partial13. This fact
contrasts with the demand for precise information of the
symptoms and diseases of the patients to establish the
appropriate diagnosis and treatment. Communication and
honesty between doctors and patients are extremely im -
portant. There is evidence that explicit communication
when the diagnosis is made, together with being open to an
open discussion on the possible errors, increase the patient-
doctor relationship and prevent the number of errors in the
treatment14. These data reflect the importance of the parti-
cipation of the patient in the decision making15. However,
generally, the patients are excluded from this process even
though they have the legitimate right to accept or reject
the treatment16. Furthermore, there have been several qual-
itative studies that describe the positive role of precise and
affective communication17. In these studies, the patient-
doctor relationship is studied through the therapeutic ef-
fect, the disease models and the patient's expectations.
Another one of the principal aspects in the patient-doc-
tor relationship refers to satisfaction levels. Patient satisfac-
tion with the care is a concept that reflects the patient's
perception regarding the care quality and treatment re-
ceived. Generally evaluated by self-report, several questionnai-
res focused on decision making18, access and use of the dif-
ferent health services19, or on the treatment satisfaction20,
among others, have been developed in recent literature.
Therapeutic alliance is crucial for the evaluation of patient-
doctor satisfaction related with the development of an em-
pathic understanding, interpersonal opening, and climate of
authenticity, confidence and acceptance17.
Based on these considerations on the different aspects of
the patient-doctor relationship considered in the scientific
literature, Van der Feliz-Cornelis, Van Oppen, Van Marwijk
et al.21developed a questionnaire that was not very long
that collected each one of the aspects mentioned briefly.
The principal objective was the development of a tool
having an easy-to-understand use and application that could
quantify the patient-doctor relationship in both general
medicine and in each one of the clinical specialties and
strategic interventions of the promotion of health. The
questionnaire was focused on the evaluation of the doctor
as an effective professional and of help for the patient, char-
acteristics considered to be of core importance in the ef-
fectiveness of psychotherapeutic interventions22. Based on
a theoretical review, the authors used Luborsky's Helping
Alliance Questionnaire (HAQ) as a baseline for the develop-
ment of the Patient-Doctor Relationship Questionnaire
(PDRQ). This questionnaire collects some of the aspects indi-
cated up to now such as communication, satisfaction with
the treatment and accessibility to the doctor.
Due to the absence of measurement instruments focused
on the patient in the quality of the patient-doctor rela-
tionship, this present study has aimed to adapt the ques-
tionnaire developed for this by Van der Feltz-Cornelis et al.21
to the Spanish language. The present study also has aimed to
verify the internal consistency and discrimination capacity
and to make the factorial validation of content, and crite-
rion of the questionnaire.
METHOD
Subjects
A total of 188 patients from 6 medical specialists in Inter-
nal Medicine of a University Hospital of the Madrid capital
were evaluated. They had a mean age of 61 years, 50.3%
were men and 49.7% women. These patients had a mean of
5.7 years of treatment and 94.1% had followed said treat-
ment with the same doctor during the time period indi cated.

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Instruments
The 15 item version of the Patient-Doctor Relationship
Questionnaire was adapted to Spanish. In the first place, the
questionnaire was translated into Spanish and then a back
translation was made into English, evaluating the level of
accuracy and adaptation of the differences found. Some
items of example are «Thanks to my doctor, I have more in-
formation about my health»; «My doctor makes an effort to
help me». The questionnaire has a 5 point Likert type scale
from 1: not at all appropriate, to 5: totally appropriate.
Procedure
The questionnaires were distributed between the months
of January and March 2005, by name and internal mail, to
the medical specialists of the Internal Medicine Department
of a University Hospital of Madrid capital. The filling out of
the questionnaire by the patients was totally self-directed
and anonymous. The evaluation procedure began with a
previous informed consent of the subjects together with an
introductory sheet that informed about the research pur-
pose. This authorization, once coded, was immediately sepa-
rated from the rest of the evaluation questionnaire in order
to maintain the participant's anonymous status. Thus, the
filling out of the questionnaire by the patients was totally
voluntary, self-directed and anonymous.
RESULTS
The data were analyzed using the SPSS 13.0 statistical
program. The mean variances and asymmetry and kurtosis
indexes of the 15 items are seen in table 1.
Based on the data obtained in variance and standard de-
viation, we observed that the variability levels in the re-
sponse were moderate and always greater than zero. Fur -
thermore, based on this table, the adjustment to normality
of each one of the items of the questionnaire could be ob-
served. In this sense, and considering the asymmetry inde-
xes, it was observed how all the items had a negative as-
ymmetry and thus a tendency to score in the upper range.
While the kurtosis index shows a general tendency to a
platykurtic or flat distribution, items 6 and 15 had tended
to a leptokurtic or pointed distribution.
Based on the 15 item correlation analyses, we observed
that the correlations are mostly greater than 0.40, except
for items 6 and 15, with the rest of the items of the ques-
tionnaire. In addition, the consistency level of the items
starting from the corrected homogeneity index show us co-
rrelations greater than 0.62, except for items 6 (rcorrected:
0.095) and 15 (rcorrected: 0.426) (table 2).
To analyze the discrimination capacity of the items of
the scale, an independent T samples analysis of the mean
differences was made, dividing the sample into three groups
based on the total score (percentile 27 and percentile 73).
The results obtained showed significance levels inferior to
0.05, except for item 6 (t1-3: -0.581; p = 0.563) and item 15
(t2-3: -1.649; p = 0.102).
After, the factorial analysis of the items was made. Its re-
sults are shown in table 3. Factorialization was conducted by
MeanVarianceSD AsymmetryKurtosis
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
Item 9
Item 10
Item 11
Item 12
Item 13
Item 14
Item 15
4.310
4.480
4.350
4.270
4.340
2.990
4.380
4.230
4.290
4.300
4.210
4.320
4.340
3.990
3.230
0.839
0.638
0.729
0.752
0.758
2.304
0.674
1.024
0.773
0.920
1.004
0.734
0.798
1.136
2.004
0.916
0.799
0.854
0.867
0.871
1.518
0.821
1.012
0.879
0.959
1.002
0.856
0.894
1.066
1.416
–1.165
–1.649
–1.275
–0.957
–1.378
–0.041
–1.466
–1.311
–1.163
–1.411
–1.268
–1.375
–1.390
–0.774
–0.196
–0.728
–2.961
–1.448
–0.283
–2.027
–1.401
–2.449
–1.245
–1.080
–1.685
–1.214
–2.224
–1.822
–0.099
–1.213
Table 1Means, variance, asymmetry
and kurtosis
Correlation element-
total corrected
Cronbach’s alpha is the
element is eliminated
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
Item 9
Item 10
Item 11
Item 12
Item 13
Item 14
Item 15
0.757
0.736
0.725
0.720
0.774
0.095
0.759
0.621
0.710
0.759
0.729
0.819
0.788
0.780
0.426
0.909
0.911
0.911
0.911
0.909
0.941
0.910
0.913
0.911
0.909
0.909
0.908
0.908
0.908
0.924
Cronbach’s α
0.918
Table 2Analysis of consistency
and reliability

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J. C. Mingote Adán, et al.
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Actas Esp Psiquiatr 2009;37(2):94-100
analysis of the principal components with Varimax rotation
according to the validation of the original questionnaire.
The factorial analysis of the 15 items showed a two fac-
tor solution, jointly accounting for 63.88% of the total var-
iance. While the first factor presents a self-value of 8.53, it
accounts for 56.88% of the variance and is formed by 14 of
the 15 items; the second factor with a self-value of 1.05 ac-
counts for 7.00% of the variance. This second factor is ex-
clusively made up of item 6 («I feel that it is difficult for me
to communicate with my doctor»). In addition, it is observed
how the last item of the first factor, item 15 («My symptoms
will probably disappear»), saturate 0.418 with the first fac-
tor and 0.326 with the second. According to Nunnally23,
each variable should present a factorial load greater than
0.40 in its factor and less than 0.30 in the rest of the fac-
tors. Thus, item 15 would present a problem of having scarce
factorial discrimination.
Based on all the analyses conducted up to now, for the
Spanish adaptation, it seems to be advisable to proceed to
the elimination of items 6 and 15. In this sense, Cronbach's
alpha index of the remaining 13 items was 0.956 and the
analysis of the differences of means to evaluate the discrim-
ination capacity of the final questionnaire showed signifi-
cant levels less than 0.05 in all the cases.
Finally, the consistency in the distribution of the final
questionnaire, elevated factorial weights and high reliability
index indicate the possibility of working with an overall in-
dicator of evaluation of the Patient-Doctor Relationship
Questionnaire. The descriptive characteristics and distribu-
tion characteristics of this global factor in the present sam-
ple are shown in table 4.
In the analysis made in the original questionnaire of Van
der Feliz-Cornelis et al.21, the authors measured the use of
9 of the 15 items from the psychometric analyses made. In
our study, with a slightly larger sample (from 165 to 188),
the best solution, both factorial as well as consistency and
discrimination, was 13 items. In this sense, we wanted to
verify to what degree both questionnaires were measuring
the same thing, that is, to study the content validity. To do
so, based on the data from the means and standard devia-
tion provided by the authors of the original questionnaire,
we made a T analysis of the differences of means. The for-
mula for the contrast of significance of mean differences
with independent samples with a different n is24,
x–
1– x–
2
(n1– 1) × S1
2+ (n2– 1) × S2
n1+ n2– 2
2
t = Sx2=
Sx×
1
n2
n1
x1= 3.437 and S1= 1.363 (n1= 165).
x2= 3.620 and S2= 0.740 (n2= 178).
For t(277)0.05~ –1.645, the t value obtained was –1.558.
Thus it is not in the critical region (it is not greater than
–1.645) and we cannot reject the null hypothesis of equality
Factors
12
s12
s7
s1
s3
s13
s4
s5
s2
s14
s11
s10
s9
s8
s15
s6
0.851
0.821
0.819
0.810
0.808
0.805
0.800
0.797
0.790
0.788
0.775
0.753
0.687
0.4180.326
0.922
Table 3 Factorial analysis
N 178
Mean
Standard desviation
Variance
Asymmetry
Standard error of asymmetry
Kurtosis
Standard error of kurtosis
Minimum
Maximum
Percentiles
10
20
30
40
50
60
70
80
90
3.617
0.740
0.548
-1.457
0.182
2.879
0.362
0.200
4.330
2.660
3.067
3.333
3.600
3.800
4.000
4.133
4.333
4.333
Table 4Description statistics and global
index distribution
√
+
11

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of means. Therefore, it is important to ratify this analysis by
the size of the effect. According to Welkowitz, Ewen and
Cohen25a value of size of the effect of less than 0.20 for a
contrast of difference of means should be interpreted as
small/null. The size of the effect d obtained was equal to
0.168 (r = 0.084), which permits us to conclude that both
questionnaires are measuring the same.
In addition, we wanted to evaluate the criterion validity
of the Spanish adaptation of the Patient-Doctor Relation-
ship Questionnaire (PDRQ). We consider that one of the most
appropriate external criteria in this case could be the time
that the patient has been with the same doctor. Thus, the
greater the time with the same doctor, the better the scores
on the quality of the patient-doctor relationship.
Based on the research made by Donahue, Ashkin and
Pathman26, the same criteria were followed to establish
the four analysis groups, that is, patients who had been
with the same doctor for one year or less (from 0 to 12
months), from 1 to 2 years (13 to 24 months), from 3 to
5 years (25-60 months) and more than 5 years (61 months
on). Of the 188 evaluated, 178 had not changed doctor
since the beginning of the treatment. The chi square
analyses used to compare the differences in sociodemo-
graphic characteristics based on each one of the groups of
years of continuity with the same doctor can be seen in
table 5. Compared with the patients who have been with
the same doctor for more than 5 years, those with one
year or less are generally between 18 and 39 years (37.5%
compared to 3.2%).
After, a logistic regression analysis was made to evaluate
the relationship existing between continuity in the treat-
ment with the same doctor and evaluation of the quality in
the patient-doctor relationship. Due to the significance ob-
tained in regards to age, each one of the analyses was made
introducing both age and gender as the first step (table 6).
The patients with more than 5 years of treatment with
the same doctor had significantly greater probability of
evaluating the quality of the patient-doctor relationship as
appropriate than those with one year or less (OR: 8.577;
95% CI: 7.904-9.250). According to these data, the probabil-
ity of considering the patient-doctor relationship as totally
appropriate was almost 9 times greater in the patients with
more than 5 years versus those of one year or less. In the 1
to 2 year and 3 to 5 year groups compared to the more than
5 year one, the differences were not significant, although
they always showed a tendency to increase the probability
of reporting more appropriate levels in the patient-doctor
relationship the greater the continuity time with the same
doctor. Thus, the data demonstrated the validity of the cri-
teria of the present adaptation of the Patient-Doctor Rela-
tionship Questionnaire (PDRQ) (table 7).
DISCUSSION
The measurement instruments of the patient-doctor re-
lationship make it possible to quantify the patient's opinion
regarding communication, satisfaction and accessibility in
the dealing with the doctor and the treatment followed1.
However, in practice, there is a lack of reliable and sensitive
measurement instruments focused on the patient that eva-
luate the quality of the patient-doctor relationship. The
adaptation of the present questionnaire is, in this sense,
% 1 year
(0-12 mo.)
(n = 40)
% 1-2 years
(13-24 mo.)
(n = 14)
% 3-5 years
(25-60 mo.)
(n = 41)
% > 5 years
(> 61 mo.)
(n = 63)
Age
***
37.5
25.0
37.5
18-39
40-64
65 +
7.1
21.4
71.5
7.5
40.0
52.5
3.2
33.9
52.9
Gender
Man
Woman
50.0
50.0
50.0
50.0
46.3
53.7
54.8
45.2
*p<0.05 significant difference of each group with that of more than 5 years.
**p<0.01 significant difference of each group with that of more than
5 years. ***p<0.001 significant difference of each group with that of
more than 5 years
Table 5 Chi square analysis of the
sociodemographic characteristics
based on number of years in
treatment with the same doctor
1 year
vs.
> 5 years
1-2 years
vs.
> 5 years
3-5 years
vs.
> 5 years
Odds ratio in quality
of the patient-
doctor relationship
95% IC
Beta
p
8.5772.3682.359
(7.904-9.250)
2.149
0.001
(1.775-2.961) (1.721-2.997)
0.862
0.146
0.858
0.179
*Results in comparison with the group of more than 5 years with the
same doctor, adjusting for age and gender.
Table 6 Analysis of logistic regression
of quality in the patient-doctor
relationship based on number
of years in treatment with
the same doctor*

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very appropriate, as it is an internationally validated ins-
trument that permits us to make the comparison between
different countries and makes international research pos-
sible.
Some of the differences between the present research and
the original one should be mentioned. The following have
been considered during the present investigation: the study po-
pulations differed both in sample size and medical specialty
as well as in sociodemographic variables. Furthermore, when
the factorial analysis of the data was made, we obtained a
different dimensionality than that of the original. Given that
the results of the factorial analysis are greatly influenced by
the sample type, the variability could be due to the differen-
ces between the samples and not so much to the question-
naire, according to the results obtained in content validity.
The items of the questionnaire presented good corrected hom-
ogeneity levels and, as a whole, Cronbach's alpha value was
greater than that described by Van der Feltz-Cornelis et al.21.
However, this difference is not extraordinary, since once the
reliability and validity analyses were made, the original ques-
tionnaire was reduced to 9 items and the Spanish adaptation
to 13 and we know that the larger the number of items the
greater the alpha indexes generally are.
One of the principal limitations of the questionnaire is
the unilateral view focused on the patient in the patient-
doctor relationship. Thus, it would be interesting to develop
an instrument oriented to the doctor in future investiga-
tions that includes each and every one of the aspects col-
lected in the present questionnaire. In addition, beginning
from the evaluation of a questionnaire focused on the per-
ceptions of the patients in regards to the attitude of help
from their doctor, we should be aware of the possibility of
response due to social desirability. In this sense, an attempt
was made to control this variable, assuring that the filling
out of the questionnaire was totally voluntary, self-directed
and anonymous. On the other hand, the scores obtained
with the PDRQ cover all the scale values. Furthermore, al -
though there is a tendency to score in the upper range, the
analyses made on the capacity of discrimination and sensi-
tivity of the questionnaire make it possible to conclude that
the validity of the scale is not influenced by the response
level, although the reliability levels could be somehow in-
fluenced. In regards to the validity of the PDRQ instrument,
we consider that new studies are necessary with another type
of patient based on diagnosis, treatment and/or medical
specialty to be able to corroborate both the content validity
and to study the external validity of the questionnaire. The
results obtained on criterion validity are based on the choi-
ce of the external criterion «continuity of care». According
to the review study made by Cabana and Jee27with more
than 5,000 articles related with patient satisfaction and
continuity of the treatment with the same doctor, the authors
concluded that there is a strong association between care
continuity and care quality, even in patients with chronic
diseases. Continuity in time permits the doctors to know their
patients better28and to have greater confidence29. Further-
more, in a sample in which percentile 50 corresponds to an
age of 65 years, the choice of continuity of care as external
criterion seems to be very adequate, above all when the older
patients in the longer patient-doctor relationships perceive
the doctor as an attentive and dedicated person30.
We believe that the adaptation made permits us to ob-
tain a reliable, valid and easy-to-fill out questionnaire. This
instrument makes it possible to evaluate the quality of the
patient-doctor relationship, making it possible to obtain an
important view of the group more than partial knowledge
of some of their aspects studied in the literature such as
communication levels or patient satisfaction, considering
the possible variability based on age. We consider that the
PDRQ questionnaire may be used as a multicultural study
tool to investigate the influence of the culture in the pa-
tient-doctor relationships. This action would make it possi-
ble to access greater knowledge of the patient-doctor rela-
tionships in intercultural interaction. In addition, based on
each one of its items, this instrument may be used as a
measurement of qualitative analysis in the daily practice,
manifesting its potential use in training programs in contin-
uing practice and education of the medical personnel.
ACKNOWLEDGEMENTS
Our sincere thanks to the nurses, clinical assistants and
doctors of the Internal Medicine Department of the Univer-
sity Hospital 12 de Octubre of Madrid, headed by doctor
Ángel del Palacio, for their interest and collaboration.
REFERENCES
1. Castillo Garzón MJ. Comunicación: medicina del pasado, del
presente y del futuro. Rev Clin Esp 2004;204:181-4.
1. My doctor understands me
2. I trust my doctor
3. My doctor is dedicated to help me
4. I can talk to my doctor
5. I feel content with my doctor’s treatment
6. My doctor helps me
7. My doctor has enough time for me
8. I benefit from the treatment of my doctor
9. My doctor and I agree on the nature of my medical symptoms
10. I find my doctor easily accessible
11. Thanks to my doctor, I feel better
12. Thanks to my doctor, I gained new insight
13. I can handle my medical symptoms now (even if my doctor
and have no further meeting)
Table 7Patient-Doctor Relationship
Questionnaire (PDRQ)

Page 7

Psychometric validation of the Spanish version of the Patient-Doctor
Relationship Questionnaire (PDRQ)
J. C. Mingote Adán, et al.
100
44
Actas Esp Psiquiatr 2009;37(2):94-100
2. Greenfield S, Kaplan SH, Ware JE. Expanding patient involve-
ment in care: effects on patient outcomes. Ann Intern Med
1985;102:520-9.
3. DiMatteo MR. Enhancing patient adherence to medical recom-
mendations. JAMA 1994;271:79-83.
4. Harpole LH, Orav J, Hickey M, Posther KE, Brennan TA. Patient
satisfaction in the ambulatory setting: influence of data collec-
tion methods and sociodemographic factors. J Gen Intern Med
1996;11:431-4.
5. Thom DH, Campbel B. Patient physician trust: an explanatory
study. J Fam Pract 1997;44:169-76.
6. Haidet P. et al. Medical students’ attitudes toward patient-cen-
tered care and standardized patients’ perceptions of humanism:
a link between attitudes and outcomes. Acad Med 2002;76(10
Suppl.):42-4.
7. Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS. The diffi-
cult doctor-patient relationship: somatisation, personality and
psychopathology. J Clin Epid 1994;47:647-57.
8. Van der Feltz-Cornelis CM, Wijkel D, Verhaak PFM, Collijn DH,
Huyse FJ, Dyck van R. Psychiatric consultation for somatizing
patients in the family practice setting: a feasibility study. Int J
Psychiatry Med 1996;26:223-39.
9. Christakis DA, Mell L, Wright JA, Davis R, Connell FA. The asso-
ciation between greater continuity of care and timely measles-
mumps rubella vaccination. Am J Public Health 2000;90:962-5.
10. Vedsted P, Mainz J, Lauritzen T, Olesen F. Patient and GP agree-
ment on aspects of general practice care. Fam Pract 2002;19:
339-43.
11. Kerse N, Buetow S, Mainous III AG, Young G, Coster G, Arroll B.
Physician-patient relationship and medication compliance:
a primary care investigation. Ann Fam Med 2004;2:455-61.
12. Blackhall LJ, Murphy ST, Frank G, Michel V, Azen S. Ethnicity
and attitudes toward patient autonomy. JAMA 1995;274:820-5.
13. Field D, Copp G. Communication and awareness about dying in
the 1990s. Palliat Med 1999;13:459-68.
14. May T, Aulisio MP. Medical malpractice, mistake prevention,
and compensation. Kennedy Inst Ethics J 2001;11:135-46.
15. Craig YJ. Patient decision-making: medical ethics and media-
tion. J Med Ethics. 1996;22:164-7.
16. Moreno-Jiménez B, Rodríguez-Carvajal R, Gálvez M, Garrosa E.
Aspectos psicosociales de la práctica clínica. Aten Prim Salud
Ment 2005;8:12-20.
17. Besing JM. Doctor-patient communication and the quality of
care. Soc Sci Med 1991;32:1301-10.
18. Lerman CE, Brody DS, Caputo CG, Smith DG, Lazaro GC, Wolfson
HG. Patients’ perceived involvement in Care Scale: relationship
to attitudes about illness and medical care. J Gen Intern Med
1990;5:29-33.
19. Steven ID, Thomas SA, Eckerman E, Browing C, Dickens E. A pa-
tient determined general practice satisfaction questionnaire.
Austr Family Physician 1999;28:342-8.
20. Beattie PF, Pinto MB, Nelson MK, Nelson RM. Patient satisfac-
tion with physical therapy: instrument validation. Phys Ther
2002;82:557-65.
21. Van der Feliz-Cornelis CM, Van Oppen P, Van Marwijk HWJ, De
Beurs E, Van Dyck R. A patient-doctor relationship question-
naire (PDRQ-9) in primary care: development and psychometric
evaluation. Gen Hosp Psychiatry 2004;26:115-20.
22. Horvath A, Gaston L, Luborsky L. The Therapeutic Alliance and
its measures. En: Miller NE, Barber JP, Docherty JP, editores. The
psychodynamic treatment research: a handbook for clinical
practice. New York: Basic Books, 1993; p. 247-73.
23. Nunnally JC. Psychometric theory, 3rded. New York: McGraw-
Hill, 1994.
24. Pardo A, San Martín R. Análisis de datos en Psicología II. Ma-
drid: Pirámide, 1998.
25. Welkowitz J, Ewen RB, Cohen J. Estadística aplicada a las cien-
cias de la educación. Madrid: Santillana, 1981.
26. Donahue KE, Ashkin E, Pathman DE. Length of patient-physician
relationship and patients’ satisfaction and preventive service
use in the rural south: a cross-sectional telephone study. BMC
Fam Pract 2005;6:40.
27. Cabana MD, Jee SH. Does continuity of care improve patient
outcomes? J Fam Pract 2004;53:974-80.
28. Flocke SA, Stange KC, Zyzanski SJ. The association of attributes
of primary care with the delivery of clinical preventive services.
Med Care 1998;36(8 Suppl.):AS21-30.
29. Kao AC, Green DC, Davis NA, Koplan JP, Cleary PD. Patients'
trust in their physicians: effects of choice, continuity, and pay-
ment method. J Gen Intern Med 1998;13:681-6.
30. Wasson JH, Sauvigne AE, Mogielnicki P, Frey WG, Sox CH, Gau-
dette C, et al. Continuity of outpatient medical care in elderly
men. JAMA 1984;252:2413-7.