The use of the first person plural often does not lead to more effective patient-provider communication. To our surprise, in encounters where the first person plural statements were used, patients were less likely to rate their provider’s communication skills highly. The use of these types of statements did not positively or negatively affect patient ratings of provider’s PDM style or their overall satisfaction. Although we hypothesized that this type of dialogue would foster the sense of an alliance between the provider and the patient, our analyses suggest otherwise.
These surprising findings might be explained by our qualitative analysis, which delineated features of first person plural dialogue that may hinder the sense of true partnership between patient and provider. We found that first person plural statements were sometimes used by providers in a manner that appeared to be persuasive, indirect, patronizing or condescending. Although we found that first person plural dialogue has both positive and negative features, it was the negative features that were most surprising to us, and which we believe help explain the negative association with patients’ experience of care.
As depicted in Figure , persuasive statements seemed to hinder communication by moving the focus of care from the patient’s wishes and values to those of the provider. We also considered instances of persuasion and indirect communication, in which providers made implicit requests of the patient, to be disempowering for the patient. Within the contexts of medication adherence, weight loss, smoking, and substance abuse, first person plural dialogue did not encourage an appropriate amount of responsibility and self-efficacy from the patient. The use of the word “we” falsely involved the provider in activities that are practically the responsibility of the patient. Under these circumstances, it appears that more direct language is desirable, language that honestly acknowledges the patient’s authority to take control of the situation.
In other instances we identified first person plural statements that appeared to foster a true sense of alliance. Statements that occurred in the context of purposefully addressing the patient’s goals, sharing medical decision-making, and legitimizing the patient-provider relationship seemed to contribute to a sense of equality between the two parties. Many of these conversations represented instances during which providers shared power with patients, giving them autonomy and control. These sorts of efforts on the part of physicians are inherently patient-centered and truly involve patients in their own care. When analyzed in the context of an overall partnership score that weighs both positive and negative statements, it appears that positive uses of the first person plural increase the patient’s odds of highly rating provider communication skills. These types of statements exemplify how a provider can better communicate with patients in order to forge a therapeutic alliances.
In our quantitative analysis, we also found that first person plural statements were used most frequently by older providers, and with patients who were younger, were more depressed, and had less social support. Extrapolating from these findings, we emphasize that first person plural statements often occur in the context of greater power inequalities between patients and providers. Surprisingly, we also noted that providers who used first person plural statements reported lower empathic tendencies. These quantitative findings are more understandable in light of our qualitative analysis. Often in these visits, the patients seemed disengaged, while the provider was attempting to engage them in some goal, without seeming to understand that the patient wanted something else. Given how important, yet dysfunctional, this dialogue seems, we suggest that providers be offered training in communication with patients regarding difficult behavior changes. In addition to training in more effective behavior change counseling strategies, medical educators may wish to consider explicitely noting the negative and positive uses of the first person plural with their students.
Several limitations should be considered when interpreting these findings. First, we sometimes found it difficult to determine the intentions or impact of particular first person plural statements. We attempted to address this issue by listening to the entire encounter, and transcribing dialogue preceding and following each statement in an effort to establish its context. However, we recognize that these statements are made in the context of an ongoing relationship with a history that is largely unknown to us. Also, the generalizability of our findings may be reduced by our HIV-specific sample of providers and patients. We wonder if this particular group of subjects may have unique tendencies based on patient demographics, physician training, and frequency of clinic visits. Although we consider this to be a possibility, we feel that most our findings are applicable outside of the realm of HIV care.
We consider our study to have important implications for the complex task of achieving partnership in patient care. Although physicians may attempt to foster an alliances with patients through the use of first person plural statements, it appears that this strategy is not always successful. Despite the sense of alliance that Reynolds Price describes in response to his physician’s use of the first person plural,1
his experience may not be universal. Provider’s use of the word “we” does not automatically create a sense of partnership between patient and provider. It is ultimately the intentions of the provider and his or her willingness to share power with a patient that forms the foundation for a true healthcare alliance. In order to empower patients, especially among vulnerable populations, providers must actively and explicitly cultivate a positive sense of alliance and shared power. By prioritizing the sharing of power and minimizing persuasive, dominating dialogue, providers can create a more patient-centered environment.