The way in which clinicians and patients communicate with one another has predicted a number of biomedical, functional, and psychological health outcomes subsequent to that consultation. (1
) These findings suggest that effective communication accomplishes more than just greater patient satisfaction, understanding, and commitment to treatment; it actually helps people get and stay healthier. However, a closer examination of this research reveals a much more complicated picture. Communication is often not related to outcomes, or the findings are inconsistent.(2
) Moreover, rarely has this research tried to identify the mechanisms or ‘pathways’ through which clinician-patient communication can lead to longer, healthier, and happier lives. (2
Understanding the pathways through which clinician communication could lead to better health outcomes is important within the context of acupuncture treatment where the patient’s participation in treatment and interactions with the clinician can contribute to effects associated with the overall therapeutic experience.(10
) Whereas communication could contribute to improved health in a number of ways (e.g., increased adherence, self-care skills), one way an acupuncturist’s communication could have health benefits is by elevating a patient’s belief in the value of treatment. This pathway likely will be particularly influential on patient-reported outcomes such as pain, function, and well-being. Positive expectations for treatment success are purportedly one of the processes underlying placebo effects (12
) as well as other non specific, psychological effects associated with having received treatment and not directly tied to the treatment mechanism itself. (14
We contend that expectancy effects are not illusory but real with therapeutic significance. A clinician’s communication with a patient can contribute to improved pain and functioning by raising expectations for treatment success and raising positive feelings toward the clinician and treatment.(12
) While expectancy and affect can be distinguished from one another theoretically,(12
) in reality they often go hand in hand, in that communicating an anticipated positive or negative outcome will influence both beliefs and feelings. While the relationship between psychological (e.g., how patients interpret their symptoms) and physiological (e.g., changes in neurobiological processes in the brain) processes is beyond the scope of this paper, a sizeable body of research indicates that patient expectations for treatment success are often associated with health improvements, particularly for subjective health outcomes such as pain and function.(16
In this study, we examine the pathway linking clinician communication→patient perception of the value of treatment→post consultation pain and physical function outcomes within the context of acupuncture treatment for patients suffering from osteoarthritis (OA) of the knee. This investigation extends previous research in three ways.
First, this study goes beyond correlational evidence and models a specific pathway through which communication can contribute to better health. Second, previous research on the therapeutic benefits of clinician-patient communication, particularly in the context of acupuncture treatment, has hypothesized direct effects of communication on outcomes and ignored the possibility of indirect influences. For example, Kaptchuk et al.(19
) reported that patients with irritable bowel syndrome had lower symptom severity and higher quality of life three weeks into treatment when their clinicians displayed an ‘augmented’ communication style (i.e., expressing empathy, care, friendliness, active listening, and positive expectations for success) than when using a ‘limited’ style (i.e., intentionally communicating little with the patient). In contrast, our earlier analysis of clinician communication of expectations (see Suarez-Almazor et al.(20
)) found that only one of several pain and function outcomes was directly related to clinicians’ communication. Specifically, OA patients in the ‘high expectations’ condition (whose acupuncturists expressed hope and optimism that treatment would reduce pain and improve function) reported better joint-specific pain control compared to patients whose clinicians were assigned to the ‘neutral expectations’ condition (whose acupuncturists expressed uncertainty and a ‘wait and see’ approach about whether treatment would work). Neither the Suarez-Almazor et al. or the Kaptchuk et al. studies explored the possibility of indirect effects of communication that contribute to improved outcomes through a psychological mechanism such as positive affect and higher efficacy expectations.(9
Finally, in contrast to the above studies, we examine communication effects in relation to a clinician’s individual communication style rather than to the clinician’s assignment to an experimental condition. In other words, clinicians assigned to an experimental condition will have some individual variation in communication.(21
) For example, two clinicians assigned to the same experimental condition, such as convey optimism, may both communication some degree of optimism, yet one might be perceived as somewhat more optimistic than the other. This investigation tests the effects directly and indirectly associated with an acupuncturist’s actual communication of expectations during the important initial visit where treatment expectations are first discussed.