Patient–Provider Communication

Patient–provider communication, interaction between patients and professional and familial caregivers in formal health-care contexts, has significant influences on healthcare outcomes. During health-care, patients interact with numerous health-care professionals (e.g., primary providers, specialists, nurses) and familial providers (e.g., elderly adults’ children, spouses, young children’s parents). Familial providers interact with health-care professionals on behalf of patients (Eggly et al. 2006), patients behave differently in family members’ presence (Greene et al. 1987), and patient–provider communication affects health outcomes (e.g., pain and distress) (Cline et al. 2006). However, the majority of patient–provider communication research has investigated physician–patient dyads.

Health-Care Relationships

The type of physician–patient relationship that develops varies with relational control (Beisecker & Beisecker 1993). Relational control refers to the process of establishing who has the right to define and direct a dyad’s actions. In paternalism, physicians take control while patients yield control (e.g., unquestioningly accept physician judgments). Participatory models (e.g., mutual participation, participative decision-making, therapeutic alliance) imply both parties’ active involvement and relatively equal control (interdependence, information exchange, and listening). In consumerism, patients take charge of their health-care, seek information independently, sometimes request treatments, and, if dissatisfied, seek other physicians.

Equal relational control is an ideal unlikely to be achieved in practice, but active patient involvement is assumed desirable. Due to differences in conceptual and methodological approaches, critics disagree about whether patient-centered interaction (which theoretically privileges patients over providers) leads to improved outcomes (Mead & Bower 2000). However, a participatory model and/or patient-centeredness typically are assumed desirable by researchers and medical educators. Evidence generally associates active patient participation, with positive health-care outcomes.

Outcomes

Patient–provider communication affects health outcomes (Brown et al. 2003). Abundant research has found that patient satisfaction with health-care is related to patient–provider communication. Early observational research found patient satisfaction to be predicted more by quality than quantity of communication; later research showed communication length and quality to be unrelated. Physician communication behaviors associated with patient satisfaction include: providing information, discussing psychosocial and quality-of-life issues, offering emotional support, empathy, including families, and listening (Thompson & Parrott 2002).

Substantial evidence links patient satisfaction to adherence (compliance) to treatment regimens, and thus to health and medical outcomes. Communication variables that influence patient satisfaction generally affect adherence. Additional patient outcomes affected by communication include: psychological (e.g., anxiety, distress) and physiological responses (e.g., blood pressure, heart rate, pain), health-care needed (e.g., hospitalization length, medication taking), problem/symptom resolution, health status, and quality of life. Better communication quality leads to improved provider outcomes: reduced malpractice claims, consultation length, doctor shopping, and marginal physician use; as well as increased appointment keeping (Brown et al. 2003) and clinical trial enrollment (Albrecht et al. 2003).

Micro-Level Patient–Provider Communication Research

Research has been conducted in two general ways: (1) obtaining patient/provider self-reports regarding perceptions of communication, and (2) observing actual communication. Although patient–provider communication was long assumed important, observational investigations did not begin until the 1960s. State-of-the art research observes micro-level communication patterns (e.g., who talks, forms and functions of talk, specific nonverbal behavior).

Depending on theoretical or practical interest, researchers may focus only on physicians’ or patients’ communication behavior or on relationships between their communication behaviors. Researchers generally distinguish between two dimensions of messages: informational and relational. Informational-level messages typically contain medical content (e.g., symptoms, diagnosis, treatment, side-effects, prognosis). Relational-level messages include explicit relational content (e.g., “I like having you as my doctor”), as well as implicit messages (e.g., interruptions, closed versus open questions, empathy, friendliness, gaze) that influence affiliativeness (i.e., closeness, liking) and relational control (i.e., dominance, conversational control).

Over time, for observation and measurement, investigators have most relied on audio recording patient–provider interaction for subsequent analysis. State-of-the art research relies on unobtrusive video-recording systems, which permit subsequent coding of complex nonverbal and verbal behavior, precise time assessments (e.g., length of talk, silence, touch time), and real-time coding of patient, family member, and provider communication behavior (Penner et al. 2007).

Various observational coding systems have been used to analyze transcripts, audio tapes, and video tapes of interactions. (See 2001 special issue of Health Communication for applications of numerous coding systems to a common sample.) The typical unit of analysis is an utterance (speaking turn) or thought unit (oral equivalent to a simple sentence). Seminal research applied Bales’s interaction process analysis (IPA) to provider patient communication. Designed to study small group interaction, the IPA categorizes verbal interaction into task and socio-emotional categories. Subsequent coding systems were designed specifically for medical interaction. Depending on theoretical interest (e.g., relational control, communication competence), additional interpersonal communication coding systems have been applied to physician–patient communication.

Roter’s interaction analysis system (RIAS), the most widely used coding system, focuses on physician–patient social exchange of resources and incorporates task and socioemotional categories similar to Bales’s IPA, such as information giving/gathering in psychosocial and medical content areas and relational talk (social/emotional talk, agreements/ disagreements, and partnering talk). Other coding systems focus on areas of theoretical or practical interest. The measure of patient-centered communication (MPCC) assesses patient-centeredness, including physician exploration of patient’s disease or illness experience, physician understanding of patient’s psychosocial context, and “finding common ground” (physician–patient agreement regarding problems, goals, and roles). The Karmanos accrual assessment system (KAAS) was designed to observe conversations about clinical trials, and includes global communication ratings applicable to medical interaction in general. The global assessments are relatively unique in making assessments at the dyadic rather than individual (patient or physician) level (e.g., connectedness, closeness, dominance; Eggly et al. 2006).

Nature Of Research

Physician–patient communication research reflects several trends: (1) much early research was descriptive and qualitative; (2) most research has occurred in primary care but increasingly researchers are investigating specialized care, particularly cancer care (Arora 2003); (3) research has focused far more on physicians than patients; (4) research has focused predominantly on verbal communication.

Several research topics have received substantial attention. Studies of effects of patient social characteristics generally indicate that physician communication behavior varies based on patient gender, age, and socio-economic status (Cooper & Roter 2003). Females, elderly patients, and patients of lower socio-economic status generally fare worse than their counterparts with regard to informational and relational communication quality.

Research investigating communication competence and communication skills training has attended far more to physicians than patients. Reviews conclude that communication skills are “teachable,” but little agreement exists regarding what skills should be taught and what framework should guide training (Thompson & Parrott 2002). Although little research has focused on patient communication training, and that training typically has been limited to information-seeking skills, evidence generally supports its value for health outcomes (e.g., reduced blood pressure; Cegala 2006).

A significant communication challenge for physicians is discussing “bad news” with patients, including terminality and other sensitive issues (e.g., diagnosis of serious health problems, poor prognosis, and difficult treatment regimens). Cultural expectations influence physicians’ disclosure of “bad news.” Although medical education and training often includes “bad news delivery,” little evidence exists for the efficacy of commonly advocated approaches.

Evidence is growing that macro-level phenomena (the Internet; direct-to-consumer advertising of prescription drugs, and more recently of genetic testing; complementary and alternative medicine; social support groups) affect micro-level patient–provider communication (Cline 2003). Exposure to these phenomena may enhance patients’ actual or perceived knowledge and empower them to communicate more actively with providers. Typical research involves content analyses to identify potential influential factors. Investigations of actual effects on physician–patient communication (e.g., patients bringing information to visits, time consumption, relational impact) generally have been limited to self-report data. Critics agree that these phenomena encourage patient participation, but debate whether specific effects benefit or harm physician–patient relationships and health-care outcomes. More investigation is needed. Email is a largely uninvestigated technological advance that directly influences physician–patient communication; its impact on health-care is debated. If macro-level phenomena ultimately improve health-care, differences in access to them may enhance health-care disparities.

Perhaps the most important contemporary issue is the impact of patient–provider communication on racial and ethnic health-care disparities (Cooper & Roter 2003). Patient–provider communication may contribute to disparities, given the importance of communication for health-care outcomes and evidence regarding effects of social characteristics (i.e., gender, age, social class) on that communication. Little research has addressed this issue. However, patients rate race-discordant (versus race-concordant) physician–patient interactions as less satisfying and participatory. Whether these differences are rooted in stereotypes and expectations, or actual micro-level interaction patterns differ on the basis of race concordance, is not clear. Future research needs to identify disparity-enhancing patient–provider communication processes and develop efficacious interventions.

References:

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