The findings of this investigation indicated that not only were physicians’ communication behaviors linked to their perceptions of patients, both were influenced by a variety of factors, the most powerful being the patient’s communication, the patient’s ethnicity, and the physicians’ orientation to the doctor-patient relationship. These findings have important implications for future research and clinical practice.
First, physicians were more patient-centered, less contentious, and showed more positive affect to patients they judged to be better communicators, more satisfied with care, and more likely to adhere to treatment. This finding is consistent with a growing body of evidence indicating that how a physician perceives a patient (likeable, intelligent, adherent) is related to how that doctor treats the patient (Amir, 1987
; Beach, Roter, Wang, Duggan & Cooper, 2006a
; Gerbert, 1984
; Hall et al., 1993
; Hall et al., 2002
; Van Ryn et al., 2006
). However, to assume a causal pathway from perception to communication would be premature. As shown in and , other factors, such as the patient’s communication and the physician’s personal attributes, appeared to influence both physician perceptions and communication.
Second, patients’ expressions of positive affect consistently predicted more positive physician communication (patient-centeredness, positive affect) and judgments (patient as a good communicator, satisfied with care). Physicians also were more patient-centered with more involved patients. Conversely, physicians were more contentious with contentious patients whom they also viewed as less effective communicators and less satisfied. These results likely reflect the dynamics of communicative reciprocity and mutual influence in medical encounters. One person’s expression of positive affect typically elicits similar behavior from another thereby creating a mutually friendly, supportive interaction. Similarly, patients who ask questions, express concerns, and state preferences provide opportunities for physicians to provide information, offer support, and accommodate requests which, in turn, legitimize continued patient involvement. Yet, the reciprocity also may be negative in that contentiousness on the part of one interactant could breed contentiousness and negative perceptions from the other interactant, at least in some medical encounters.
Third, considerable variability in physicians’ communication was related to differences among individual doctors, particularly with respect to the physician’s orientation to the physician-patient relationship. Doctors who self-reported a patient-centered orientation were rated by coders as using a more informative, supportive, and facilitative communication style than did doctors holding a more doctor-centered orientation. Perhaps physicians who value the patient’s perspective and participation have an understanding of the patient that facilitates both the task (explaining medical issues, describing treatment options) and relationship (showing respect, encouraging patient participation) functions of communication. Because previous studies have demonstrated that students adopt progressively less patient-centered orientations in later years of medical school (Haidet et al., 2002
; Haidet & Stein, 2006
), our findings suggest that communication skill training must be an ongoing and sustained part of medical and continuing education.
Fourth, considered collectively, patient demographics and concordance had little effect on physician communication and perceptions with one disturbing exception—physicians were more contentious with black patients whom they also perceived as less effective communicators and less satisfied with care. Follow-up analyses indicated that the communication of black physicians with black patients was not significantly different from that of white and Asian doctors, although black and white physicians did perceive patients as better communicators than did Asian physicians. Several explanations could account for these findings. First, there could a subtle bias toward the communication of black patients. This would be consistent with other research indicating that, compared to white patients, black patients (a) are more likely to believe that a good self-presentation during the office visit is important to getting good medical care (Malat, Van Ryn & Purcell, 2006
), (b) need to be more assertive to receive more thorough diagnostic testing (Krupat et al., 1999
), and (c) are more likely to have negative attributes assigned to them by physicians (Van Ryn & Burke, 2000
). Second, for cultural or other reasons, physicians may have more difficulty interacting with some black patients, thus leading to more contentious behavior and less positive impressions. In turn, some black patients may struggle in their communication with physicians given past experiences within the health care system (Matthews, Sellergren, Manfredi & Williams, 2002
). Regardless of the reason, race and ethnicity continue to be associated with communicative difficulties in medical encounters in ways that affect quality of care and could contribute to health disparities (Ashton, Haidet, Paterniti, Collins, Gordon, O’Malley et al. 2003
The study had several limitations. First, our sample size of just over 200 interactions from clinics within a large southern US city was perhaps too small and localized to generalize to other settings. Second, while our findings likely reflect mutual influence between physician and patient communication behavior, we did not examine how these cycles of positive and negative communication get started. For example, were patients more active participants because of the physicians’ patient-centered communication, or were physicians more informative and supportive because patients were asking questions, expressing concerns, and stating preferences? Third, we acknowledge that physician-patient communication and outcomes can be affected by other variables not examined in this study including the patient’s health status, physician specialty, reason for the visit, and type of health care facility.
Fourth, findings related to the patient’s ethnicity are important, but tell us nothing of why they occurred. More attention to cognitive and affective processes (attitudes, stereotypes) that account for these race-related communicative disparities is needed. As moderators of communication process and outcome relationships, demographic characteristics are difficult to change, but affective-cognitive processes underlying these effects may be amenable to interventions for improved communication. Finally, while we found little evidence of concordance effects, more research needs examine concordance in relation to measures of the quality of the relationship (e.g., trust, perceived similarity, rapport), the latter being the likely mediator of concordance effects on patient outcomes.