W. Qidwai  ( Department of Community Health Sciences, Family Medicine Division The Aga Khan University, Karachi )
R. H. Dhanani  ( Department of Community Health Sciences, Family Medicine Division The Aga Khan University, Karachi )
F. M. Khan  ( Department of Community Health Sciences, Family Medicine Division, Medical )

Health care providers are coming under increasing pressure to demonstrate that they incorporate the views of users when planning and evaluating services.1 Within the rapidly changing climate of primary care, there is an increasing need to evaluate the reactions of patients to real and proposed changes in practice.2 It has been shown that there are areas of patient dissatisfaction, which can be focused by hospital managers, in order to improve service quality.3 Mismatch between patient expectation and the service received is related to decreased satisfaction.4,5
It has been demonstrated that patients benefit from physicians who keep the focus on them.6 Patient waiting time is an issue that has remained a factor in the determination of patient satisfaction. Major portion of a patient visit time is consumed in activities other then actually seeing a physician.7 It is important for health services planners to ascertain an acceptable waiting time for patients which, if achieved, may lead to overall satisfaction.
Denial of a parent\'s expectation of an antibiotic prescription for their child, can still lead to parent satisfaction provided a contingency plan is offered.8 Therefore patient satisfaction is not only achieved by meeting their expectation of a physician, but also on how the whole situation is handled, by the health delivery team.
Patient satisfaction surveys done elsewhere cannot help improve patient satisfaction at any given facility. This is because patient satisfaction is determined by their cultural background.9
Based on these given facts, we decided to study the expectations and satisfaction of patients visiting Family Medicine Clinics, at the Aga Khan University Hospital, in Karachi, Pakistan.

1.Edwards C, Staniszewska S. Accessing the user\'s perspective. Health Soc Care Community 2000;8:417-24.
2.Mcdonald AL, Langford IH. Observations and recommendations for assessing patient satisfaction in a primary care setting using a previously validated questionnaire. Health Soc Care Community 2000;8:109-18.
3.Al-Omar BA. Patients\' expectations, satisfaction and future behavior in hospitals in Riyadh City. Saudi Med J 2000;21:655-65.
4.McKinley RK, Roberts C. Patient satisfaction with out of hours primary medical care. Qual Health Care 2001;10:23-8.
5.Jackson JL, Kroenke K. The effect of unmet expectations among adults presenting with physical symptoms. Ann Intern Med 2001;134:889-97.
6.Kiyohara LY, Kayano LK, Kobayashi ML, et al. The patient-physician interactions as seen by undergraduate medical students. Sao Paulo Med J 2001; 119:97-100.
7.Xakellis GC Jr, Bennett A. Improving clinic efficiency of a family medicine teaching clinic. Fam Med 2001;33:533-8.
8.Mangione-Smith R, McGlynn EA, Elliott MN, et al. Parent expectations for antibiotics, physician-parent communication and satisfaction. Arch Pediatr Adolesc Med 2001;155:800-6.
9.Mendoza Aldoza J, Piechulek H, Al-Sabir A. Client satisfaction and quality of health care in rural Bangladesh. Bull World Health Organ 2001;79:512-17.
10.Al-Doghaither AH, Saeed AA. Consumers\' satisfaction with primary health services in the city Jeddah, Saudi Arabia. Saudi Med J 2000;21:447-54.
11.Grouse A, Bishop R. Non-medical technicians reduce emergency department waiting times. Emerg Med (Fremantle) 2001;13:66-9.
12.Lin CT, Albertson GA, Schilling LM et al. Is patients\' perception of time spent with the physician a determinant of ambulatory patient satisfaction? Arch Intern
Med 2001;161:1437-42.
13.Al-Doghaither AH, Abdelrhman BM, Saeed AA. Patients\' satisfaction with physicians\' services in primary health care centres in Kuwait city, Kuwait. JR Soc Health 2000;120:170-4.

In today\'s day and age, patients are considered equal partners in the care of their health1. It is not merely the physician deciding as to what is good for the patient. Therefore it becomes necessary for us to survey patients\' expectations and to see how they can be fulfilled. The survey that we carried out was in line with this view.
The demographic background of the study population suggests that it is more educated and better placed socio-economically then the rest of the population. It is therefore reasonable to assume that the expectations of this group will be more then those out in the community with less education and socioeconomic status. Moreover, the demographic profile has been shown to have an influence over the satisfaction levels of patients.10
Waiting time is a hot topic not only among the patients but physicians as well. Ideally, there should be no waiting time but in reality patients have to wait for a certain time period to see the physician. The next question in this regard is as to,what is an appropriate waiting time acceptable to the patient? Also whether we can reduce the adverse impact of waiting time through other remedial measures such as providing various facilities in the waiting room such as reading material.
An expected average patient waiting time of 12.69 minutes, against an actual of 45.55 minutes, is a challenging target to achieve. Waiting time in our clinics is comparable to that found in other family medicine clinics, where an average waiting time of upto 80.5 minutes has been reported.7 Hiring of non-medical staff such as helpers to assist with the patient flow can help reduce patient waiting time.11 Perceived ambulatory visit duration and meeting or exceeding patient expectation of time needed to be spent with the physician are determinants of patient satisfaction.12 Further work is recommended to clarify the factors influencing patient waiting time and their relationship with patient satisfaction.12 Further work is recommended to clarify the factors influencing patient waiting time and their relationship with patient satisfaction.
In the waiting room, the patient doesn\'t want to wait for the physician but once inside the doctor\'s room, he doesn\'t want to conclude the consultation soon. In our survey, the expectation to spent 16.37 minutes with the doctor is not very difficult to achieve from the present 13.89 minutes. This is less than other family practice clinics where consultation time of 24.66 to 27 minutes has been reported.6,7 Further studies are recommended on this issue.
We need to ensure the availability of newspapers in the clinics, as a means to reduce the burden of waiting time. The sharing of information on doctor\'s attributes that improve patient satisfaction such as patient listening will go a long way in improving quality of care given to our patients. Moreover, effective communication has been documented to improve patient satisfaction in earlier studies.13
Our study results show that our patients want an explanation of the diagnosis and treatment and not necessarily want a prescription or an investigation or a referral to a specialist, at the end of the consultation. The sharing of this information with our practicing physicians on matters of prescription need, investigation requests and referral will hopefully lead to changes in practice, which will enhance patient satisfaction levels.
Privacy and confidentiality are important to patients and they would certainly prefer not to have any third person in the consultation room. Our study shows that they are more willing to accept resident doctors then nursing or medical students in the consultation room. One could argue that they are more willing to accept those who can contribute to their health care (Resident doctors) in comparison to those who can\'t (Nursing or medical student). One could recommend that whosoever is present with the physician in the consultation room, should try to contribute and support the consultation process. This may result in more acceptability of the concerned person during the consultation process. We recommend more work in this area, since it is identified as a source of dissatisfaction for the patients. It appears that the cost of care is not a major issue for the patients. The reason may be that they are getting service of similar quality at a higher cost outside. This issue needs further research.

The cross sectional survey covered 316 respondents. The mean age was 33.81 years, with 105 (33.2%) women, and 211 (66.8%) men, the majority were married, with education above intermediate level and were in private or government service or were housewives (Table 1).
The median patient waiting time was 30 minutes, against an expectation of 12.69 minutes. Only 57 (18%) of the respondents were seen within 15 minutes.
Reading newspaper, watching television, reading magazine, reading Quran and listening to music were quoted as ways to lessen the burden of waiting to see a physician (Table 2).
Objections to the presence of medical student, nursing student, resident doctor, nurse and an observer, in the consultation room have been documented (Table 3) Reasons quoted for the objection include "issues of privacy/confidentiality"among 98 (49.2%),"lack of justification" among 44 (22%), "discomfort" among 28 (14.1%), and "interference with the consultation process" among 9 (4.5%).
The average consultation time with the physician was 13.89 minutes (range from 1 to 60 minutes), against an expectation of 16.37 minutes. 76 (24%) of the respondents had a consultation time of more then 16 minutes.
Patient expectation prior to consultation in terms of listening by the doctor with patience, explanation of the diagnosis and treatment, prescription of medicines, ordering of investigations and specialist referral has been compared with what actually happened during the consultation (Table 4).
The expected average cost for doctor\'s consultation was Pakistani Rs. 124 (range from 0 to 500). Patient\'s are charged Rs. 70/- for doctor\'s consultation, 196 (61.8%) of the respondents were satisfied with the consultation based on these charges while 53 (16.7%) were not and 67 (21.5%) were not sure.

A cross sectional survey of 316 patients was carried out, at the Family Practice Clinic of the Aga Khan University hospital at Karachi, Pakistan. Patients were offered at random to participate in the study after the objectives were explained. The participating patient signed a consent form, after assurance of confidentiality was provided. A questionnaire, based on the study objectives was developed and administered. Data on the demographic profile of the patients was also collected.