Physicians’ communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor?

Abstract

Although physicians’ communication style and perceptions affect outcomes, few studies have examined how these perceptions relate to the way physicians communicate with patients. Moreover, while any number of factors may affect the communication process, few studies have analyzed these effects collectively in order to identify the most powerful influences on physician communication and perceptions. Adopting an ecological approach, this investigation examined: (a) the relationships of physicians’ patient-centered communication (informative, supportive, partnership-building) and affect (positive, contentious) on their perceptions of the patient, and (b) the degree to which communication and perceptions were affected by the physicians’ characteristics, patients’ demographic characteristics, physician–patient concordance, and the patient's communication. Physicians (N=29) and patients (N=207) from 10 outpatient settings in the United States participated in the study. From audio-recordings of these visits, coders rated the physicians’ communication and affect as well as the patients’ participation and affect. Doctors were more patient-centered with patients they perceived as better communicators, more satisfied, and more likely to adhere. Physicians displayed more patient-centered communication and more favorably perceived patients who expressed positive affect, were more involved, and who were less contentious. Physicians were more contentious with black patients, whom they also perceived as less effective communicators and less satisfied. Finally, physicians who reported a patient-centered orientation to the doctor–patient relationship also were more patient-centered in their communication. The results suggest that reciprocity and mutual influence have a strong effect on these interactions in that more positive (or negative) communication from one participant leads to similar responses from the other. Physicians’ encounters with black patients revealed communicative difficulties that may lower quality of care for these patients.

Introduction

The quality of care a patient receives depends in part on the physician's communication skills. Physicians who are informative, show support and respect for the patient, and facilitate patient participation in care generally have patients who are more satisfied, more committed to treatment regimens, and who experience better health following the consultation (Henman, Butow, Brown, Boyle, & Tattersall, 2002; Jahng, Martin, Golin, & DiMatteo, 2005; Kaplan, Greenfield, & Ware Jr., 1989; Ong, de Haes, Hoos, & Lammes, 1995; Stewart et al., 2000; Street et al., 1993; Trummer, Mueller, Nowak, Stidl, & Pelikan, 2006). Quality of care may also be affected by physicians’ perceptions of patients. For example, physicians’ liking for their patients has been associated with patients’ ratings of satisfaction with care and more positive evaluations of the physician's behavior (Hall, Epstein, DeCiantis, & McNeil, 1993; Hall, Horgan, Stein, & Roter, 2002). Moreover, physicians’ communication and perceptions of patients appear to be interconnected. Physicians have provided more information, expressed more empathy, and showed more positive affect toward patients they respected and viewed favorably (Beach, Roter, Wang, Duggan, & Cooper, 2006; Levinson & Roter, 1995).

Because physicians’ communication and perceptions are related to outcomes, it is critically important to account for variability in physicians’ behavior as well as understand why different doctors talk and perceive different patients differently. With such an understanding, researchers and educators will be better positioned to effectively examine relationships between communication and outcomes as well as design interventions for improving the quality of health care.

To examine these issues, we adopted an ecological approach (Aita, McIlvain, Backer, McVea, & Crabtree, 2005; Street, 2003) that takes into account the interplay of multiple physician, patient, and contextual factors that collectively influence physician–patient interactions. An ecological approach is unique to traditional approaches to the study of communication in medical encounters. For example, some studies take a ‘single factor’ approach by examining the influence of one variable such as gender (Hall & Roter, 1998) or age (Greene, Adelman, Charon, & Friedmann, 1989) on physician–patient encounters. However, the influence of any one variable (e.g., ethnicity) may vary depending on the presence of other factors (e.g., the patient's level of education, the physicians’ communication style). While some studies have examined multiple variables (Cooper et al., 2003; Siminoff, Graham, & Gordon, 2006), little attention has been given to the processes by which these factors may have influence. In contrast, an ecological approach recognizes that within the context of any medical encounter, a number of processes affect the way physicians and patients communicate and perceive one another. In this study, we focus on four sources of potential influence—the physician's communication style, the patients’ characteristics, physician–patient demographic concordance, and the patient's communication (see Fig. 1).

First, how a physician communicates with and views a patient may simply depend on the doctor's style. Some physicians as a matter of routine provide more information, use more partnership-building, are more supportive, and are more willing to talk about psychosocial topics than are other doctors (Roter et al., 1997; Street (1991a), Street (1992); Zandbelt, Smets, Oort, Godfried, & de Haes, 2006). A physician's style of communicating with patients may have evolved from repeated experiences with certain kinds of patients, his or her philosophy of care (Krupat et al., 2000; Levinson & Roter, 1995), or socialization related to gender (Bertakis, Helms, Callahan, Azari, & Robbins, 1995; Hall & Roter, 1998), culture (Waitzkin, 1985), and medical training (Bertakis et al. (1998), Bertakis et al. (1999); Paasche-Orlow & Roter, 2003). In this investigation, we were particularly interested in whether physicians’ communication and perceptions were related to their orientations to the provider–patient relationship (Haidet et al., 2002; Krupat, Bell, Kravitz, Thom, & Azari, 2001; Krupat, Hiam, Fleming, & Freeman, 1999). That is, do physicians who report a stronger belief in sharing control and understanding the patient's perspective (i.e., a more patient-centered orientation) use more forms of patient-centered communication (e.g., clear explanations, partnership-building, support) and view their patients more favorably than do physicians oriented more toward biomedical issues and doctor control?

Second, variability in physicians’ communication and perceptions may be related to the patients’ demographic characteristics. Even the most well-meaning and egalitarian physicians may have stereotypes or biases based on a patient's demographic status (Burgess, Fu, & Van Ryn, 2004; Van Ryn, Burgess, Malat, & Griffin, 2006). Racial bias, in particular, has been implicated in research showing that some physicians associate more negative attributes (e.g., non-compliant, less intelligent, more likely to abuse drugs and alcohol) to minority and less educated patients (Van Ryn & Burke, 2000), perceptions that in turn may affect physicians’ informativeness (Amir, 1987) and medical decision-making (Krupat et al., 1999; Schulman et al., 1999). Such findings have led some to explore whether demographic concordance between physician and patient may facilitate better relationships and more positive health care interactions because the physician and patient have some element of shared identity. Some evidence supports this claim, particularly with regard to racial concordance (Cooper et al. (2003), Cooper-Patrick et al. (1999); LaVeist & Nuru-Jeter, 2002; Saha, Komaromy, Koepsell, & Bindman, 1999). Although there is little evidence indicating that physicians provide better care to patients similar in age or gender, we nevertheless examined whether differences in physicians’ communication and perceptions are uniquely related to physician–patient concordance with respect to race, age, and gender (see Fig. 1).

Finally, the patient's communication style can have a powerful effect on physician behavior and beliefs. The medical encounter, like other forms of social interaction, requires that the participants cooperate and coordinate their talk. Thus, any one interactant can exert considerable influence over the other (Street, 2001; Street & Millay, 2001). For example, physicians typically are more informative, accommodating, and supportive when patients ask questions, make requests, offer opinions, and express their fears and concerns (Gordon, Street, Sharf, & Souchek, 2006; Heszen-Klemens & Lapinska, 1984; Kravitz et al., 2005; Street (1991a), Street (1992); Street, Krupat, Bell, Kravitz, & Haidet, 2003). Physicians generally are more responsive to the actively involved patient in part because they have a better understanding of the patient's needs and concerns and in part because of conversational norms (e.g., ‘answers’ should follow ‘questions’, utterances should be topically connected) (Street, 2001). Moreover, any analysis of variability in physician communication should take into account the patient's communication because it is often confounded with patients’ demographic characteristics. For example, black patients in some studies have been less active communicators than were white patients (Gordon et al., 2006; Johnson, Roter, Powe, & Cooper, 2004; Siminoff et al., 2006; Wiltshire, Cronin, Sarto, & Brown, 2006), women are more likely to discuss their feelings and emotions than are men (Hall & Roter, 1995; Street, Gordon, Ward, Krupat, & Kravitz, 2005; Street et al., 1993), and college educated patients are often more assertive and inquisitive than patients with a high school education or less (Siminoff et al., 2006; Street Jr., Voigt, Geyer Jr., Manning, & Swanson, 1995).

In summary, physicians’ communication and perceptions of patients may be a function of various factors emerging from different aspects of communication processes. The importance of taking into account the collective influence of these factors can be demonstrated by contrasting two investigations. Siminoff et al. (2006) reported that physician–patient communication in cancer consultations varied across several patient demographic characteristics. Physicians gave more information, used more partnership-building, and had more emotional talk with younger, better educated, and white patients. Yet, these same patients also tended to ask more questions and volunteer more information. Are these differences in physicians’ communication a function of patient demographics per se or of the patient's communication? In contrast, a recent study of lung cancer consultations takes a more ecological approach (Gordon et al., 2006). This study found that physicians gave less information to black patients than to their white counterparts. This finding alone might suggest physician bias. However, the race effect on physician information-giving vanished once the patients’ communication was entered into the model. That is, black patients received less information than whites because they asked fewer questions and were less assertive, behaviors that elicited more information from physicians. Thus, our investigation examines the independent effects of various factors in order to identify the more powerful influences on physicians’ communication and perceptions.