html xmlns=”http://www.w3.org/1999/xhtml”>

Chapter 2

Provider–Patient Communication

Chances are you have had an experience similar to the following when visiting the doctor. You arrive 30 minutes early for your appointment for a persistent cough, and fatigue, and find that you have to wait 30 minutes in the waiting area for a nurse to bring you into an examination room where you have to wait another 10 minutes for the doctor to arrive. Finally, the doctor arrives, briefly listens to your lungs, and asks you only a few questions before calling in the nurse to give you a prescription for some antibiotics. You might feel that the doctor did not spend as much time as you would have liked him or her to spend with you, or perhaps you had questions about whether or not you were contagious, questions about the prescription, or how long your symptoms might last. Maybe you did not get the opportunity to voice your concerns about how frequently you have been sick lately, or you never got an opportunity to ask the doctor for a note for your boss verifying that you are sick. You may have left the doctor’s office feeling unsatisfied with the visit because you were still uncertain about what caused you to be sick, what to expect in terms of getting better, or because he or she did not meet your other needs. Research indicates that communication interventions to improve quality of care should target both providers and patient communicative behaviors (see e.g. Epstein et al., 2007; Sparks, 2007, 2008; Sparks & Villagran, 2010). Research reveals physicians who are more patient-centered are perceived as better communicators, resulting in more satisfied and compliant patients (Street, Gordon, & Haidet, 2007).

The reality for most doctors and patients is that the fear, dread, and terror that can accompany certain diagnoses (such as cancer or HIV) require a greater emphasis on communication processes to combat the uncertainty and negativity greatly affecting an individual’s cognitive and emotional capacity in ways never before experienced (Sparks & Villagran, 2010). Open, honest, communication between providers and patients can be a valuable weapon against the assault on self-identity that often accompanies a negative diagnosis. Communication becomes more important as cognitive, affective, and behavioral responses to illness intersect with biological problems that patients must face and overcome (Villagran & Sparks, 2010). Negative experiences such as these that you may have had with your doctor or other healthcare providers are often due to a variety of communication problems that commonly occur within healthcare settings. While it might be easy to blame providers in these cases, it is important to remember that communication problems are rarely one-sided, and there may have been a variety of reasons for them. Communication between providers and patients can potentially lead to successful health outcomes and improved quality of life, or it can create major problems for both providers and patients depending upon how it is handled. Many patients feel that their doctors do not listen to them, they are controlling, or they are not sensitive to many of their concerns. However, people often do not recognize that they play an important role as patients in the provider–patient relationship, and the way they communicate with their physician and other providers is important in terms of receiving the care they need in a satisfying manner. Providers also want their patients to be satisfied with the care they receive. Health communication does not just influence whether or not we are satisfied with our healthcare providers. Scholars within the fields of medicine, nursing, and communication have extensively studied provider–patient communication over the last few decades, and they have found that how providers and patients communicate in healthcare settings can potentially impact physical and psychological health outcomes, and problems such as medical errors and malpractice suits.

This chapter explores many aspects of provider–patient relationships. Specifically, it examines how providers and patients often differ in their perceptions of healthcare and healthcare needs, characteristics of communication between provider and patient, and successful and unsuccessful outcomes of provider–patient interaction.

Provider and Patient Views of Health and Healthcare

Providers and patients often have very different views about health and healthcare. The perspectives of providers are heavily influenced by the specialized training and education they receive in their training and through their day-to-day work in healthcare settings. Most patients typically do not have specialized training in healthcare or related subjects such as biology and anatomy. Instead, everyday people learn about health and the healthcare system largely through the media, interpersonal channels, and their own subjective everyday experiences of health (Cline, 2011). The following sections explore the different perspectives providers and patients have of health and the healthcare system, and how these perceptions can influence provider–patient communication as well as health and quality of life outcomes.

Provider Perspective

Provider Training

In many ways, providers learn about many aspects of health in ways that are similar to patients (at least prior to their training). For example, providers learn about a variety of health issues and lifestyle behaviors that affect health from the media, in the same way that patients do. In addition, providers have typically been patients themselves at some point in their lives. Yet, the specialized training most providers receive socializes them in ways that can lead to a much different perspective of health and healthcare than the average patient. The amount, length, and complexity of training, of course, depend upon the type of provider we are talking about. Physicians, physician assistants, nurses, and technicians differ from each other in their education and training, but all of these providers share some commonalities in terms of their socialization into medical and health occupations.

Being a medical doctor is one of the most difficult professions an individual can prepare for in terms of education and skills training, and this is one of the reasons why physicians have such a high status among healthcare professionals. Most physicians begin their college education as pre-medicine majors, and they take an extensive amount of coursework in the physical and biological sciences. Similar to other standardized tests, potential medical students have to take the Medical College Admission Test (MCAT) exam and obtain a high enough score to get into a medical school. Medical school is an arduous process for most medical students, who in addition to hundreds of hours of study and clinical training have to cope with rites of passage such as hazing and often intense criticism from medical faculty and peers.

Medical school is also a socialization process where physicians learn formal medical terminology and informal jargon. In addition, medical students often earn a privileged status due partially to the power and status that society attributes to physicians and the reinforcement of these perceptions during day-to-day activities in medical school (du Pré, 2004), such as when medical students interact with patients and lower-status providers (e.g. technicians) during clinical rounds. While many medical schools now teach students about the importance of communication in healthcare settings, and there are classes that emphasize communication skills, the majority of physician training is focused on aspects of physical health and the development of clinical skills. Following medical school (which typically requires four years of study), most states require an internship period followed by a residency period (time varies depending upon state licensure requirements and specialty) prior to obtaining a license to practice medicine.

Physicians, of course, are among many healthcare professionals who comprise the provider segment of the healthcare system. Physician assistants, nurse practitioners, technicians, pharmacists, occupational therapists, and dieticians are some of the many types of providers that are typically seen in most hospitals and clinics. Like physicians, these occupations vary in terms of amount of education, training, and status. In terms of communication, these providers often interact with patients as frequently (or more often than) physicians and are important contributors to successful patient outcomes.

Other health fields, such as dentistry, also have similar diversity and status differences among providers. Dental school can be similar to medical school in terms of education, training, and stress. Dentists parallel medical doctors in the world of dentistry as regards professional status. Other dental occupations, such as dental hygienists and dental assistants, vary as to level of education and training. In most states, a Bachelor of Science degree is needed to become a dental hygienist whereas only a two-year degree or certificate is required to be a dental assistant. Health organizations also typically have a number of staff positions, such as receptionists, office managers, and individuals who handle insurance claims. While the focus of this chapter is primarily on physician–patient communication, it is important to recognize that patients interact with many other providers when seeking healthcare, and a number of the provider–patient communication issues that are examined in this chapter can be applied to other providers as well. However, given the education and social status of physicians, and their important role in medical decision-making when diagnosing and treating health problems, it is not surprising that most communication research has focused on physician–patient interactions.

Provider Communication Skills Training

As you probably have already observed, healthcare providers spend a great deal of their time communicating with patients. However, it may surprise you to know that until relatively recently most providers have received relatively little training about how to effectively communicate with patients. Over the last several decades, researchers have found that communication skills training may improve provider–patient communication, and effective provider communication skills have been linked to positive health outcomes for patients, such as improved compliance, satisfaction with care, and benefits to physical and psychological health (Aspden, Wolcott, Bootman, & Cronewett, 2007; Kaplan, Greenfield, & Ware, 1989; Stewart, 1995). Perhaps the most emotionally difficult communication providers must master is breaking bad news in an empathetic and comforting manner (Sparks, Villagran, Parker-Raley, & Cunningham, 2007; Sparks & Villagran, 2010). Patients create opportunities for providers to express empathy during medical interactions, even when the patient is relatively unfamiliar with the phy­sician, but physicians most often deal with the opportunity by acknowledging the situation without really sharing their own experiences or feelings (Bylund & MaKoul, 2005). Direct communication of the basic bad news message focuses on the topic itself, as opposed to the social or emotional implications of the message for the patient or provider (Sparks et al., 2007). Empathic communication can bolster patients’ views of a provider’s communication competence, and most often expresses understanding for the patient’s feelings, without actually sharing the patient’s emotions (Hemmerdinger, Stoddard, & Lilford, 2007). Beach et al. (2004) found that physicians rarely self-disclose anything about themselves in medical encounters, and disclosure of personal feelings is rare. Providers most often use a direct style of delivering bad news.

Most likely because of the rigorous training dealing with physical aspects of health in medical schools, nursing schools, and other health-related occupational training, communication skills training is a relatively underdeveloped part of the medical/healthcare curriculum at most universities and colleges in the US. While efforts by medical school and health science faculties in recent years have succeeded in adding more content dealing with psychosocial concerns in medical and health-related courses (including communication issues), communication skills training is still typically only a small part of medical and health education. However, the growing evidence from research that suggests communication skills, such as the ability to competently break bad news to patients (Eggly & Tzelepis, 2001; Wakefield, Cooke, & Boggis, 2003), have important health implications for patients has gained the attention of influential organizations such as the American Medical Association (AMA) (Association of American Medical Colleges, 1999). The AMA requires all medical schools to test medical students on their knowledge of communication skills as part of the medical licensing process (van Zanten, Boulet, & McKinley, 2007).

Despite the belief among professional medical organizations, such as the AMA, that communication skills are an important part of quality healthcare, people studying to be healthcare providers often have negative attitudes toward communication skills training (Batenburg & Smal, 1997; Rees, Sheard, & McPherson, 2002) and toward taking communication skills training courses. Medical students often feel that these courses are basically common sense or too easy, or they feel that they already have sufficient communication skills for practicing medicine. Compared to courses in medicine, biology, and other physical sciences, some medical students and other future providers often view communication as a “soft science,” or as having less scientific rigor and/or practical value, and this can lead to the perception that communication skills are relatively unimportant, mainly because they may have not had much exposure to the sophisticated research conducted by health communication scholars. For example, for most of these students, few have had training in communication outside of an undergraduate public speaking class. Yet, communication skills are not “soft” when you stop to consider the enormous impact of costly medical errors that are often related to misunderstandings resulting from communication problems (Cohen, 2007; Valente, Antlitz, Boyd, & Troisi, 1988). For example, medical error costs have been estimated at US$887 million (Aspden et al., 2007) and they frequently lead to increased patient suffering and death (Gandhi et al., 2003). Given the number of communication problems that can potentially occur between provider and patients and these and other negative health outcomes related to communication, it appears that physicians and other providers would benefit from communication skills training.

When communication skills are taught in medical education, “many courses do not introduce teaching of communication skills until midway into the medical curriculum, to coincide with the traditional starting point of the clinical component of training” (Humphris & Kaney, 2001, p. 225), and communication skills training has been found to be inconsistent within the curriculum of other providers, such as pharmacology students (Noland & Rickles, 2009). Third- and fourth-year medical student training is much more focused on actual clinical work than the training of first- and second-year students, who primarily deal with classroom lectures about communication or simulated training with standardized patients (people who pretend to be patients). It appears that actual experience with patients is important for learning and practicing medical communication skills. Kaufman, Laidlaw, and Macleod (2000) found that medical students who had performed basic communication skills with patients in a clinical setting had more confidence in their ability to communicate with patients than medical students who lacked this experience. Female medical students also tend to have more positive attitudes toward communication skills learning than male students, and researchers have found that male medical students are slower at learning communication skills than females (Marteau et al., 1991; Wright et al., 2006).

Challenges Providers Face in Healthcare Delivery

Rising Costs of Healthcare and Competition 

Americans spend over $1 trillion on healthcare each year, and this figure is projected to increase substantially over the next decade (US Census Bureau, 2005). Given these costs, providers face a number of challenges in communicating with patients and providing quality care in today’s healthcare system. The pressure from health organizations to provide services to a large number of patients while simultaneously cutting costs in order to remain financially viable has influenced provider behaviors in many ways. Increased competition in terms of the number of hospitals and health facilities providing healthcare in most US markets has given consumers many different choices of where to obtain healthcare, and health organizations have become increasingly concerned about losing market share to competitors. In many urban areas, specialized health organizations such as cancer centers, acute care service facilities, and women’s health centers are competitors to larger hospitals. While these specialized services give consumers more choices in terms of obtaining services, the increased competition from their presence has augmented economic pressures in these markets, and they have led many organizations to raise provider workloads while also limiting many types of services that providers are allowed to offer patients in an effort to stay competitive financially.

Impact of Managed Care on Provider–Patient Communication 

Since the mid-1980s, the rise of managed care has been an important response to rising costs and increased competition. Managed care refers to “a financial and organizational arrangement for the provision of health care services” (Lammers, Barbour, & Duggan, 2003). The term managed care is often perceived negatively because it has become synonymous with the idea of control by big business, loss of autonomy, and limited choices over services. However, most providers would have a difficult time surviving financially without managed care, and most patients would not be able to afford healthcare services if these organizations did not exist. We will examine managed care in greater depth in Chapter 6.

Most managed care plans place financial restrictions on the types of procedures, medications, diagnostic tests, and other treatment recommendations physicians can make to any given patient as a means of controlling costs. This practice is known as capitation. Capitation helps to keep the overall costs of managed care plans relatively low for consumers by eliminating costly procedures and service in cases when lower-cost alternatives can be found. However, in cases where the patient would benefit from a more expensive procedure or medication, providers and patients often feel frustrated if the plan will not pay for these services (or only a small portion) and the patient has to cover these costs. The first author’s wife recently had to have her physician write to her managed care organization to request increased coverage for a $600 a month medication that is normally not covered by her plan because her physician thought the medication would be helpful for her condition.

Working within a managed care system is often a source of stress for providers who often feel that their ability to provide patients with the best care possible is compromised by the restrictions of the managed care health plan. Providers often feel too constrained by the limitations of plans, and some may resent having plan administrators dictate the course of patient treatment. Physicians often feel pressure to see patients for shorter periods of time, and this may lead to communication behaviors that negatively affect the provider–patient relationship. In addition, because the provider–patient relationship under managed care plans is subject to the conditions of the plan, this relationship can be disrupted when a patient’s plan is bought by another managed care organization or if the organization decides to drop a provider from the patient’s list of eligible providers.

Privacy and Provider–Patient Relationships

Providers often struggle with managing information about patients as well as information pertaining to patients in healthcare settings. For example, patients are typically asked to reveal significant amounts of private and sensitive information in medical interactions (Duggan & Petronio, 2009; Petronio & Sargent, 2011), such as information about sexual activities, embarrassing information about bodily functions, the truth about diet and exercise practices, fears about illness, and issues such as domestic abuse. At the same time, providers know information about patients, such as how long they will likely live if diagnosed with a terminal illness, the amount of pain or cost involved with certain medical procedures, and issues that could potentially violate patient confidentiality. Nurses in particular often struggle with the need to know certain private things about their patients while simultaneously feeling the need to shield them from certain types of information in their attempts to balance patient care and patient confidentiality.

One theory that is helpful for understanding these types of predicaments for providers is Communication Privacy Management Theory (Petronio, 2002). This theory posits that people believe that they are the owners of their private information and they assume the right to control access to it. However, there are expectations about the responsibility for managing information, and healthcare professionals often assume they are co-owners of patient information (Petronio & Reierson, 2009). Yet, the need to gather private information from patients in healthcare often leads to a one-way street where patients disclose sensitive information while nurses and other practitioners do not share sensitive or private information about their own lives with patients. In addition, as mentioned above, nurses and other healthcare professionals often shield patients from certain types of information, particularly if that information could potentially increase fear, discomfort, or violate patient confidentiality. In an attempt to establish personal and professional boundaries, providers may withhold information from patients, and this can lead to perceived interpersonal distance between providers and patients (Petronio & Sargent, 2011). Communication Privacy Management Theory is often used as a framework for better understanding the strategies people use to manage tensions surrounding the communication of private or sensitive information as well as how the rules for communicating about private information shift depending upon the situation or context.

Provider Perceptions of Patients and Communication

While physicians are trained in medical school to conduct medical interviews, communicating with patients effectively can be an extremely complex process. In a relatively short amount of time, physicians must be able to make one or more diagnoses from hundreds of possible diseases and medical conditions, and patients’ self-disclosures about their medical history and their ability to articulate their chief complaint play a crucial role in helping physicians narrow down a wide array of competing possibilities for the causes of their condition or source of concern (Mentzer & Snyder, 1982). Many diseases and conditions can have similar symptoms. For example, chest pain can be associated with something as benign as indigestion or as serious as a myocardial infarction (heart attack).

Because identifying the causes of patient problems is largely a process of elimination, physicians and other providers need specific information from patients to help rule out factors that are not influencing the patient’s condition. Gathering this information from a patient is often a difficult task for providers. They will typically ask a number of questions they feel are useful for narrowing down probable causes of the patients’ condition while simultaneously steering away from information that they perceive to be irrelevant. Providers rarely rely solely on patient self-disclosures about problems, and the information that a patient provides is corroborated with information from physical exams, diagnostic tests, consultations with peers, and information from medical books and databases. Physicians who adhere to a more biomedical approach to medicine tend to focus specifically on the physical dimension of health, and their communication with patients tends to be very focused and specific, such as gathering information about physical symptoms (Roter et al., 1997).

Problems can occur when information that a provider thinks is irrelevant is perceived by the patient to be relevant, and a patient might feel a provider is being insensitive if one or more of his or her comments are ignored. Complicating the situation further, providers are not always correct when it comes to assessing the causes of a patient’s condition initially, and in these cases further information from the patient is often crucial to help establish the right diagnosis. Patients may also withhold sensitive information about their lifestyles, or about body parts or functions they feel uncomfortable talking about, and patients often vary in their ability to accurately disclose information about their health. For example, some patients do not want to disclose information about drinking, eating, and smoking habits because they feel their provider will negatively judge them or because they are afraid that this information might raise their medical insurance premium. It is also difficult for many patients to talk about their sex organs, bowel movements, or other topics they don’t perceive to be appropriate or relevant. Talking about these types of issues also violates many ethnic and cultural norms, and this can be problematic in health settings where there is a diverse patient population.

Other factors, such as the age of the patient, are associated with problematic provider–patient communication. Young children often lack the developmental skills to give a provider accurate information about their health history or symptoms, and older adults with cognitive impairment may have a difficult time recalling or communicating health information that might be useful to providers in making a correct diagnosis (Nussbaum, Ragan, & Whaley, 2003). This can create additional challenges for providers when communicating with pediatric or older adult patients.

As you can see, providers must walk a fine line between attempting to obtain the information they need from a patient in order to make a correct diagnosis, assessing what might be irrelevant information and discouraging it, and encouraging the patient to provide information he or she may be reluctant to discuss with the provider but may be relevant to the case.

Assessing Patient Cues and Provider Expectations 

Physicians and other providers are trained to rely on both verbal and nonverbal cues from patients when assessing their health problems. However, preexisting beliefs and attitudes toward patients can influence the ways in which providers communicate with them. Physicians’ interpretations of patient cues not only affect their interaction with patients but can also influence their medical decisions when treating patients (Geist & Hardesty, 1990). For example, social cues, such as race, gender, and age, and physical cues, such as if a patient is overweight, have been found to influence the type of information a physician provides to the patient and the type of treatment options he or she discusses. Providers also assess patient attitude cues, such as whether a patient has a “good” attitude or if he or she is seen as a “bad patient” (typically a complainer/arguer, or someone who challenges the doctor’s authority). Doctors often try to get rid of “bad patients” more quickly. A problem is that providers’ perceptions of patients are often based upon socialization and prior experiences with patients. Providers, like all human beings, may engage in selective perception, or the tendency to perceive information in ways that are consistent with past experiences.

Providers’ expectations about patients are often based on verbal and nonverbal patient cues, and this may influence their recommendations for treatment and the amount of information they provide patients. For example, provider expectations about patient adherence has been found to influence the degree to which doctors will discuss or advocate colorectal cancer screening with patients (Dulai et al., 2004; Shokar, Carlson, & Shokar, 2006).

Patient Perspective

Patient Socialization

Most people learn about the healthcare system from a variety of sources, including the mass media, family members, and friends, and through their experiences interacting with providers when seeking healthcare (Brashers, Goldsmith, & Hsieh, 2002; Cline, 2011). All of us have been patients at one time or another, but few people critically examine how they learn the role of being a patient or their own communication behaviors when interacting with providers. Much of what we know about being a patient comes from what we see and hear in the mass media. Television shows, such as “Grey’s Anatomy,” give us insight into the world of medicine, and through these types of shows we see examples of how patients interact with providers. These insights can sometimes lead people to develop unrealistic expectations, such as expectations about the friendliness and efficiency of their providers or their ability to effectively diagnose and treat illness. We will examine the relationship between health in the mass media and individual perceptions in Chapter 8.

Most people learn perceptions of health and the healthcare system through everyday language (Cline, 2003, 2011). In other words, our perceptions of reality about health and health situations are shaped by our day-to-day interactions. This perspective is known as the social construction of reality (Berger & Luckman, 1966). Our families and friends play an important role in socializing us when it comes to learning about providers and how to behave as a patient, and over our lifetime the language we encounter involving health each day influences our perceptions over a long period of time. Even our first-hand experiences with providers and healthcare settings are mediated through language, and common perceptions of illness, providers, the healthcare system, and many other aspects of health are shaped by the way in which language about health is used by the people in our social networks.

Language is rarely neutral, and common uses of language, such as metaphors like “doctors are mechanics,” convey meanings and understandings about doctors and drug use that imply certain behaviors. For example, if a woman thinks her doctor is essentially a mechanic, then this understanding of a doctor might influence her to think about doctors in very specific ways. Most individuals have relatively little interaction with mechanics other than telling them what needs to be fixed and obtaining an estimate, and mechanics feel little need to convey warmth or empathy to a car when fixing a radiator. Thus, referring the term “doctor” to the term “mechanic” conveys certain expectations for a doctor’s behavior, such as the doctor being somewhat impersonal and perfunctory when “repairing” a broken arm.

Other factors, such as health history, gender, socioeconomic status, culture, and age, play an important role in socializing patients. Individuals who have an ongoing health problem are more likely to see providers more frequently than people with fewer health problems and they often develop different perceptions of providers and health settings due to their relational history with providers and their more extensive experience with the healthcare system. Women are more likely to seek healthcare than men in general in the US, they are more likely to make regular visits to providers such as gynecologists for female-specific health concerns, and they often experience more problems with healthcare than men (Beck, 1997). Cultural differences, including ethnic differences, sexual orientation, and religious beliefs, are important factors in patient socialization (see Chapter 5). For example, some immigrants mistrust the US healthcare system or do not follow mainstream cultural conceptions of health. Finally, older adults in our society often have very different views of providers and the healthcare system than younger adults. Many older adults lived the majority of their life in a time when few people questioned a physician’s authority and before the advent of managed care, and these experiences often impact perceptions older adults have of healthcare and the way they communicate with providers. Not only do these factors influence patient perceptions of healthcare, but also providers often communicate with patients much differently based upon age, gender, status, and ethnicity.

Patient Perceptions and Expectations

Think about how you think about health and healthcare. It is likely that the way you see them has been influenced by a variety of sources, such as television and other mass media, our everyday interactions with others, our first-hand experiences with being ill and going to the doctor, or a combination of all of these things. Each of these experiences influences our current perceptions of health and health providers. Over time, these experiences are stored in memory as schema, which are mental structures or templates that help guide our behaviors (Reed, 1988; Schank & Abelson, 1977). Schema are useful to us since they help to reduce the amount of thinking, or cognitive effort, we exert when performing daily activities. For example, if we had to process all of the information available to us each time we went to the doctor, such as understanding the role of receptionists, nurses, or the process of the medical interview, as if we had never experienced them in the past, we would probably suffer from what is called cognitive overload, or too much information for our brain to process.

Fortunately, schema give us a mental blueprint that helps to guide our expectations and behaviors in medical settings. However, because schema are based upon previous experiences, they can influence our expectations and communication behaviors during provider–patient interaction (O’Hair, Allman, & Moore, 1996). People may react positively or negatively when their initial expectations for a social situation are violated, and this appears to be true in health settings. For example, if a patient expects her new doctor to be warm and empathetic based upon her previous experiences with other physicians, and the new doctor violates this expectation by communicating in a cold and distant manner, then the patient will probably be unsatisfied with the interaction. However, another patient, such as an elderly male, might expect his doctor to be controlling, and he may be uncomfortable about the interaction if the physician violates this expectation by encouraging him to be more involved in selecting treatment options.

It is important to recognize that patients differ considerably in terms of their perceptions of providers and their expectations for provider–patient interaction. Some patients may not expect their doctor to talk about their lifestyles, feelings, or to have time to answer their questions, while other patients may have high expectations for these behaviors. However, many patients desire both technical and interpersonal competence in providers, although in the case of physicians, technical competence is often one of the most important expectations for patients (Anderson, 2001).

Patient expectations can be influenced by broader perceptions of the provider–patient relationship. For example, patients who have a paternalistic view of provider–patient relationships tend to feel that their role as patients is to obey and cooperate, that the provider should take a dominant role during provider–patient interaction, that the provider is more knowledgeable than the patient, and that the provider has their best interest in mind (Beisecker & Beisecker, 1993). Patients who have a paternalistic view of the provider–patient relationship tend to expect and be satisfied with a provider who communicates in ways that are consistent with this view.

Other patients hold a consumeristic view of the provider–patient relationship and are more likely to take an active role when communicating with a doctor (e.g. ask questions, communicate concerns), expect the provider to be less dominant during interaction, and place less emphasis on the provider’s authority or status (Beisecker & Beisecker, 1993). Patients with a consumeristic view tend to have much different expectations about provider–patient interactions than patients with a paternalistic view. They see the relationship more as an exchange of information between the two parties, similar to a business transaction that would take place among providers and consumers of other types of services. In other words, patients with this view of the provider–patient relationship often feel: “I am paying a lot of money for this visit… I should get what I want!” This need may override perceptions of a physician’s social status. For example, think about how much money you pay for college tuition. College students often do not care about how prestigious a professor is if they do not feel they are getting their money’s worth from a class (e.g. if they are not learning much or the professor is boring).

Yet, the consumeristic view of medicine is not without its problems. Sometimes we do not know what is best for us as patients. Similarly, college students often do not have the expertise in a class to know what is important to learn about a given subject, and they may object to having to read certain books or participate in some assignments. In much the same way, patients often object to some tests or procedures and may perceive them as unimportant or excessive, while their doctor may view them as a crucial part of treating a patient’s health problem.

Health Beliefs/attributions and Patient Behavior 

Patient beliefs about health and the attributions they make regarding causes of health problems can affect their behaviors in important ways within healthcare settings. Martin (2007) found that people who believed they had a low level of susceptibility to develop carpal tunnel syndrome at their jobs (even if they were engaging in tasks that put them at risk for developing carpal tunnel syndrome) were less likely to engage in help-seeking behavior from providers. Beliefs surrounding the severity of chronic health problems that people are living with have been found to influence how often the visit the doctor, seek information from providers, and how well they adhere to suggested treatments (Cameron & Leventhal, 2003). For example, patients with asthma who believe that the condition in is not serious are less likely to adhere to corticosteroid treatments (Chambers et al., 1999), and patients living with high blood pressure are less likely to see their physician or adhere to medicine if they do not believe that high blood pressure makes a person more susceptible to heart disease or strokes (Kressin et al., 2007).

Patient Uncertainty

Think about how worried you might be if you were to suddenly develop a rash that rapidly spreads across your body. Is it poison oak, food poisoning, or something worse? The experience of uncertainty is directly linked to the communication processes of gathering and interpreting information about an illness (Babrow, 2001; Brashers, 2001; Parrott, Stuart, & Cairns, 2000), and it can affect provider–patient communication in a variety of ways. Patients often experience considerable uncertainty in provider–patient interactions because their knowledge level of medicine is typically much less than their physician (Sheer & Cline, 1995). In addition, contradictory information about diseases from the media, family, and friends and uncertainty about the healthcare system are among the many reasons patients feel uncomfortable when talking to healthcare professionals (Shore, 2003).

Sources of uncertainty during times of illness and when visiting the doctor can stem from many sources, such as the technical language and discourse used by physicians, the known potential for mistakes by the healthcare provider, and the stress of gathering accurate information while attempting to stay positive when coping with an illness (Babrow, Kasch, & Ford, 1998). Reducing uncertainty about illness may help patients cope with their health problems better, but this is not always the case (Czaja, Manfredi, & Price, 2003). Sometimes, a diagnosis of a life-threatening illness, such as cancer or HIV, may increase uncertainty rather than reduce it. While the patient may learn that the symptoms he or she is experiencing are due to cancer, the diagnosis may raise a host of uncertainties, such as uncertainty about their prognosis, treatment options, and how the disease will affect his or her relationships.

Austin Babrow (2001) developed problematic integration theory in an effort to investigate the communicative processes people facing illness use to manage health information in order to deal with uncertainty. Babrow (2001, 2007) argued that the meaning of uncertainty is largely dependent on the values of the individual who is experiencing an illness, with those values guiding the ways that information is used to manage uncertainty. Problematic integration theory posits that uncertainty is a complex phenomenon, and some people seek to increase uncertain rather than reduce or avoid it (Babrow, 2007). In addition, a person’s desire to seek or avoid information influences the ways in which he or she ultimately copes with health issues. For example, a person with cancer may decide to gather certain types of information about the most aggressive forms of chemotherapy if he or she primarily values stopping the progression of cancer, regardless of the side effects of the treatment in an effort to reduce uncertainty about the disease. In addition, if an individual knows he or she has cancer, this may influence the decision to seek support from others (Babrow, 2007). However, a person who suspects he or she has HIV may avoid seeking information (such as an HIV test or information about symptoms) because living with uncertainty may be more comfortable than dealing with knowing that he or she has an HIV positive status. This is especially the case when a person believes that being HIV positive will lead to being negatively stigmatized by others or if the person fears confronting his or her own mortality.

Problematic integration theory has been a helpful framework for understanding patients’ experiences with uncertainty surrounding a variety of health-related issues, including pregnancy and birth (Matthias, 2009), breast cancer (Dennis, Kunkel, & Keyton, 2008), and end-of-life decision-making (Hines, Babrow, Badzek, & Moss, 2001). Problematic integration theory will likely continue to be an important framework for understanding patient uncertainty and coping strategies for confronting health concerns in the future.

Patient Needs and Goals

Have you ever seen a doctor even when you were feeling relatively well so that you could get a note from him or her to help document an absence from work or school? Or perhaps there have been times when you were not really suffering from symptoms, such as a rash or a pain in your stomach, when visiting the doctor, but you were concerned that the symptoms might be a sign of a larger health problem. Patients often have multiple needs and goals when they communicate with physicians and other providers. While many patients go to their doctor to obtain relief from physical symptoms, they also have other needs that they want their providers to meet. These include the need for the provider to validate or legitimize their health concern. For example, after several visits to the emergency room for abdominal pain several years ago, the first author of this book was told on each visit that it was “most likely indigestion,” and he was told to take an antacid. At the time, he was working on his doctoral dissertation, and several physicians told him that the indigestion was probably related to stress. However, he felt that the pain might be related to a more serious problem despite the fact that his doctors had dismissed the problem as “nothing serious.” He felt angry that nobody seemed to take the problem seriously. Finally, after going to the emergency room one night at 3:00am with severe pain, a doctor decided to run a blood test and a sonogram, and it turned out that he needed emergency gallbladder surgery. As in this case, patients often want physicians to validate their perceived health problem as a legitimate problem.

Even when a patient is experiencing physical symptoms, the need to manage the symptoms is secondary to the patient’s need to reduce his or her fear over possible causes of the symptoms. For example, a patient may have an ongoing skin rash that is causing him some discomfort, but due to his past history of unprotected sex with multiple partners, coupled with information from a pamphlet he read about symptoms of HIV that include skin rashes, this patient may be more concerned about whether or not he has HIV than obtaining relief for the rash. Other patients might have a need to confess their medical fears to a provider. Some people suffer from health problems in silence and they are afraid to see a doctor because of the fear that the symptoms might be caused by a serious disease (such as cancer). In this scenario, the physician might be the first person a patient has told about the symptoms after living with the fear of them for weeks, months, or years, and the patient’s need to alleviate or understand the symptoms might be secondary to getting the issue out into the open. In addition, patients also have a need for providers to convey concern, emotional support, reassurance, and interpersonal warmth during medical interviews. Having these needs fulfilled by the provider may be just as important as or more important to the patient than the need for medical treatment.

Provider–Patient Interaction

Provider–patient communication has seen many changes in recent years. Until relatively recently, providers and patients were both accustomed to a paternalistic approach toward healthcare where the doctor “knows best” and should not be questioned. Today, healthcare providers are encouraged to focus more on their patients and their needs, while patients are taking more responsibility for their care. Communication scholars and medical researchers have become increasingly interested in provider–patient communication in the past decade, and even the Journal of the American Medical Association (JAMA) now devotes a regular section to provider–patient communication issues. The following section explores characteristics of provider–patient communication and their relationship with various outcomes. It begins by exploring communication accommodation theory as a conceptual framework for studying provider–patient communication.

Communication Accommodation Theory as a Framework for Understanding Provider–Patient Interaction

Stay updated, free articles. Join our Telegram channel

Join