As predicted, patients oriented toward shared control in the doctor-patient relationship asked more questions, expressed more concerns, and were more assertive than were patients preferring doctor control. However, physicians' beliefs about control were not related to their use of partnership building. This may be due to the smaller number of physicians (n
= 20) compared to the number of patients (n
= 135), or because we balanced physicians' gender with their beliefs about control. As mentioned earlier, women health care providers tend to use more partnership statements than do men12,15
and they generally have a stronger orientation toward sharing control.13,14
By balancing physician gender with orientation toward control, our research design may have nullified the potential influences of both on physician behavior.
Second, consistent with other investigations,10,11,20,21
our finding of a reciprocal relationship between partnership building and patient participation supports the notion that communication in medical encounters is a process of mutual influence. Although some patients, such as those preferring shared control, are generally inclined to be actively involved in the consultation, other patients may need encouragement. In this study, approximately 14% of the active patient participation occurred only after being prompted by the physician's partnership efforts. Conversely, partnership building also serves to affirm and support patient involvement given that approximately one-third of the partnership statements were in response to the patient's expression of an opinion, concern, or question.
Finally, although congruence in physicians' and patients' orientations toward control have been linked to outcomes such as patient satisfaction and intent to comply,13,16
we failed to find a relationship between relational congruence and physician-patient communication. Apparently, associations between congruence and the communication process are more complex than the simple notion that “congruence is good and noncongruence is bad.” More research is needed to better understand what impact, if any, relational congruence has on communication in medical encounters.
Although our results provided some support for our hypotheses, this investigation had several limitations. First, our focus on partnership building alone may have been too narrow for assessing how a physician's communication is related to his or her orientation toward control. We would have had higher scores of partnering behavior had we also assessed other “patient-centered” responses such as paraphrasing, checking for understanding, vocal back-channels, statements of counseling and support, and nonverbal behaviors indicative of attentive listening.7,8,29
Future research on physicians' orientation to the doctor-patient relationship should examine a broader range of behaviors that might be considered patient-centered.
Another limitation is the generalizability of our findings. Approximately 25% of the patients refused to participate and, of those who did, almost 30% failed to fully complete the questionnaires. In addition, we limited our sample to the patients of doctors scoring at the extremes of the PPOS scale. Future research should determine whether a larger sample would replicate our findings as well as provide greater statistical power for testing the effects of a physician's orientation toward control on his or her communication with patients.
A third limitation of this and related studies concerns the assessment of communication as a process of mutual influence. Correlational analyses identify covariation, but only imply mutual influence. Our effort to code the sequential connections between partnership building and patient participation behaviors is arguably a step in the right direction. However, in addition to coding how often partnership building elicited patient involvement, we also should assess how often it failed to do so. Such a measure would provide insight into the types of patient-centered behaviors that more effectively elicit patient involvement in care.
Limitations notwithstanding, however, the results of this investigation have several important implications for clinical practice. First, within any group of physicians or patients, individuals will differ in their beliefs about control in the physician-patient relationship. Although the PPOS measure is relatively brief, it may not be feasible for physicians to use it in their clinical practices. Instead, physicians could tap into patients' expectations for their relationship with the doctor by using simple partnership-building tactics such as “Do you have any other issues that you would like to discuss?” or “Do you have any preferences or concerns about how we should treat this?” The patient's response to questions like these would provide information that the doctor could then use to formulate his or her own communication strategies for the consultation.
Second, our findings of mutual influence between partnership building and patient participation indicate that both patients and physicians can use their own communication to help the other be a more effective communicator. For example, if they are not receiving sufficient information, support, and personalized care, patients can engage in simple, but powerful communication tactics (asking questions, expressing concerns, offering opinions) that often will elicit more of these resources from physicians.5,10
A number of patient activation programs have been developed using a variety of educational methods including booklets,30
and presentations by nurses and staff.33
These interventions often are quite effective because patients may need little more than encouragement, a belief in the legitimacy of patient involvement, and a few communicative strategies (e.g., writing down questions and concerns, rehearsing) to increase their participation in the consultation.34
Our findings also show that physicians can use partnership statements to stimulate greater participation from passive or uninvolved patients.11,20,21
It is important to note, however, that partnership building and other patient-centered behaviors are communication skills that may require training to be used most successfully. For example, despite the fact that physicians in this study used more partnership statements with males, these patients still tended to participate less than female patients. To help physicians learn how to use patient-centered responses more effectively, training programs need to be intensive, provide opportunities for practice and feedback on performance, present role models, provide follow-up assessments and, importantly, have institutional support and incentives promoting the value of effective communication with patients.34–36
Finally, what remains unanswered in this and related research is the ethical tension of whether patient-centeredness represents a partnership with the patient or an accommodation to the patient's expectations, even when these expectations call for high doctor control and a more narrow focus on biomedical health issues. However, apart from the physician's and patient's relational orientations, a case can be made for the value of patient-centered communication and for greater patient participation in the consultation. Even if a patient wants the physician to make the medical decision, he or she may still have questions or concerns that should be expressed and brought to the doctor's attention. This could contribute to better treatment plans in light of research indicating that the physicians' facilitation of the patient's expression of concerns contributes to patients feeling understood and to physician-patient agreement on the nature of the patient's problem.29,37