For the process of health care to be successful, patients and their providers must be able to communicate with one another clearly and efficiently. Interpersonal communication involves an exchange of messages or meanings between people, in this case between patient and provider. Communication can have many differing kinds of content and can take several forms. Whereas many people associate communication messages in medical practice with an exchange of thoughts or information, communication can also involve an exchange of feelings or emotions. In addition to verbal communication, the content of what patients and practitioners say to one another, communication can also be nonverbal. Touch, facial expressions, body position, and the use of space communicate important messages, and sometimes the way in which things are said (paralinguistic cues such as tone, speed, and inflection) can be as important as content. Although patient-provider communication is typically face to face, communication may also take place across media such as e-mail and the Internet.
It is not difficult to see how failures of communication can create problems. Patients who are told to take two pills a day for 4 weeks are not likely to do well if they understand the instructions as four pills a day for 2 weeks. Yet the nature of patient-practitioner communication can be considerably more subtle than this. How much each party communicates and what is communicated provide evidence of the very nature of the patient-provider relationship.
Communication and the Patient-Provider Relationship
Although others have updated and elaborated their classic description, Szasz and Hollender described three models of the patient-provider relationship that are characterized by different styles of communication. The activity-passivity model is one in which the pattern of communication is highly asymmetrical. The physician is the expert, the patient is treated much like a work object, and little communication is necessary because it is assumed that the patient has little to contribute. Although this might be appropriate clinically in the cause of acute trauma or coma, when a provider takes this sort of attitude toward the treatment of patients in general, the provider’s communications are often in the form of orders.
The guidance-cooperation model involves more of a give and take between patient and provider, but the exchange is still far from symmetrical. Providers ask for input from the patient, the patient is valued for being able to add relevant information, but decision making is still in the hands of the provider. Rather than giving orders, communication from provider to patient takes the form of recommendations. Third, the model of mutual participation involves a pattern of communication in which patient and provider are seen as relative equals. The patient’s input is openly invited and valued, and the provider offers patients alternatives or options from which to choose. The kind of communication pattern found here is more like that between two adults than between adult and adolescent, or adult and child, as in the previous two models.
The most typical way in which patient-provider communication has been described is from the perspective of patient-centered care. Patient-centeredness has been studied from two closely related perspectives. Contrasting the patient-centered style with one that is doctor-centered, Byrne and Long distinguished the two in terms of authority and power. Providers who are doctor-centered set the agenda for communication, monopolize the discussion, and offer relatively little information to patients. Those who are patient-centered allow their patients to help set the agenda for the visit, invite their patients’ participation, offer information, and ask for feedback to be sure that the transfer of information has been successful.
Contrasting patient-centeredness with a style that is disease-centered, others such as Moira Stewart have suggested that the purpose of patient-centered communication is to allow the provider to see the problem through the patient’s eyes, to understand the patient’s ideas, expectations, and feelings. This approach focuses on the concept of “illness,” the problem as subjectively interpreted by the patient, rather than “disease,” the problem as objectively defined from a biomedical perspective. According to this approach, patient-centered providers communicate with their patients about the their lifestyles and other relevant psychosocial issues with the goal of satisfying the needs and meeting the expectations of the patient for treatment. Although the term patient-centered care has been one of the most widely used in the field of medical communication, some researchers have proposed the term relationship-centered care as preferable because it places the emphasis on neither the provider nor the patient alone, but on the two-person unit as the focus of greatest interest.
Studies of patient-provider communication have found that the communication process leaves considerable room for improvement. The average length of a visit with a physician is in the range of 16 to 26 min, although, surprisingly, the quantity of time for patient and practitioner to communicate has not decreased in spite of the movement toward managed care. At the beginning of the visit, patients typically get about 18 to 24 sec to speak before they are interrupted, which is usually while explaining their first concern (which is not necessarily their most important one). Interruptions during the patients’ exposition of problems can result in the raising of hidden agendas at the end of the visit, or the possibility that the concern is never raised at all. In a recent study by Robert Bell and his colleagues, almost 10% of the patients studied had at least one unvoiced desire. In other studies, patients and their physicians were found not to agree on the main presenting problem in 50% of their visits; half of the psychosocial and psychiatric problems that patients had were missed by their physicians.
Differences in the communication styles of male and female practitioners are considerable. On the average, female physicians who practice primary care have visits that are 10% longer than those of their male counterparts. They engage in more talk that is positive, involve their patients more often as partners, and focus more on emotions. Male and female physicians do not differ in the amount they talk about biomedical issues; however, female physicians ask their patients more questions about psychosocial issues and offer more counseling in this arena.
Communication and Outcomes
The quality of patient—provider communication can affect many significant outcomes. Good communication is associated with greater satisfaction on the part of both the patient and the practitioner and with higher levels of adherence to medical recommendations. When providers want to change their patients’ behavior (such as getting them to stop smoking or to drink more responsibly), the style of communication can make a significant difference. When patients are counseled in a way that is argumentative and controlling (e.g., “You must… “; You should…”), they are not likely to adhere to recommended changes, but when their autonomy is supported and providers acknowledge the resistance or ambivalence of their patients, patients are more likely to accept their providers’ recommendations and change their behavior. Other outcomes associated with good communication include improvement in patients’ emotional health and better physical functioning and symptom resolution.
A finding of considerable interest is that patient-provider communication is closely associated with malpractice claims. Among the most significant reasons sighted in malpractice suits are that patients feel deserted by their doctors, their views have been devalued, and they have received poor information, and that the doctor failed to take into account their perspective. In a comparison of the behavior of a sample of internists who had been sued twice or more to those who had never been sued, nonsued physicians more often told their patients what was going to happen during a visit, encouraged their patients to talk, solicited their opinions, checked to see if patients understood what they were told, and used more humor.
Assessing and Improving Communication
Given the importance of good communication skills, increasing attention has been directed to assessing competence in communications among practitioners, and using this information for important decisions. The accreditation status of residency programs in the United States will soon be determined by the achievement of educational outcomes in six areas, one of which is communications. In addition, the American Board of Medical Specialties has agreed to base the certification and recertification of specialists according to their ability to demonstrate competence in communications in addition to other biomedically related skills. Finally, because not all practitioners are born with good communications skills, training programs for medical students and other clinicians-in-training as well as practicing medical providers have grown in number. A review of these indicates that communications skills can be learned, and that education and training in communications skills result in changed provider behavior and greater patient satisfaction.
Debra Roter and Judith Hall asserted that “talk is the main ingredient of medical care… it is the fundamental instrument by which the doctor-patient relationship is crafted and by which therapeutic goals are achieved.” In recent years, a growing body of research has documented this, showing that patient-provider communication can be measured and that it affects important outcomes. Future research is likely to identify those elements of the communication that are most critical, thereby enabling providers to further master the art of medicine.
- Beckman, H. B., & Frankel, R. M. (1984). The effect of physician behavior on the collection of data. Annals of Internal Medicine, 101, 692-696.
- Beckman, B. B., Markakis, K. M., Suchman, A. L., & Frankel, R. M. (1994). The doctor-patient relationship and malpractice: Lessons from plaintiff depositions. Archives of Internal Medicine, 54, 1365-1370.
- Bell, R. A., Kravitz, R. L., Thorn, D., Krupat, E., & Azari, R. (2001). Unsaid but not forgotten: Patients’ unvoiced desires in office visits. Archives of Internal Medicine, 161, 1977-1984.
- Bertakis, K. D., Roter, D. L., & Putnam S. (1991). The relationship of physician medical interview style to patient satisfaction. Journal of Family Practice, 32, 175-181.
- Byrne, P. S., & Long, B. E. L. (1976). Doctors talking to patients. London: Her Majesty’s Stationary Office.
- Davenport, S., Goldberg, D., & Millar, T. (1987). How psychiatric disorders are missed during medical consultations. Lancet, 2, 439-440.
- DiMatteo, M. R., Reiter, R. C., & Gambone, J. C. (1994). Enhancing medication adherence through communication and informed collaborative choice. Health Communication, 6, 253-265.
- Emmanuel, E. J., & Emmanuel, L. L. (1992). Four models of the physician-patient realtionship. Journal of the American Medical Association, 267, 2221-2226.
- Levenstein, J. H., Brown, J. B., Weston, W. W, Stewart, M., McCracken, M. C., & McWhinney I. (1989). Patient centered clinical interviewing. In M. Stewart, & D. Roter (Eds)., Communicating with medical patients (pp. 107-120). Newbury, CA: Sage.
- Levinson, W, Roter, D. L., Mullooly, J. P., Dull, V. T, & Frankel, R. M. (1997). Physician-patient communication: The relationship with malpractice claims among primary care physicians and surgeons. Journal of the American Medical Association, 277, 553-559.
- Lewin, S. A., Skea, Z. C., Entwhistle, V., Zwarenstin, M., & Dick, J. (2001). Intervention for providers to promote a patient-centered approach in clinical consultations. Cochrane Database of Systematic Reviews, 4.
- Mechanic, D., McAlpine, D. D., & Rosenthal, M. ( 2001). Are patients’ office visits with physicians getting shorter? New England Journal of Medicine, 344, 198-204.
- Miller, M. R., Benefield, G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455-461.
- Robbins, J. A., Bertakis, K. D., Helms, L. J., Azari, R., Callahan, E. J., & Creten, D. A. (1993). The influence of physician practice behaviors on patient satisfaction. Family Medicine, 25, 17-20.
- Rost, K., & Frankel, R. M. (1993). The introduction of the older patient’s problems in the medical visit. Journal of Aging and Health, 5, 397-401.
- Roter, D. L., & Hall, J. A (1992). Doctors talking with patients/patients talking with doctors. Westport, CN: Auburn House.
- Roter, D. L, Hall, J. A., & Aoki, Y. (2002). Physician gender effects in medical communication: A meta-analytic review. Journal of the American Medical Association, 288, 756-764.
- Starfield, B., Wray, C., Hess, K., Gross, R., Birk, P. S., & D’Lugoff, B. C. (1981) The influence of patient-practitioner agreement on outcome of care. American Journal of Public Health, 71, 127-131.
- Stewart, M. A. (1995) Effective physician-patient communication and health outcomes: A review. Canadian Medical Association Journal, 152, 14231433.
- Stewart, M. A., Brown, J. B., Donner, A., McWhinney, I. R., Oates, J., Weston, W. W, et al. (2000) The impact of patient-centered care on outcomes. Journal of Family Practice, 49, 796-804.
- Suchman, A. L., Roter, D., Green, M., & Lipkin, M., Jr. (1993). Physician satisfaction with primary care office visits. Medical Care, 31, 1083-1092.
- Szasz, P. S., & Hollender, M. H. (1965). A contribution to the philosophy of medicine: the basic model of the doctor-patient relationship. Archives of Internal Medicine, 97, 585-592.
- Tresolini, C. P., and the Pew-Fetzer Task Force. (1994). Health professions education and relationship-centered care. San Francisco: Pew Health Professions Commission.
- Williams, G. C., & Deci, E. L. (2001). Activating patients for smoking cessation through physician autonomy support. Medical Care, 39, 813-823.
Back to Health Psychology.