Physicians with a more accurate understanding of their patients’ health beliefs should be better positioned to reconcile differences between their own and their patient’s illness perceptions and propose treatments more suited to the patient’s unique needs and personal circumstances.1,42
While some studies have examined differences between physicians’ and patients’ perspectives on health and health care,12,19,20,43,44
very few studies have examined how well physicians understand their patients’ health beliefs and what factors contribute to a better understanding. Using the CONNECT instrument,27
which assesses six domains of patients’ and physicians’ illness representations, this study investigated patient, physician, relationship, and communication factors that predicted how well physicians understood their patients’ health beliefs. Several findings are noteworthy and have important implications for clinical practice and future research.
First, physicians had a relatively poor understanding of their patients’ health beliefs. Specifically, physicians generally underestimated the degree to which patients perceived meaning in their conditions, believed they were at fault, saw value in natural remedies, had a sense of control over the condition, and preferred being a partner in their care. In addition, on four of the six domains (fault, meaning, value of natural remedies, and desire for a partnership), physicians thought the patients’ beliefs were not significantly different from their own beliefs, thus assuming a shared understanding when in fact this was not the case. These findings are consistent with other studies indicating that physicians perceive the quality of their interactions with patients differently than do patients,23,45–47
tend to underestimate patients’ desire for information18
and shared decision-making,48
and misjudge patients’ literacy levels.22,49
Our study makes an important contribution to this body of work by now demonstrating similar patterns of misunderstanding about not just the outcome of the medical encounter, but also about the nature of the health condition being addressed. Shared understanding between physician and patient is not only a critically important foundation for informed decision-making,50
it is arguably a pathway for optimizing patient trust, adherence, and disease outcomes.1,51
While much of the literature describing the importance of developing a shared understanding situates such activities in the context of either cross-cultural encounters52
or health problems of extraordinary significance (such as end of life decision making),20
our findings suggest that physicians may misperceive how their patients understand relatively common medical issues, such as blood pressure control. Our findings point to the need for physicians and patients to develop a shared understanding in these routine everyday encounters prior to decision making, as widely espoused in the chronic care model of illness management.53
A second important finding in this study is that physicians had a better understanding of patients’ health beliefs following those encounters in which patients more frequently asked questions, expressed concerns, and stated preferences and opinions. While other studies have linked patient involvement to a number of post-consultation outcomes,54–58
our findings demonstrate that active patient participation also helps physicians become more aware of their patients’ health beliefs. Such understanding forms the foundation for formulating therapeutic plans that patients are more likely to follow, since such plans take into account the patient’s perspective on how the illness works and what therapies are feasible, given their unique circumstances.38
Third, our study suggests that the patient’s ethnicity also may be related to how well physicians understand their patients. Compared to the beliefs of Caucasian patients, physicians had a poorer understanding of African-American patients’ preferences for a partnership and the meaning of the condition to Hispanic patients. Doctors also had a poorer understanding of patients’ sense of control over health when the patient was of a different race. Other studies have shown that, even when taking into account racial differences in patient participation (minority status patients are often less participatory26,37,59,60
), minority patients experience less trust61,62
, and are sometimes perceived by clinicians more negatively.26,35,63
Taken as a whole, these results suggest that understanding the patient’s perspective is more complex when physicians and patients come from different cultural and ethnic backgrounds, and they underscore the need for skills training in narrative medicine, history building, and other forms of cultural competence.64–66
To what extent physician understanding of patients’ health beliefs improves decision-making and the quality of care patients receive is an important area for future research as well as identifying the most efficient, effective means to provide information on patient’s health beliefs to clinicians. For example, would physicians get a better of understanding of their patients’ health beliefs if this information was gathered as a preconsultation assessment, was part of the medical history, or through longer visits that might allow patients more opportunities to be active participants?67
Evidence to date also demonstrates that more active patient participation in the consultation can be increased with patient activation interventions that can be efficiently deployed prior to a patient’s visit using various methods (e.g., coaching,56,68
interactive computer programs,71,72
Our results also have implications for professional development and medical education. Given the current primary care environment and its inherent time pressures, physicians do not have the luxury to pursue lengthy discussions of patients' views about multiple aspects of their medical histories. However, patients' histories often contain important pieces of contextual information that can lead to important insights about their perspectives,75
and patients often reveal this information in the form of subtle verbal and nonverbal cues,76
which physicians often miss.77,78
In ongoing work, we have been developing educational interventions to help physicians follow patients' cues and efficiently understand the significance and meaning of this information.79
The protocols used in this study to measure understanding may be useful when evaluating such educational interventions.
This study has several limitations. First we did not examine whether the accuracy of physician understanding was related to post-consultation outcomes. This is an important goal for future research. Second, we cannot draw strict conclusions regarding causation because we did not get pre-consultation assessments of physicians’ understanding of their patients’ models. Third, while relatively balanced with respect to gender concordance, the study sample was not balanced with respect to racial concordance in that all Hispanic patients and all Asian physicians were in non-concordant interactions. Fourth, physicians in this study represented different types of practices (e.g., VA vs. hospital clinics) and experience levels, yet a sample of only 29 physicians was too small to determine whether these and other unidentified physician factors were related to their understanding of patients’ health beliefs. Finally, although our analysis included several patient variables, others (e.g., health status) were not and may have contributed to unmeasured effects on physician understanding.
In conclusion, an important feature of patient-centered care is physician understanding of their patients’ health beliefs and values. In one of the first investigations of its kind, this study quantified such understanding, revealed gaps in physician awareness of their patients’ health beliefs and found that physicians understood patients better when patients were more participatory. Less understanding was to some degree also associated with patients’ ethnicity. Future research should further explicate factors that contribute to better physician understanding of their patients and test interventions that target these processes.