Patient Fidelity to Medical Services: The Roles of Authenticity and Affective Trust

Abstract

Purpose: The supply of and demand for medical services continue to increase as the current social environment changes. Consequently, competition among medical institutions is intensifying and hospitals must establish appropriate management strategies to improve the medical services they provide. This study suggests that the authenticity of doctors is a factor in improving medical-service quality and examines the effect authenticity has on the affective trust and satisfaction of patients. Design, methodology, and approach: The study utilized previous studies to examine the significance of potential variables, established hypotheses and used a questionnaire to confirm these hypotheses. The questionnaire was distributed to patients who had visited a hospital in the previous six months. Responses were analyzed empirically using structural equation modeling. Findings: The analysis found that a physician's authenticity has a significant impact on the affective trust of patients. While patients' affective trust does not have a similar strong impact on patient satisfaction, physician authenticity does have a significant impact on patient satisfaction. Conclusion and implications: This study examined the roles of authenticity, affective trust, and patient satisfaction in doctor-patient relationships in the medical services field. The implication of the findings is that physician authenticity is a prerequisite for patient satisfaction of medical services.

1. Introduction

The demand for medical services is increasing as a result of changes in today’s social environment, such as aging of the population. The importance of medical services the services that treat patients’ illnesses and injuries is growing, and becoming increasingly specialized (Buchbinder & Thompson, 2010). Medical services are becoming more systematized and scientific as the COVID-19 pandemic persists. Competition among hospitals is fierce as the number of health care-related professions grow at an accelerated speed (Taner et al., 2007). However, it is possible for a hospital to obtain a competitive advantage based on marketing decisions and management strategies that are centered on the advancement of medical services and perceptions of patients’ quality of life. Thus, identifying factors that will improve the quality of medical services is critical in gaining an advantage in a fiercely competitive environment. This study focuses on the management of doctor-patient relationships, an important and necessary component of quality health care (Donabedian, 1986). The study’s findings suggest that the authenticity of doctors is related to the evaluation of medical service encounters between doctors and patients.

It is difficult to determine the quality and performance uncertainty in this determination because service-performance levels change according to consumer characteristics even when the service is provided by the same service providers; this happens due to the heterogeneous quality of services (Parasuraman et al., 1991). In reducing this uncertainty and forming mutually positive relationships, Chiou et al. (2002) considered trust to be a significant factor. Berry (1995) asserted that a continuous relationship between service providers and consumers could be maintained if a high level of trust is developed in the relationship. Therefore, building trust in consumers is a key factor in service management. Since the level of ambiguity is higher for medical services than for other services, consumers of medical services feel a greater degree of uncertainty. It is thus difficult for patients, considered the consumers of medical services, to feel satisfaction and loyalty when they do not trust the doctors who are the service providers in this relationship (Platonova et al., 2008). Therefore, doctors must strive to treat patients with authenticity in order to build their trust and satisfaction.

Against this background, research regarding the effect of doctors’ authenticity on the affective trust and satisfaction of patients could be expected to provide results that suggest differentiated strategies for hospitals or medical institutions to secure a competitive edge. Therefore, this study focuses on the importance of authenticity in doctor-patient relationships. It also identifies the causal relationship between authenticity and affective trust and analyzes the effect of this relationship on satisfaction, an outcome variable in the relationship. Determining the effect of doctors’ authenticity on the affective trust and satisfaction of patients may establish the importance of doctors’ authenticity as well as extend understanding about the role of affective trust in the field of medical services.

2. Literature Review

2.1. Authenticity

The concept of authenticity, also expressed by terms such as “honesty” and “genuineness,” has been investigated in diverse fields of study, including sociology, business administration, and psychology. What is the true meaning or the best definition of authenticity? Avolio et al. (2004) define authenticity as the maintenance of one’s own integrity. Park et al. (2015) defines authenticity as when one’s internal state, such as one’s beliefs and emotions, is consistent with one’s external behavior. Gilmore and Pine (2007) assert that authenticity is the state of consistency between one’s inner and outer selves. Although these and other researchers have defined the concept of authenticity in different ways, it can be described within a larger common framework as the expression of honest behavior without hiding one’s internal state of being.

The concept of authenticity is a significant factor from a marketing perspective, too. A service offered with authenticity cannot be copied easily and hence, can offer a differentiated service to consumers (Gilmore & Pine, 2007). Thus, authenticity is a necessary condition that service providers must possess. The concept of service-provider authenticity has been investigated in several studies. Beverland and Farrelly (2010) assert that consumers not only feel a sense of likability when they perceive the presence of authenticity, but also wish to strengthen their relationships with service providers because of it. Neff et al. (2006) state that as consumers prefer sincere behavior from service providers rather than behaviors that feel fake, authentic behavior is important for people working in the service sector. In today’s world, as the competition among service companies intensifies and services become specialized, consumers’ expectations have increased. Therefore, service providers must offer services that are accompanied by a sense of authenticity to remain competitive and improve consumer satisfaction levels.

Price et al. (1995) looked at the components of authenticity in a single dimension and Wang (1999) presented objective sincerity and compositional sincerity as the building blocks of authenticity. Beverland et al. (2008) argued that pure sincerity and moral sincerity were sub-factors of authenticity. Since authenticity is defined by different structures depending on the field of study, it is important to look at authenticity according to the purpose of the study.

Yagil and Shnapper-Cohen (2016) defined authenticity in the medical services field as when doctors exhibit authentic behavior and when patients react actively to this behavior. Jagosh et al. (2011) asserted that when doctors lacked authenticity, patients felt negative emotions and doctor-patient relationships ultimately deteriorated. Palmieri and Stern (2009) stated that lies—the opposite of the concept of authenticity—lead to feelings of anger, despair, and a sense of betrayal in patients. Therefore, while doctors are at times required to engage in emotional labor with regard to treatment of patients, it is important for doctors to provide medical services with a sense of authenticity and without an artificial attitude. Patients want doctors to exhibit behavior that is sincere and without pretense.

2.2. Affective Trust

The concept of trust, explained by terms such as “belief” and “confidence,” is the intention of one party to rely on another party in an interpersonal relationship (Tran et al., 2020). Since trust is a factor that may strengthen relationships, it is garnering attention in diverse segments of business administration, such as production management, and marketing. Trust is being investigated as a key factor in the service sector specifically because trust not only attracts new consumers but is also important for the retention of existing consumers (Yang & Shim, 2018). Researchers categorize trust in business administration into different types, depending on the purpose. Cook and Wall (1980) categorized trust into vertical trust (trust formed in superior-subordinate relationships), lateral trust (trust formed between colleagues), and institutional trust (trust formed by institutions or by chief executives). Similarly, Levering (2000) categorized trust into three groups: trust in institutions, trust in superiors, and trust in colleagues. For Lewis and Weigert (2012), trust was categorized into two levels: affective trust and cognitive trust. This study’s investigation of trust is based on this research of two-level trust by Lewis and Weigert (2012), as it is not possible to view doctor-patient relationships as vertical and horizontal relationships within an institution.

Cognitive trust is centered on the ability or expertise of the other party and signifies that the other party can be relied on to execute work in an efficient manner. According to Lewis and Weigert (2012), cognitive trust is built on rational reasoning and is the trust that the other party will faithfully fulfill their role with a sense of responsibility. The concept of cognitive trust can be summarized as the careful decision of whether the other party should be trusted, a decision based on rational information or knowledge of the other party’s abilities or skills.

Affective trust is trust in the other party on an emotional level. Specifically, affective trust can signify the level of certainty one party has in the other party, based on the interest expressed by the latter (Johnson & Grayson, 2005). Affective trust is present when one party perceives the other party’s intention to provide assistance in the relationship (Nyaga et al., 2010). To summarize these existent research studies, affective trust can be considered the trust based on emotional ties. As emotional ties become deeper, they further reduce feelings of uncertainty in the relationship and are helpful in producing positive emotions (Lewis & Weigert, 2012). This study examines affective trust solely from the perspective of patients.

Thom et al. (2004) define the concept of trust in the medical community as the level of trust that patients place in doctors and in the medical services they provide. Berry et al. (2008) state that trust in medical services is described as a belief in the care and consultation of doctors. Trust plays an important role in doctor-patient relationships, impacting the success of treatments (Leisen & Hyman, 2004), since the contents and methods of medical services are left to the discretion of the doctor, and the practice of care always poses a risk. Therefore, the greater the trust in doctors, the greater a patient’s perceived satisfaction; this perceived satisfaction leads to return visits. This study examined affective trust exclusively in doctor-patient relationships. In these relationships, affective trust expresses qualities that result from the depth of credibility and trust (Johnson & Grayson, 2005). Johnson and Grayson (2005) examined factors related to the relationship between service providers and consumers, including value and interest, among others, setting up those factors as the measurement variables of affective trust. They conclude that affective trust, which requires emotional judgments such as those with value, ideological homogeneity, and a sense of fellowship, is more important than cognitive trust in interpersonal relationships.

2.3. Satisfaction

Oliver (1980) explains the concept of satisfaction with expectancy-disconfirmation theory (EDM). The theory states that when the performance of a particular service exceeds consumers’ expectations, a positive inconsistency is created that causes consumers to feel a sense of satisfaction. Conversely, when performance falls under consumers’ expectations, a negative inconsistency is created that causes consumers to feel a sense of dissatisfaction. The concept of satisfaction as an important factor in the service sector has been investigated by many studies, as consumer satisfaction has the potential to lead to continuous usage intention. Lien et al. (2017) determined that WeChat’s service quality and the level of consumer satisfaction had positive effects on the usage intention of consumers. Deng et al. (2010) assert that a sense of satisfaction with experiences related to information technology (IT) has a positive effect on consumers’ usage intention. Therefore, satisfaction can be considered a key factor not only for consumers, but also for the sustainability of service providers and service-providing businesses.

Satisfaction has also garnered attention as a factor in the field of medical services (Park, 2019; Potluri & Angiating, 2018). Patient satisfaction is defined by Fox and Storms (1981) as the consistency between patient expectations and the doctors’ methods of treatment and the treatment results. Moreover, they asserted that patients feel a sense of dissatisfaction when their expectations are inconsistent with their perceptions of treatment by doctors. Therefore, patients experience satisfaction when their expectations of medical services are met. Andaleeb (2001) explains that, as patient satisfaction is a concept perceived in relation to the quality of medical services, it is important for hospitals to provide medical services that are satisfactory to patients to retain consumers. To achieve the goals of patient satisfaction and retention, medical services must be supported by high-quality standards of treatment by doctors, friendly service, and an ease of procedure for patients (Thi et al., 2002).

3. Derivation of Hypotheses and Research Model

This study hypothesized that the authenticity of docto rs is an antecedent of affective trust that can be perceive d by patients. The study also aimed to verify empirically, the effect of the relationship between authenticity and a ffective trust on patient satisfaction.

3.1. Authenticity and Affective Trust

In today’s world, consumers want services to be authentic and not disingenuous (Harter, 2002). Service providers must continuously strive to provide services that have a sense of authenticity, not only because authenticity is a key factor in differentiating one service from another, but because authenticity is an element that can be provided to consumers who seek high-quality services (Greenbaum, 2000). The recent spread of COVID-19 has had a negative psychological effect on both doctors and patients. Doctors’ fatigue have increasingly intensified due to excessive workloads and interactions with patients who are also ever more uneasy (Montemurro, 2020). If, as a result of this negative psychological effect, doctors provide impersonal and mechanical medical services without a sense of authenticity, there is a significant possibility that patients will feel a sense of displeasure. Thus, even in difficult times, doctors must provide medical services with sincerity that leads patients to feel emotional stability.

A number of studies have confirmed the relationship between authenticity and trust. Portal et al. (2019) determined that brand authenticity has a significant impact on brand trust. Kim and Kim (2019) asserted that when consumers feel a sense of authenticity from online reviews, it leads to consumer trust. Finally, Cheshin et al. (2018) conducted an empirical analysis of how trust is formed when consumers perceive appropriateness and authenticity. These existent studies have shown that a sense of authenticity in service, can have a positive effect on the formation of consumers’ affective trust. Therefore, the following hypothesis is derived:

H1: The authenticity of doctors will have a positive impact on the affective trust of patients.

3.2. Affective Trust and Satisfaction

The concept of trust, which can be described as one party’s belief in the other party (Doney & Cannon, 1997), has been researched in diverse fields. Trust plays an important role in business-to-consumer (B2C) relationships because it is a key factor in relationship marketing and because it represents one party’s feelings about, and evaluations of, the other party. Hong and Cho (2011) determined empirically the positive effect that consumer trust and loyalty have on consumers’ purchase intention. Han and Hyun (2015) described the concept of trust in medical services to be the doctors’ ability to perform their work and the doctors’ behavior of listening attentively to patients. A number of researchers have conducted studies investigating the relationship between patient satisfaction and the concept of affective trust. Montaglione (1999) determined that patient trust has a positive effect on patient satisfaction and loyalty. A study by Baker et al. (2003) determined empirically that the level of patient satisfaction increases as the level of trust that patients place in doctors grows. Similarly, Thom et al. (2002) conducted an empirical analysis of how patients with a low level of trust in their doctors also experience a decrease in satisfaction. Trust plays a vital role in doctor-patient relationships, as it can increase patient satisfaction and, thus, further strengthen the relationship between doctors and patients. Therefore, the following hypothesis is derived:

H2: The affective trust of patients will have a positive impact on patient satisfaction.

3.3. Authenticity and Satisfaction

The field of medical services can be considered distinct since it is directly connected to the lives of patients. The services are described as risky and costly, therefore patient satisfaction is far more important than consumer satisfaction in other fields.

In this study, authenticity is suggested to be an antecedent of satisfaction. Authenticity in the service sector is considered as the sincere treatment of consumers by service providers (Harter, 2002). Neff et al. (2006) asserted that the attitude that consumers want from service providers is authentic and not disingenuous and artificial. Therefore, the authenticity of service providers can be considered an important factor in consumers’ perceptions of satisfaction.

The relationship between authenticity and satisfaction has been determined empirically, by many studies. Tran et al. (2020) determined that authenticity has a greater effect on satisfaction than price fairness or service quality. Enz and Mattila (2002) asserted that when consumers feel a sense of authenticity from service providers, it leads to an increase in consumer satisfaction. DiPietro and Levitt (2019) found that when consumers perceive authenticity in the service provided by restaurants, this perception has a significant impact on consumer satisfaction and on intention to revisit the restaurant. From these works, it can be presumed that a sense of authenticity in service will have a positive effect on consumer satisfaction. Therefore, the following hypothesis is derived:

H3: The authenticity of doctors will have a positive impact on patient satisfaction. 

The study’s hypotheses were combined to create the research model depicted in Figure 1. A verification process was carried out based on this model.

Figure 1: Research Model

4. Research Method and Empirical Analysis

4.1. Data Collection

This study aimed to examine empirically, the effect of patients’ perceptions of doctors’ authenticity on the affective trust and satisfaction of patients in doctor-patient relationships. To achieve this goal, questionnaires were created using Google Surveys and distributed by email and KakaoTalk, one of the most commonly used messaging applications in South Korea. The questionnaire survey was conducted from September 1, 2020 to September 30, 2020. The survey sample was limited to individuals who had visited the hospital during the previous six months. This limitation was set since it was believed that respondents might respond with distorted memories if they visited the hospital longer than six months. Of the 800 distributed questionnaires, 253 copies were collected (collection rate: 31.6%); 11 questionnaires with unreliable responses were excluded, leaving 242 responses used in the final analysis.

Table 1 presents the sample characteristics. The largest age-group category of respondents comprised persons in their 50s and the second largest, comprised respondents in their 60s. More than half of the respondents resided in Busan Metropolitan City, Ulsan Metropolitan City, and the province of Gyeongnam, South Korea. The majority had visited a primary hospital. Specifically, the data showed that respondents’ frequency of visits were the highest in the department of internal medicine, followed by orthopedics and dentistry. Further, the majority of the respondents were middle-aged individuals who had visited health care facilities such as clinics or public health centers for treatment of visceral diseases or joint diseases.

Table 1: Sample Characteristics

4.2. Definition and Measurement of Variables

The questionnaire included four categories, including a category for determining the demographic characteristics of the sample. The remaining three categories were authenticity, affective trust, and satisfaction. This study referenced the methodologies and findings of previous studies to obtain the content validity of variables; each variable was associated with three detailed questionnaire items. A 5-point Likert scale was used to measure within each question, the respondents’ degree of perception. The scale was designed where 1 = strongly disagree, 3 = neutral, and 5 = strongly agree. The measurement variables’ definitions and reference sources are shown in Table 2.

Table 2: Operational Definition of Variables

4.3. Reliability and Validity Tests

The study verified the reliability of the measurement variables before testing the hypotheses. SPSS 18.0 software was used to calculate Cronbach’s alpha. In the field of social science research, a value of 0.7 or higher generally indicates that reliability was achieved (Hair et al., 2010). For this study, values of 0.915 for authenticity, 0.816 for affective trust, and 0.921 for satisfaction demonstrated that reliability had been achieved.

Subsequently, a confirmatory factor analysis was conducted with AMOS 18.0 software in order to test convergent validity. In addition, indices such as GFI, CFI, TLI, RMR, and RMSEA were utilized to measure the goodness-of-fit of the research model proposed. The resulting values were CMIN/DF=2.443, GFI=0.953, CFI=0.981, TLI=0.968, RMR=0.030, and RMSEA=0.077, all of which satisfied the standards recommended by Hair et al. (2010).

The average variance extracted (AVE) and construct reliability of the measurement variables were determined in order to test convergent validity. Convergent validity is obtained if the value of the average variance extracted (AVE) is more than 0.5 and the value of construct reliability is more than 0.7 (Hair et al., 2010). In this study, the following values were determined: authenticity (AVE=0.738, CR=0.894), affective trust (AVE=0.619, CR=0.829), and satisfaction (AVE=0.800, CR=0.923).

Finally, the average variance extracted (AVE) of the measurement variables was measured and correlation coefficients were calculated to verify the discriminant validity of the variables. The standard used to assess discriminant validity is that the correlation between variables must be smaller than the square root of AVE for each variable. Results are shown in Table 3. The diagonal values (*) signify the square root of AVE for each variable.

Table 3: Results of Discriminant Validity Analysis

4.4. Empirical Analysis

In this study, a structural equation model using AMOS 18.0 software and maximum likelihood estimation was utilized to verify the hypotheses. The results of the analysis determined that the goodness-of-fit of the structural model was GFI=0.953, CFI=0.981, TLI=0.968, RMR=0.030, and RMSEA=0.077; values that satisfied the goodness-of-fit standards recommended by Hair et al. (2010). Accordingly, the hypotheses were tested on the basis of the path analysis model, and the results are presented in Table 4. The first hypothesis, that authenticity has a positive effect on affective trust, was accepted. The second hypothesis that affective trust has a positive effect on satisfaction was rejected, while the third hypothesis that authenticity has a positive effect on satisfaction was accepted. Thus, this study demonstrated that the authenticity of doctors acts as an antecedent of patients’ affective trust and satisfaction. However, it also demonstrated that emotion-based affective trust does not have a direct effect on patient satisfaction.

Table 4: Results of Hypotheses Tests

5. Discussion, Implications, and Limitations

5.1. Discussion

This study suggests that affective trust is an antecedent of increased satisfaction in patients, consumers of medical services. The study also suggests that the authenticity of doctors, providers of medical services, is a factor that impacts the affective trust of patients. An empirical analysis of the relationship between the two factors was conducted, producing multiple results. First, the authenticity of doctors was found to have a positive effect on affective trust in patients. This result is consistent with the findings of previous studies, demonstrating the positive relationship between authenticity and trust in service encounters (Cheshin et al., 2018; Matthews et al., 2020). Consumers experience a greater degree of trust at an emotional level when service providers approach consumers with sincerity and authentic behavior. The results in this study indicate that any impersonal or artificial behavior and speech exhibited by doctors does not help patients build affective trust in the doctor-patient relationship. The inference is that when doctors provide medical services, they must strive to present authenticity so that patients feel a sense of personal touch.

Meanwhile, the affective trust that patients place in doctors was not shown to have a significant impact on patient satisfaction. This result is in contrast to the findings of previous studies that examined the relationship between trust and satisfaction in the existing service sector (Fang et al., 2014; Rosenbaum et al., 2006). The study’s result can be explained with the following perspective. As medical services are both directly and indirectly connected to the health of patients, it is difficult for emotional factors to lead to full satisfaction with the service. Of course, all patients wish to have their medical issues resolved within a short amount of time. To achieve this, doctors’ expertise, including their knowledge and technical skills, is needed. Meanwhile, affective trust is a subjective indicator, as it is trust based on emotional factors such as feelings of goodwill. Affective trust is not based on the abilities or skills of the other party. Cognitive trust—trust that is based on the abilities or expertise of the other party—can be expected to play a greater role than affective trust in doctor-patient relationships.

The authenticity of doctors was determined to have a positive effect on patient satisfaction. This result is consistent with the findings of previous studies that demonstrated a positive causal relationship between authenticity and satisfaction (Muskat et al., 2019; Wong et al., 2018). Satisfaction is an important factor in managing corporate sustainability within a fiercely competitive management environment, as empirically evidenced from Wu et al. (2018)¾a sense of satisfaction leads to return visits¾and Srivastava and Sharma (2013)¾satisfaction leads to repurchase intentions. Thus, satisfaction is not only an essential factor for consumers but also essential for service providers to yield a profit. Doctors must continuously strive to improve patients’ perceptions of satisfaction and to accomplish this, treat patients with an attitude that is authentic.

5.2. Implications

The theoretical implications of this study are as follows. First, this study examined the causal relationship between affective trust and patient satisfaction with doctors. Punyatoya (2019) determined that the affective trust of online consumers has a positive effect on consumer satisfaction. Dowell et al. (2015) conducted an empirical analysis to establish the critical role that affective trust plays in the relationship satisfaction aspect of business-to-business relationships. However, unlike the findings of previous studies, affective trust was not found to have a positive effect on satisfaction in the results of this study. Despite this finding, the study’s significance lies in the relationship between affective trust and satisfaction and was examined empirically, in the context of doctor-patient relationships in medical services.

Second, this study examined the authenticity of doctors as a factor in medical service encounters between doctors and patients. Many of the previous studies on authenticity have focused on the tourism and food service industries (Jang et al., 2012; Zatori et al., 2018). Few studies have investigated the significance of authenticity and analyzed empirically, its effect in the field of medical services. The significance of this study is that it reveals a factor that may advance medical services by confirming that the authenticity of doctors is important in the promotion of patients’ affective trust and satisfaction.

The practical implications suggested by this study are as follows. First, study findings emphasize the importance of doctors’ authenticity in raising the level of patient satisfaction. While doctors often focus on technical skills to improve the financial performance of hospitals, they tend to pay less attention to aspects of sincerity and authenticity in providing medical services. However, this study has demonstrated that doctors’ authenticity is vital to raising levels of patient affective trust and satisfaction. Thus, when doctors provide medical services to patients, it is important for them to treat patients with a sense of authenticity in addition to offering their exceptional technical skills. In other words, doctors must continuously strive to provide care where patients feel a sense of personal touch.

Second, in the past, patients visiting hospitals may have believed that the abilities of different doctors were generally equal. Hence, it could be inferred that cognitive trust—perceived trust based on the abilities of the other party—was less important in the field of medical services. In other words, assuming that service and skill levels were equal across the board, patients may have regarded emotion-based affective trust as more important and patronized hospitals where doctors and personnel treated them in a friendly and personal manner. However, in this study, patients’ affective trust was not shown to have a significant impact on patient satisfaction. It is important to note that this result may be connected to the COVID-19 pandemic that began in December 2019. On September 26, 2020, the number of confirmed COVID-19 cases in South Korea surpassed 23,000 cases. As the risk of COVID-19 infection rises, with no specific method of treatment till date, the results of this study may demonstrate that patients desire cognitive rather than affective trust in doctors. Doctors must continue to develop their professional skills and technical abilities in addition to authentic attitudes.

5.3. Limitations

The study suffers from a few limitations from which suggestions and directions for future studies can be derived. First, it focused only on affective trust as a sub-factor of trust in the doctor-patient relationship. Many previous studies, including those of Lewis and Weigert (2012), have suggested cognitive trust, apart from affective trust, as a sub-factor of trust. Therefore, future studies should also examine cognitive trust in doctor-patient relationships, investigating the importance of trust from a more macro perspective. Second, affective trust was shown to have an insignificant impact on satisfaction, which is contrary to the results of previous studies. Therefore, future studies should examine why affective trust does not lead to satisfaction in the field of medical services, keeping in mind the possibility that the COVID-19 environment could be an anomaly.