Doctor-Patient Communication

Doctor-patient (or client-professional, practitioner-patient, and lay-professional) communication has been the focus of scholarly study and public concern for several decades. Within medicine, communication is increasingly seen as a critical skill set in the delivery of care. The doctor-patient relationship is a special kind of relationship; while patients may not know their doctors in a personal sense (and often, vice versa), they are nonetheless asked to disclose intimate details of their personal lives and reveal their bodies for examination. This vulnerability is not reciprocated from doctors to patients. There is, therefore, a degree of social imbalance in this relationship (albeit one that is socially sanctioned), which may have a bearing on communication. Barriers to effective communication between doctors and their patients, including such factors as class, gender, race, and health literacy, are discussed.

Keywords: Cultural Competence; Communication; Functionalism; Healthcare Disparities; Medical Encounter; Patient Centered Care; Role Format; Sick Role

Overview

Doctor-patient (or client-professional, practitioner-patient, and lay-professional) communication has been the focus of scholarly study and public concern for several decades. Within the medical field, communication is increasingly seen as a critical skill set in the delivery of care. The doctor-patient relationship is a special kind of relationship; while patients may not know their doctors in a personal sense (and often, vice versa), they are nonetheless asked to often disclose intimate details of their personal lives and reveal parts of their bodies for examination. This vulnerability is not reciprocated from doctors to patients. There is, therefore, a degree of social imbalance in this relationship (albeit one that is socially sanctioned). This may have a bearing on communication, that is, the full range of spoken, facial, bodily, and symbolic expressions that people use when they interact and exchange information with each other.

Classic studies in sociology have highlighted the potential for conflict in doctor-patient communication and identified how assumptions about patients based on class, gender, age and race influence the content and tone of communication. Moreover, research has shown that patients who understand their doctors are more likely to acknowledge their health problems, understand their treatment options, modify their health-related behaviors at their doctor’s recommendation, and adhere to treatment recommendations. Given this compelling evidence, a growing number of medical schools now provide their students with both formal and informal instruction on how to communicate with patients and how to develop interpersonal skills to support effective communication (Travaline et al., 2005). Further, teaching and assessing communication skills has become integral in the accreditation of a school’s medical program, though a wide variation in technique remained (Makoul, 2003). Such skills, which include listening, explaining, questioning, counseling and motivating patients, are becoming core competencies for medical practice, and in the United States, demonstration of such skills is required for licensure and board certification. Nonetheless, there continue to be many barriers to effective communication between doctors and their patients, including such factors as gender, race, and health literacy.

Communication & the 'Ceremonial Order of the Clinic'

Physician-patient communication has been central to scholarly research for at least fifty years and the ideal medical encounter (for which effective communication is critical) is increasingly viewed as one that is patient-centered (Mead & Bower, 2000) from obtaining the patient's medical history to conveying a treatment plan. The medical or clinical encounter entails much information sharing about symptoms, diagnosis, and treatment options in what has been historically and is increasingly recognized as a therapeutic relationship that provides the first step toward healing (Travaline, Ruchinskas & D'Alonzo, 2005). However, studies of patient-doctor communication demonstrate that communication is rarely patient-centered and is in fact influenced by many characteristics and ideas.

There is a surprising degree of regularity and ritual associated with communication between doctors and patients, or, more correctly, with the medical encounter. In a classic study of outpatient clinic visits in Scotland, Phil Strong (1979) found that there is an unspoken set of rules and rituals that guide the medical encounter or consultation. These rituals, encoded as role formats (or as sociologist Erving Goffman might put it, social scripts), provide tacit resources that both patients and doctors call upon, depending on their assessment of the encounter (that is, what kind of consultation they consider it to be). Strong identifies four such formats:

• Bureaucratic (doctor and patient are both polite and avoid conflict, though doctors assume patients to be less than competent);
• Charity (doctors draw attention to patients' incompetence);
• Clinical (in which the doctor and patient tacitly agree on the doctor's expertise and authority); and
• Private (in which the doctor focuses on "selling" his competence).

Core to these formats is the way the doctor typically asserts control over the communication process and directs the conversation by the following tactics: interrupting patients or breaking off conversation; excluding the patient by writing while they tell their story; and eliciting information from patients but not explaining why such information was required. Strong (1979) notes that such tactics cement the asymmetry between doctor and patient, and subsequent studies in social psychology have confirmed their use.

Conflict & Power

Indeed, studies of doctor-patient communication often begin with the observation that the relationship between doctors and their patients is unequal in terms of power, status, and knowledge. For instance, in Talcott Parsons's (1951) discussion of the sick role (a socially deviant state), the patient is entitled to be sick, provided she or he assumes certain obligations, such as making an effort to get well. Accordingly, doctors are obliged to help patients get well. How they interact and communicate with each other is central to how the sick role is negotiated since doctors occupy a position of authority in relation to the patient (Nettleton, 1992). While such asymmetry is unproblematic in a functionalist view of the social world, it ignores the potential for conflict between doctor and patient or the potential for value judgments to influence the process of making clinical decisions.

For instance, doctors may discount information that patients provide and be dismissive toward them. In studies of how patients use emergency rooms, researchers have found that doctors are often dismissive of patients because, in their view, based on the symptoms that patients describe, some patients should not be in the emergency room in the first place. That is, patients are judged as being overanxious (especially mothers of young children, see Roberts, 1992) or, in certain situations (such as patients who are injured but who have also been drinking alcohol), may be judged for behaving in ways that are seen as irresponsible. In such cases, patients may be judged as "normal rubbish" (Jeffery, 1979); that is, they are seen as presenting with symptoms that are considered inappropriate or trivial. While doctors usually do not explicitly inform patients of what they are thinking or what their value judgments are, they may communicate disapproval non-verbally by not listening to patients, not demonstrating empathy, or rushing through their medical care. More recent research confirms that in situations characterized by prejudice and fear, such as in the case of consultations about HIV risk, doctors may handle communication ineffectively in ways that make patients feel uncomfortable or even stigmatized (Epstein et al., 1998).

Barriers to Doctor-Patient Communication

Social characteristics such as gender and race influence the content and tone of doctor-patient communication, and many studies have demonstrated how the social backgrounds of both patients and doctors create barriers to effective communication. Many studies have found social class, gender, and racial differences as factors in physician communication style, that is, how physicians talk with patients and communicate non-verbally.

Social Class

First, social class differences are significant in determining how doctors communicate with their patients. Although there have been some changes in medical school recruitment, medicine is largely practiced by members of the middle, upper-middle, or upper class and, as such, reflects values associated with economic independence and autonomy (Mechanic, 1974). These values influence communication style, especially in terms of the language and the forms of expression used by doctors. For instance, members of the middle class tend to be more verbally explicit, while working-class members tend to rely more on nonverbal communication. This means in doctor-patient encounters between middle-class physicians and working-class patients, physicians may be more likely to talk than their patients (Cooper & Roter, 2003). In addition, patients whose health literacy levels are low (that is, they have difficulties reading and understanding written medical information), which is often associated with social class, are more likely to report poor communication with doctors in face-to-face encounters (Schillinger et al., 2004).

Gender

Second, there are differences between male and female physicians in the way they interact with their patients in general (Brody & Hall, 2000). Male physicians have been found to engage less in nonverbal gestures that communicate warmth and empathy, such as smiling, eye contact, nodding, hand gesturing, direct body orientation (facing the patient), and "back-channel responses" (such as saying "mm-hmm" to acknowledge what the patient is saying) (Cooper & Roter, 2003). Similarly, observation studies have found that male physicians talk more than female physicians, and when they do so, they are more likely to provide the patient with biomedical information than to engage in psychosocial conversation that explicitly invites comment from patients about their expectations, feelings, and life circumstances (Krupat et al., 2000). On the other hand, female patients are more likely to ask questions than male patients, which may explain why they are given more information than male patients (Waitzkin, 1985) or given information rather than emotional support. These differences in communication style may translate into differences in how physicians treat their female patients, which researchers have historically explained in terms of patriarchal or sexist ideologies (Nettleton, 1992). In the twenty-first century, gender is a fluid concept; however, providers making presumptions about a patient’s gender or about how male and female patients behave should be limited. Further, doctors need to be cognizant of the way in which gender exists on a spectrum and take into account how the patient wants to be addressed.

Time Factors

Third, doctors may lack the time and skills to communicate effectively with patients. Patient consultations are generally short, and doctors learn to describe and understand disease and illness in a specialized language, which patients may view as "jargon." Such jargon gets in the way of establishing common ground between doctors and patients (Stacey, 1988) and may contribute to patient dissatisfaction (Williams, Weinman & Dale, 1998). The use of medical jargon around patients can also lead to confusion regarding diagnosis and treatment plans, which can have serious consequences for the patient’s health (Gotlieb, et al., 2022).

Race

Finally, there are differences in race and ethnicity. For instance, doctors and patients are more likely to communicate effectively with each other if they share a similar racial or ethnic background or are "race concordant" (Cooper-Patrick et al., 2000). In particular, African American patients experience less participatory visits with their doctors (that is, they are less likely to be included in making decisions about their care) than other racial or ethnic groups. Indeed, one study found that when African American and Hispanic patients are able to choose their physician, they are more likely to choose a physician who is racially concordant (Saha et al., 1999) because they feel such physicians are more likely to be culturally sensitive to their needs and more likely to share their values, beliefs, and experiences. When patients and physicians do not share a similar racial and ethnic background, visits are likely to be shorter, patients are less likely to participate in decisions about their care, and tend to be less satisfied with their physician (Cooper-Patrick et al., 2000).

However, racial concordance between doctor and patient does not necessarily, on its own, contribute to the quality of communication between doctor and patient (Misra-Hebert, 2003), and it is not necessarily the case that if the patient and physician are of the same race, there are no barriers to communication. In part, racial or ethnic similarity is a marker for cultural similarity, whereby members of a group share beliefs, values, mannerisms, and behaviors that are learned and shared by the members of a group (Misra-Hebert, 2003) and extends beyond racial, ethnic, or gender boundaries. Accordingly, cultural competence has become increasingly important in doctor-patient communication.

In 1973, the Journal of the American Medical Association (JAMA) published a landmark article titled “Does Race Interfere With the Doctor-Patient Relationship? In 2021, JAMA revisited the topic of race in patient-physician relationships and determined the healthcare system still struggles with issues of inequity and bias when it comes to issues of race and ethnicity, and this continued to affect communication between doctors and patients (Satcher, 2021).

Further Insights

Patient-Centered Care

Communication matters because it has consequences for patient health and health outcomes. Broadly, studies have found that when communication is effective (i.e., when patients are able to ask questions, doctors talk less than patients and provide socioemotional support along with providing biomedical information), care is more patient-centered. When care is patient-centered, there is some evidence that patient outcomes are better, such as pain control, blood pressure, health status (Stewart, 1995), and patient satisfaction (Kaplan et al., 1995). Concomitantly, communication lies at the heart of patient-centered care. Patient-centered care emerged in the late twentieth century as an approach to medicine that is sensitive to patients' cultural and personal preferences and values, family relationships, and lifestyles (Institute of Medicine, 2001). In a report published in the New England Journal of Medicine, researchers concluded that patient-centered care is an essential value-based healthcare that benefits not just the patient but doctors and healthcare systems as well. Further, there are unique approaches to patient-centered care in a doctor’s office versus a hospital setting (NEJM Catalyst, 2017). Patient-centered care includes the patient and his or her family as part of the healthcare team and emphasizes participation and collaboration, and encourages patients to take responsibility for being involved in decisions about their care. Consequently, communication skills are increasingly taught as a set of technical skills, not only in medical schools but also as part of continuing medical education. Behaviors that are thought to be associated with effective communication include:

• Gathering data from the patient, for instance, through open-ended questions;
• Building rapport with patients by using empathy, reassuring patients, and responding when patients express emotions;
• Building partnerships with patients by asking for their input and opinion and inviting patients to solve problems jointly; and
• Counseling (Roter, 2000).

Teaching Communication Skills

While many medical schools teach communication skills to their students, there is considerable debate over which skills to teach and how to teach them. For instance, some training tools focus on improving communication in the context of poor health literacy and emphasize using plain, nonmedical language, slowing down speech, limiting information, and offering it in different formats, such as images as well as text (Weiss, 2009). Other tools emphasize how racial and ethnic issues affect communication and focus on cultural competency and the need to understand, respect, and empathize with the patient’s perspective or focus more generically on patient-centeredness and the need to incorporate the patient as a key player in the healthcare team.

Overall, there is a growing body of behavioral research to support training approaches and content, and at least some agreement on core skills, such as listening, using open-ended questions to elicit patient information, providing and explaining information, counseling and educating patients, and taking patient preferences into account. Moreover, teaching these skills has become more of a priority in relation to healthcare disparities. The Institute of Medicine ("Unequal Treatment," 2002) published a report that identified doctor-patient communication as a possible source of disparities for minority patients. A consequence of this report, and the research that supports it, is that in addition to teaching communication skills to medical students and practitioners, skills in cultural competence are also required.

Communication & Cultural Competence

Cultural competence emerged in medicine as a way to bridge the "cultural distance" between physicians and patients in the interest of reducing racial disparities in healthcare. Racial disparities are "racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preference, and appropriateness of intervention" ("Unequal Treatment," 2002). Cultural competence includes ways of addressing interpersonal and institutional sources of racial disparities in healthcare (Saha et al., 2008) and is becoming especially pertinent as the proportion of ethnic minorities in the United States continues to increase and is viewed as a national priority in healthcare. Cultural bias has been identified as a potential source of disparities or at least a barrier to communication between patients and physicians, and cultural competence may be a way to overcome this barrier.

Cultural competence has many definitions, but generally refers to the ability of physicians to provide patient-centered care by "adjusting their attitudes and behaviors to the needs and desires of different patients and account for the impact of emotional, cultural, social, and psychological issues on the main biomedical ailment" (Misra-Hebert, 2003, p. 293). In practice, cultural competence means different things, but includes, first, language sensitivity—for instance, using interpreters when language barriers exist—and learning about how different cultures treat nonverbal communication (Misra-Hebert, 2003). For instance, bodily and social gestures differ across cultural groups, as do concepts about appropriate personal space. While personal space for many Anglo-Saxon Americans is generally considered to be about eighteen inches, personal space in many cultures is often considered to be much closer.

Second, cultural competence in communication includes finding out more about the patient's experience of disease. In a classic study, medical anthropologist Arthur Kleinman and colleagues (1978) argued for a distinction between disease (a biological concept) and illness (an experiential state), in which the latter is influenced by cultural norms (whether, for instance, it is acceptable to express pain in front of other people) and personal health belief systems. This argument is increasingly taken seriously by medical educators who suggest that in culturally competent care, doctors need to be able to understand the patient experience and their own interpretation of what ails them (what Kleinman et al. refer to as the "cultural construction of clinical reality").

Finally, culturally competent communication is designed to help doctors negotiate with patients in terms they understand and to which they subscribe. In practice, this means respecting patient preferences (for instance, for complementary or alternative therapies such as herbal remedies or for including family members in decision-making). Studies have shown that cultural competency training is an important addition to a medical trainee's education as it improves knowledge, skills, and attitude. However, more research is needed to develop a more uniform standard for how medical educational programs implement the training (Jernigan, et al., 2016).

Viewpoints

Improving Patient Communication

While teaching communication skills to doctors is an important corrective to the power imbalance that may be an inherent part of the doctor-patient relationship, some researchers argue that patients also need to be taught communication skills, especially among populations for whom health literacy levels are low. In part, this drive to communication may be because poor communication between doctors and patients can lead to malpractice suits, where communication errors include inadequate understandings of diagnosis or treatment or where patients feel their concerns have been ignored (Weiss, 2009). Consequently, some studies have used waiting rooms as places to talk to and coach patients about communication and, in particular, which questions to ask and how to ask them during the clinical consultation (e.g., Cegala et al., 2000). One study found that following such an intervention, patients' overall perceptions of their health improved, and their blood sugar decreased (Greenfield et al., 1988), which suggests that empowering patients to participate in their care can lead to better communication and perhaps even better health outcomes.

The Doctor-Patient Relationship Post-Pandemic

The COVID-19 pandemic altered the doctor-patient relationship in many ways which, in turn, affected communication. First, patients reported feeling a higher level of satisfaction with their providers, which has been linked to the general appreciation healthcare workers received during the pandemic for the frontline services. The doctor-patient relationship experienced new levels of empathy on both sides. Additionally, during the pandemic, many patients relied on telehealth services provided not in person but over the phone or the Internet. This brought new and unique challenges to communication between doctors and patients who could no longer physically be in front of a doctor. Post-pandemic telehealth has stayed a viable option for healthcare, so research into how it affects communication between doctors and patients is ongoing (Aguirre, 2021).

Conclusion

Doctor-patient communication has long been of concern for medical practitioners, educators, and researchers. Ineffective communication has been found to affect patient experience and outcomes and is associated with social factors such as gender, class, and race. These differences have been explained in different ways. Scholars in the political economy of health have argued that poor communication is a result of the social distance between middle-class doctors and working-class patients. The recognition that race and ethnicity also affect communication has brought new urgency to the debate because of evidence that links ineffective communication to racial disparities in healthcare. Consequently, there is a shift toward training doctors in both cultural competency and patient-centeredness, which have both been found to improve communication in ways that might reduce disparities. However, communication is a two-way street, and some patient groups advocate that patients, too, need to be coached in how to best communicate with their doctors so that they feel comfortable asking questions and participating in decisions about their treatment options and care.

Terms & Concepts

Communication: The full range of verbal, facial, bodily, and symbolic expressions that people use when they interact and exchange information with each other.

Concordance: Shared identity between patient and physician based on demographic attributes such as age, gender, or race.

Cultural Competence: The ability of physicians to provide patient-centered care by taking the needs and desires of different patients into account as well as how emotional, cultural, social, and psychological issues affect the main biomedical ailment.

Functionalism: A sociological perspective based on the application of the scientific method to the social world that sees the world as a social system with needs that need to be met in order to maintain order and stability.

Healthcare Disparities: Racial or ethnic differences in the quality of healthcare not due to access-related factors or clinical needs, preference, and appropriateness of intervention.

Patient-centered Care: An approach to medicine that is sensitive to patients' cultural and personal preferences and values, family relationships, and lifestyles.

Role Format: Rituals that guide doctor-patient communication and that both patients and doctors call upon, depending on their assessment of the encounter.

Sick Role: A special role that sanctions the absence of people from production until they are considered (by physicians) well enough to return.

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