Importance of Physician-Patient Communication

By:
Evan Peters

HCA 301 Introduction to Healthcare Organizations
Spring 2015

Jackson State University
College of Public Service
School of Health Sciences
Department of Health Policy and Management

Communication between a physician and patient is a popular subject matter in the Healthcare industry. A good, healthy relationship between physicians and patients is extremely important and extremely necessary. According to a consensus statement on physician and patient communication, “effective communication between doctor and patient is a central clinical function that cannot be delegated.” There is no evidence that communicating well with patients will make an enormous difference on any healthcare outcome. The purpose of this consensus is to evaluate the effects of various styles of communication on patient health and to identify the characteristics of excellent communication. These various studies reviewed were conducted in a numerous amount of clinical settings. Their different findings benefit physicians all over the world. For years, people generally thought that physician-patient communication was sufficient and was not a big deal. More recently, however, studies have proven this point to be extremely false. Numerous complaints arising from patients from breakdowns in physician-patient communication have been made to licensing bodies, and headlines declaring an “urgent need for MDs to relate better to patients” and criticizing the “cold, hard” manner of physicians have appeared in the medical and popular press. Some of these communication issues can come about during history taking or during discussion of how the patient’s problem should be solved. Some may be related to a lack of communication skills on the part of either the physician or the patient; communication does work two ways. Communication confusion can be described with reference to problems of diagnosis, a lack of patient involvement in the discussion or the dissatisfactory relaying of information to the patient. Studies have shown that fifty percent of psychosocial and psychiatric problems are missed, that physicians interrupt patients an average of eighteen seconds into the patient’s description of the presenting problem, that fifty-four percent of patient problems and forty-five percent of patient concerns are neither elicited by the physician nor disclosed by the patient,” that patients and physicians do not agree on the main presenting problem in fifty percent of visits and that patients are dissatisfied with the information provided to them by physicians.” These studies point to the conclusion that problems in physician-patient communication are popular and worthy of our attention. For the most part, the studies reviewed here described communication problems with reference to the flow of information from physician to patient during discussion of the management plan. Some of these studies, however, also point to the importance of emotional support from the physician as a form of communication. In addition, the distribution of power and control in the physician-patient relationship is either a clear or unclear concern in all of the various studies. Two responses to the common problems that arise in physician-patient communication are to identify the main characteristics of these problems and, second, to brainstorm educational possibilities to solve the issue. Both of these responses are suggesting that communicational skills were already taught at a younger age. Previous reviews, focused on the relation between communication and patient satisfaction, involved numerous research issues, linked communication with the lack of care, described a framework for teaching and learning communication skill and reviewed patient compliance. Although these studies either unclearly or clearly sustained good physician-patient communication, none reviewed work linking communication with patient health outcomes. In other words, in this study, the communication did not play an important role in the outcome of the patient’s overall health. Physician-patient communication, like any other sort of communication works two ways. If one party fails to communicate, there is going to be a grey area somewhere. There was an experiment conducted to describe how the race and gender of patients and physicians are associated with physicians’ participatory decision making styles. African American patients rate their visits with physicians as less involving than Caucasian patients. However, patients seeing physicians of their own race rate their physicians’ decision-making styles as more involving. Improving cross-cultural communication between primary care physicians and patients and providing patients with access to a diverse group of physicians may lead to more patient involvement in care, higher levels of patient satisfaction, and better health outcomes.
These studies have shown that African Americans and other minority patients often receive differential and less satisfactory health care than white Americans. It is uncertain how much of these racial differences in health care and outcomes can be explained by patient cultural factors, health care professional biases, or health care system biases. Differences in economic status and health insurance coverage between patients only partially explain the observed racial differences in health care. In other words, a person with a higher economic status is more likely to receive better care from his or her physician than a person who up holds a low economic status.
According to Patrick Cooper, race and ethnicity have been cited as important cultural barriers in patient-physician communication. However, not enough studies have been conducting involving cross-cultural factors in patient-physician communication. Problems in communication due to cultural differences between patients and physicians often contribute to a difference in the understanding that patients and physicians have regarding the cause of disease and the usefulness of available treatments. One of the studies conducted showed more communication when the patient and physician belonged to the same ethnic background; when African Americans had an African American physician, there was more communication than when there was an African American patient and a Caucasian physician. However, it was equally important in determining the outcome that there was a match between the physician and the patient.
Studies investigating the influence of patient gender on communication in the medical visit show that female patients generally receive more information, ask more questions, and have more partnership-building with physicians than male patients. This came as no surprise to the reader because women are naturally more talkative beings. Though studies have been conducted involving female patients, less is known about the communication style of female physicians. A few recent studies have shown that female physicians exhibit more empathy and engage in more positive talk, partnership-building, question-asking, and information-giving compared with their male counterparts. It is important for a patient, no matter male or female, to receive the kind of sympathy that a female physician provides. Studies have shown that increasing patient involvement in care by negotiation improves patient satisfaction and outcomes. In other words, when the physician puts his or her genuine opinion in the decision-making style, patients tend to give a more positive and talkative reaction. This method ultimately leads to a higher customer satisfaction rate.
One strategy to improve access to care for ethnic minority patients is to increase their participation in care. An approach that has many aspects should include patient and physician meetings to improve cross-cultural communication in various office settings. Interventions that empower ethnic minority patients to become more informed and active consumers of health care should be developed and evaluated. Additionally, since minority physicians are more likely to practice in areas with a high concentration of poor and minority patients, this study supports the argument for increasing the numbers of minority physicians in the workforce altogether. Furthermore, communication training programs for medical students, residents, practicing physicians, and health professionals of all ethnic backgrounds should include an emphasis on understanding and addressing the needs of a patient population that is becoming more culturally diverse. Cultural competence is described as the demonstrated awareness of three population-specific issues in the delivery of health care: health-related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy. Health care organizations should incorporate evidence-based medicine as well as the viewpoints of ethnic minority patients, patients with low levels of education and literacy, poor health status, and other various organizations. Improving cross-cultural communication in health care settings may lead to more patient involvement in care, better overall treatment, higher quality of care, and better health outcomes. Several studies and experiments have been conducted to review the instruments used to assess patient-doctor interaction from 1986 to 1996. Each instrument was reviewed under the following categories: name of the instrument, description, number of items, reliability, validity, current use and special notes. Overall, forty-four instruments were obtained and reviewed. Of these, twenty-one were used in only one published study each between 1986 and 1996 and fifteen have never been validated. While most instruments have been shown to be reliable and trustworthy, very few instruments have been directly compared with another instrument designed to assess patient-doctor interactions. According to Boon, further verification of existing instruments and incorporation of assessment of non-verbal communication between the patient and the doctor are needed. Published papers were reviewed to identify the instruments used to assess patient-doctor communication and references cited by the author as pertaining to the instrument were found. If the measurement instrument was not published in the literature, the authors were contacted in an effort to get the original instrument for review. Also, various experts across North America and surrounding countries were invited to provide unpublished instruments for study. The following information was collected for each measurement instrument: description of the instrument, number of items, reliability, validity, current use, and special notes regarding the use of each instrument. The instruments were classified into two types according to their primary use: the assessment and teaching of patient-doctor communication skills, and the assessment of patient-doctor communication for research purposes. The instruments within each of the categories were then divided into different categories based upon the method of obtaining data for analysis including: the observation and analysis of interactions in real-time, the use of standardized patients, video-taped interactions, audio-taped interactions, and self-reports from the individuals involved in the interaction. Several instruments involved in this experiment involved video-tape. Other instruments have been designed specifically to analyze the video-taped interactions. According to Boon, some use Likert scales to assess physicians’ interpersonal skills such as the Brown University Interpersonal Skill Evaluation, Campbell’s Assessment of Trainees, Hopkin’s Interpersonal Skills Assessment, Bensing’s General Consultation Judgement, and the General Practice Interview Rating Scale. Another instrument which uses rating scales is the Pendleton’s Consultation Rating Scale. This system uses visual scales to describe specific dimensions of the patient-physician interaction. Others, like the Davis Observation Code seventy-two and seventy-three, the Maastricht History Taking Advice Checklist forty-six and forty-seven, the Lehmann-Cote Checklist seventy-four, and the SEGUE Framework forty-four and seventy-five use checklists, charts, and collect present scores. There are, however, differences in the units of analysis for those that use checklists. The Davis Observation Code uses short, consecutive intervals, while the unit of analysis for the other three instruments is the patient-doctor interaction in its entirety. Another method which considers the whole interaction as its unit of analysis is the Levels of Involvement Model seventy-six and seventy-seven, where coders are asked to assess the highest level of involvement along a continuum of pre-defined psychosocial parameters that the physician reaches during any given interaction with a patient. In addition, the Patient-Centered Method fifteen, eighteen, twenty-three, twenty-four, sixty, sixty-one, sixty-two, sixty-three, sixty-four and sixty-five provides operational definitions for coders to assess the patient-centered components of the patient-doctor interaction. Another novel approach is the use of the Standard Index of Communication and the Standard Index of Discrimination seventy-eight, seventy-eight and eighty. For the former, students or physicians are asked to view video-taped scenarios and their role-playing response is assessed. Secondly, everyone who is involved is asked to view video tapes of four sample responses to the scenarios and assess them. The Profile of Nonverbal Sensitivity eighty-one and eighty-two uses a completely different approach. This instrument is a forty-five minute video tape which is used to assess an individual’s ability to understand the emotion communicated by another through facial expression, body movements and face tone. Some instruments designed to analyze video-taped interactions can also be used to assess audio-taped interactions. The collection of audio-taped data is less costly and often more convenient, however, much of the non-verbal communication data is lost with this data collection method. One educational instrument designed specifically to analyze audio-taped patient-doctor interactions is the Telephone T.A.L.K. eighty-three, eighty-four and eighty-five instrument which uses scales to assess interpersonal communication between patients and physicians on the telephone. In addition, nine research instruments have been used primarily to assess audio-taped interactions. Seven different types of interactional process analysis were identified among the instruments in the Research category: Bales’ Interaction Process Analysis nine, eleven, eighty-six, eighty-seven and eighty-eight; Butler’s Method for the Interactional Analysis of physician-patient consultations eighty-nine, the Cancer-specific Interactional Analysis System ninety and ninety-one, Kaplan’s Measurement of Physician-Patient Communication thirteen, the Physician-Patient Interaction Coding System ninety-two, Roter’s Interaction Analysis System seven, nine, twelve, ninety-three, ninety-four, ninety-five, ninety-six and ninety-seven, and Stiles Verbal Response Mode ninety-eight, ninety-nine, one hundred, one hundred one, one hundred two, one hundred three, one hundred four, one hundred five, one hundred six and one hundred seven. The number of coding categories varies from Stiles’ eight categories to Kaplan’s thirty categories. Other instruments used checklists to identify the presence or absence of specific physician or student behaviors during the audio-taped interaction including: the Byrne-Long Checklist of Behaviors one hundred eight, and the Communication and Decision-Making Checklist. The growing interest in the field of patient-doctor communication has resulted in a growth of communication assessment instruments. However, few are widely used and many have never been demonstrated to be reliable or valid, making it extremely difficult to compare the findings of different studies. Rather than continuing to develop instruments for each new research project, it is suggested that clinicians and researchers work together to document the reliability and validity of existing scales. Changes and additions to existing instruments should then be made based on the outcome of these investigations. An important part of the verification process is a need for the direct comparison of specific instruments in the assessment of the specific data sets. These types of studies will not require large amounts of funding, as many researchers currently have access to large data sets which have been analyzed using only one instrument. If more experiments were done where a set of audio and video-taped interactions were observed by research teams using their own respective instruments, there would be an addition to the knowledge that these researchers already have. This would also provide excellent feedback for the originators of each assessment instrument. Finally, in the near future, researchers should try their best to free the existing instruments from any impurity that they might have. Physician-patient communication is an extremely important subject matter. Lack of effective communication between these two parties could ultimately lead to the downfall of the well-being of a patient.

Works Cited
Boon, H. (2015, February 11). Patient-physician communication assessment instruments: 1986 to 1996 in review. Retrieved April 11, 2015.
Cooper-Patrick, L. (1999, August 11). Race, Gender, and Partnership in the Patient-Physician Relationship. Retrieved April 11, 2015.
Stewart, M. (1995, May 1). Effective physician-patient communication and health outcomes: A review. Retrieved April 11, 2015.