Media and Medicine
Talking W i t h the Doctor, 2 by Mary B. Daly and Barbara S. Hulka
Communication and satisfaction a#ect patients’ compliance with medical advice and instructions. Increasing specialization of physicians and the disappearance of the traditional family doctor has in many cases fragmented the pattern of medical care experienced by patients who must seek various services from a battery of professionals on a short-term basis, rather than developing a more comprehensive, long-term relationship with one provider of care. The recent introduction of paraprofessionals like the physician’s assistant and the family nurse practitioner has also altered the content of services offered by the physician and may serve to limit the personal contact between physician and patient. It is not susprising, then, that expressions of dissatisfaction with medical care have grown in volume and reflect a basic sense of confusion and frustration with the health care system on the part of the general population. This report is concerned with the nature of the doctor-patient relationship, with particular emphasis on the communication process as it interacts with patient satisfaction and compliance. Vuori et al. (12) have conceptualized the doctor-patient relationship in terms of three basic functions: (a) application of the physician’s knowledge and skills to the condition; (b) expressive interaction dealing with the emotional aspects of the condition and its treatment; and (c) the communication of information. While the importance of the first function is generally accepted, there is evidence that the role of the expressive and communicative aspects of the relationship may be underestimated by the medical profession. In a study of 800 outpatient visits to Children’s Hospital of Los Angeles, Korsch and her associates (7, 8, 4 ) explored the effect of verbal interaction Mary B. Daly and Barbara S. Hnlka, M . D . ,are Instrnctor and Associate Professor, respectively, in the Department of Epidemiology, University of North Carolina at Chapel Hill.
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Media and MedicinelTulking With the Doctor
between doctor and patient (in this case the mothers of children being seen) on patient satisfaction and compliance with medical advice. A number of communication barriers were found to interfere with the interaction between doctor and patient, and to contribute to patient dissatisfaction, including: (a) lack of warmth and friendliness on the part of the physician; ( b ) failure of the physician to understand the patient’s main concerns and worries; (c) lack of fulfillment of patient expectation in learning the nature of their child’s illness; and ( d ) the use of confusing medical terminology. The most serious and common complaint offered as a source of dissatisfaction was that the physician showed too little interest in the mother’s concern about her child. Reader (10) questioned 50 patients at a New York medical clinic to discover what they expected from their doctors. Interpersonal relations were mentioned as frequently as technical competence (58 and 60 percent respectively) as requisite qualities in a good physician. In addition to increased satisfaction, successful communication between patient and physician has been shown to effect compliance with medical instructions. In the Los Angeles study referred to above, it was established that failure of the physician to achieve a successful pattern of communication was significantly related to non-compliance as measured by adherence to drug regimens, diet, return appointments, and other advice concerning daily activity and roil tines. Fifty-three percent of the highly satisfied mothers cooperated completely with the doctors’ advice, whereas only 17 percent of the highly dissatisfied mothers did so (8). More specifically, when a mother‘s expectations about the diagnosis of her child’s illness were tinfulfilled, the rate of noncompliance increased from 11 percent to 24 percent. Davis (2) analyzed 154 new patient visits to a general medical clinic and found patients’ failure to comply with doctors’ advice to be associated with a pattern of interaction characterized by formality, antagonism, and mutual withholding of information and expression. One consistent finding of the studies mentioned above, which is central to the dynamics of the commrinication process, is the failure of patients to verbally express their real fears and needs to their physicians. Twenty-six percent of the mothers in Korsch’s study told interviewers that they had never mentioned their greatest concern about their child’s illness to their doctor (8). Furthermore, 65 percent of their expectations were not expressed during the medical visit (7).
While patients express dissatisfaction with the communicative aspects of the doctor-patient relationship, they are unable or unwilling to verbally express their latent needs and concerns. This failure to establish rapport is often attributed to some manifestation of social distance between doctors and patients which is created by educational and social class distinctions, and enhanced by the use of medical jargon un-
148
Journal of Communication, Summer 1975
familiar to the patient. In discussing the impact of social distance on communication between doctors and patients, Plaza (9) mentions a lack of mutual trust, problems of vocabrilary deficiencies, and a clash of perspectives as social class factors which contribute to communication failures. Duff and Hollingshead ( 3 ) found that the relative social status of doctors and hospitalized patients became a crucial element in the nature of the doctor-patient interaction during the hospital stay. As the social gulf between doctors and patients widened, patients were treated less as unique individuals seen within the context of family situations, and more as disease states to be treated with modern medical techniques. However, it is likely that snccessful communication between doctors and patients is not simply a reflection of social class differences but the result of various patient, physician, and situational characteristics. Figure 1 has been proposed in order to conceptualize some basic facets of the doctor-patient interaction, and to indicate their relationship to one another. In this model, communication s~iccess,patient satisfaction, and compliance are all seen as separate dimensions or outcomes of the process of the doctor-patient interaction. At the same time, they are conceived within a mutually dependent process in which each of the dimensions can affect the others. The process is outlined as a dynamic one, in which each element of the system feeds back to the others, and in which personal, social, and environmental characteristics can contribute at each level to the interaction process.
It has been possible to apply this conceptualization to data collected in a series of primary health care settings. For several years, the American Academy of Family Practice and the Department of Epidemiology at the University of North Carolina have been engaged in a joint endeavor to measure the organization, utilization, and assessment of primary medical care in Fort Wayne, Indiana (5). The study design has incorporated a dual approach which attempts to assess both the determinants of utilization of the primary health care system and the effectiveness of various forms of medical practice. The conceptual framework for the latter phase has been the “indicator case” model, whereby patients experiencing and receiving treatment for one of four medical conditions have been identified through their physicians and enrolled on a random basis into the study. Among the data collected were a number of measures of the doctor-patient relationship, including patient satisfaction, compliance, and the communication of relevant information from doctor to patient, as well as selected patient, physician, and environmental characteristics. Patient satisfaction was measured on a three-dimension scale, including professional competence, personal qualities, and cost/convenience. The communication measure reflected the proportion of items of information transmitted by the physician which had actually been retained by the patient. The two measures of compliance used were kept appointments and appropriate use of prescription drugs. Among 363 women receiving prenatal care from primary care physicians, a
150
Media and MedicinelTalking With the Doctor
Figure 1: Conceptual model of doctor-patient interaction
positive relationship between each component of the satisfaction scale and level of communication was demonstrated for those attending solo practitioners. This finding was not borne out among women who attended group practices. It is proposed that among the patients of solo practitioners, the association between increased patient satisfaction and successful communication may reflect the qualitative intensity of the doctor-patient interaction which is possible within the context of a steady one-to-one relationship (1). A similar analysis of 518 mothers who brought their babies to private physicians for regular medical care showed an overall increase in communication level among women attending solo practitioners. In addition, levels of successful communication rose with increasing patient satisfaction, particularly in the area of satisfaction with professional competence (1). On the other hand, no major beneficial effect from good communication in terms of increased patient satisfaction or compliance could be demonstrated among 242 patients with diabetes (6). However, the significance of communication was illustrated in relation to individual items from the overall set of com-
151
Journal of Communication, Summer 1975
munication items. In the areas of urine testing, carrying diabetic identification, and taking the prescribed antidiabetic medication, excellent behavioral compliance on the part of patients was demonstrated when prior commrinication from physician to patient had been good.. The major problem appeared to’be the relatively low levels of communication which had been achieved in each of these instructional areas. These few examples underscore the importance of communication in the complex interplay of factors which contribute to the quality of the doctorpatient interaction. Samora (11) has stated:
Perhaps if the goal of medicine is the diagnosis and treatment of disease, the quality of communication between practitioner and patient makes little dtference, so long as an adequate medical history can be obtained and the necessary cooperation of the patient in doing or refraining from doing certain things can be assured. But if the goal is more broadly interpreted, if the concern is with the person who is sick and the purpose is to relieve, reassure, and restore him-as would seem to be increasingly the case-the quality of communication assumes instrumental importance and anything that interferes with it needs to be noted, and if possible, removed.
REFERENCES 1 . Daly, M. B., B. S Hulka, and L. L. Knpper. “Assessment of the Doctor-Patient Relationship: 11. Communication as a Function of Patient Satisfaction.” Unpublished paper, 1975. 2. David, M. S . “Variations in Patients’ Compliance with Doctors’ Advice: An Empirical Analysis of Patterns of Communication.” A.P.H.A. 58 (2), 1968, pp. 274-288. 3. Duff, R. S . , and A. B. Hollingshead. Sickness and Society. New York: Harper & Row, 1968. 4. Francis, U., B. Korsch, and M. J . Morris. “Gaps in Doctor-Patient Communication: Patients’ Responses to Medical Advice.” New Englnnd Journal of Medicine 280 (lo), 1969, pp.
535-540. 5. Hrilka, B. S . , and J. C. Cassel. “The AAFP-UNC Study of the Organization, Utilization, and Assessment of Primary Medical Care.” A.P.H.A. 63 (Z), 1969, pp. 494-501. 6. Hrilka, B. S . , L L. Kripper, J. C. Cassel, and F. Mayo. “Doctor-Patient Communication and Outcomes Among Diabetic Patients.” Journal of Community Health, in press. 7. Korsch, B., E. Gozzi, and U. Francis. “Gaps in Doctor-Patient Communication: I. Doctor-Patient Interaction and Patient Satisfaction.” Pediatrics 42 ( 5 ) , 1968, pp. 855-871. 8 Korsch, B , and V. Francis Negrete. “Doctor-Patient Communication.’’ Scientific American 227, 1972, pp. 66-75. 9. Plaza, A. O., L. M. Cohen, and J . Samora. “Communication Between Physicians and Their Patients in Outpatient Clinics.” 10. Reader, G., L. Pratt, and M. Mudd. “What Patients Expect from their Doctors.” The Modern Hospital 89, 1957, pp, 88-94. 1 1 . Samora, J., L Sannders, and R. F. Larson. “Medical Vocabulary Knowledge Among Hospital Patients.” Journal of Health and Human Behavior 2, Summer 1961, p. 92. 12. Viiori, H., T . Aakri, E. Aine, R. Erkko, and R. Johansson. “Doctor-Patient Relationship in the Light of Patients’ Experiences.” Social Sdence and Medicine 6, 1972, pp. 723-730.
152
Talking W i t h the Doctor, 2 by Mary B. Daly and Barbara S. Hulka
Communication and satisfaction a#ect patients’ compliance with medical advice and instructions. Increasing specialization of physicians and the disappearance of the traditional family doctor has in many cases fragmented the pattern of medical care experienced by patients who must seek various services from a battery of professionals on a short-term basis, rather than developing a more comprehensive, long-term relationship with one provider of care. The recent introduction of paraprofessionals like the physician’s assistant and the family nurse practitioner has also altered the content of services offered by the physician and may serve to limit the personal contact between physician and patient. It is not susprising, then, that expressions of dissatisfaction with medical care have grown in volume and reflect a basic sense of confusion and frustration with the health care system on the part of the general population. This report is concerned with the nature of the doctor-patient relationship, with particular emphasis on the communication process as it interacts with patient satisfaction and compliance. Vuori et al. (12) have conceptualized the doctor-patient relationship in terms of three basic functions: (a) application of the physician’s knowledge and skills to the condition; (b) expressive interaction dealing with the emotional aspects of the condition and its treatment; and (c) the communication of information. While the importance of the first function is generally accepted, there is evidence that the role of the expressive and communicative aspects of the relationship may be underestimated by the medical profession. In a study of 800 outpatient visits to Children’s Hospital of Los Angeles, Korsch and her associates (7, 8, 4 ) explored the effect of verbal interaction Mary B. Daly and Barbara S. Hnlka, M . D . ,are Instrnctor and Associate Professor, respectively, in the Department of Epidemiology, University of North Carolina at Chapel Hill.
148
Media and MedicinelTulking With the Doctor
between doctor and patient (in this case the mothers of children being seen) on patient satisfaction and compliance with medical advice. A number of communication barriers were found to interfere with the interaction between doctor and patient, and to contribute to patient dissatisfaction, including: (a) lack of warmth and friendliness on the part of the physician; ( b ) failure of the physician to understand the patient’s main concerns and worries; (c) lack of fulfillment of patient expectation in learning the nature of their child’s illness; and ( d ) the use of confusing medical terminology. The most serious and common complaint offered as a source of dissatisfaction was that the physician showed too little interest in the mother’s concern about her child. Reader (10) questioned 50 patients at a New York medical clinic to discover what they expected from their doctors. Interpersonal relations were mentioned as frequently as technical competence (58 and 60 percent respectively) as requisite qualities in a good physician. In addition to increased satisfaction, successful communication between patient and physician has been shown to effect compliance with medical instructions. In the Los Angeles study referred to above, it was established that failure of the physician to achieve a successful pattern of communication was significantly related to non-compliance as measured by adherence to drug regimens, diet, return appointments, and other advice concerning daily activity and roil tines. Fifty-three percent of the highly satisfied mothers cooperated completely with the doctors’ advice, whereas only 17 percent of the highly dissatisfied mothers did so (8). More specifically, when a mother‘s expectations about the diagnosis of her child’s illness were tinfulfilled, the rate of noncompliance increased from 11 percent to 24 percent. Davis (2) analyzed 154 new patient visits to a general medical clinic and found patients’ failure to comply with doctors’ advice to be associated with a pattern of interaction characterized by formality, antagonism, and mutual withholding of information and expression. One consistent finding of the studies mentioned above, which is central to the dynamics of the commrinication process, is the failure of patients to verbally express their real fears and needs to their physicians. Twenty-six percent of the mothers in Korsch’s study told interviewers that they had never mentioned their greatest concern about their child’s illness to their doctor (8). Furthermore, 65 percent of their expectations were not expressed during the medical visit (7).
While patients express dissatisfaction with the communicative aspects of the doctor-patient relationship, they are unable or unwilling to verbally express their latent needs and concerns. This failure to establish rapport is often attributed to some manifestation of social distance between doctors and patients which is created by educational and social class distinctions, and enhanced by the use of medical jargon un-
148
Journal of Communication, Summer 1975
familiar to the patient. In discussing the impact of social distance on communication between doctors and patients, Plaza (9) mentions a lack of mutual trust, problems of vocabrilary deficiencies, and a clash of perspectives as social class factors which contribute to communication failures. Duff and Hollingshead ( 3 ) found that the relative social status of doctors and hospitalized patients became a crucial element in the nature of the doctor-patient interaction during the hospital stay. As the social gulf between doctors and patients widened, patients were treated less as unique individuals seen within the context of family situations, and more as disease states to be treated with modern medical techniques. However, it is likely that snccessful communication between doctors and patients is not simply a reflection of social class differences but the result of various patient, physician, and situational characteristics. Figure 1 has been proposed in order to conceptualize some basic facets of the doctor-patient interaction, and to indicate their relationship to one another. In this model, communication s~iccess,patient satisfaction, and compliance are all seen as separate dimensions or outcomes of the process of the doctor-patient interaction. At the same time, they are conceived within a mutually dependent process in which each of the dimensions can affect the others. The process is outlined as a dynamic one, in which each element of the system feeds back to the others, and in which personal, social, and environmental characteristics can contribute at each level to the interaction process.
It has been possible to apply this conceptualization to data collected in a series of primary health care settings. For several years, the American Academy of Family Practice and the Department of Epidemiology at the University of North Carolina have been engaged in a joint endeavor to measure the organization, utilization, and assessment of primary medical care in Fort Wayne, Indiana (5). The study design has incorporated a dual approach which attempts to assess both the determinants of utilization of the primary health care system and the effectiveness of various forms of medical practice. The conceptual framework for the latter phase has been the “indicator case” model, whereby patients experiencing and receiving treatment for one of four medical conditions have been identified through their physicians and enrolled on a random basis into the study. Among the data collected were a number of measures of the doctor-patient relationship, including patient satisfaction, compliance, and the communication of relevant information from doctor to patient, as well as selected patient, physician, and environmental characteristics. Patient satisfaction was measured on a three-dimension scale, including professional competence, personal qualities, and cost/convenience. The communication measure reflected the proportion of items of information transmitted by the physician which had actually been retained by the patient. The two measures of compliance used were kept appointments and appropriate use of prescription drugs. Among 363 women receiving prenatal care from primary care physicians, a
150
Media and MedicinelTalking With the Doctor
Figure 1: Conceptual model of doctor-patient interaction
positive relationship between each component of the satisfaction scale and level of communication was demonstrated for those attending solo practitioners. This finding was not borne out among women who attended group practices. It is proposed that among the patients of solo practitioners, the association between increased patient satisfaction and successful communication may reflect the qualitative intensity of the doctor-patient interaction which is possible within the context of a steady one-to-one relationship (1). A similar analysis of 518 mothers who brought their babies to private physicians for regular medical care showed an overall increase in communication level among women attending solo practitioners. In addition, levels of successful communication rose with increasing patient satisfaction, particularly in the area of satisfaction with professional competence (1). On the other hand, no major beneficial effect from good communication in terms of increased patient satisfaction or compliance could be demonstrated among 242 patients with diabetes (6). However, the significance of communication was illustrated in relation to individual items from the overall set of com-
151
Journal of Communication, Summer 1975
munication items. In the areas of urine testing, carrying diabetic identification, and taking the prescribed antidiabetic medication, excellent behavioral compliance on the part of patients was demonstrated when prior commrinication from physician to patient had been good.. The major problem appeared to’be the relatively low levels of communication which had been achieved in each of these instructional areas. These few examples underscore the importance of communication in the complex interplay of factors which contribute to the quality of the doctorpatient interaction. Samora (11) has stated:
Perhaps if the goal of medicine is the diagnosis and treatment of disease, the quality of communication between practitioner and patient makes little dtference, so long as an adequate medical history can be obtained and the necessary cooperation of the patient in doing or refraining from doing certain things can be assured. But if the goal is more broadly interpreted, if the concern is with the person who is sick and the purpose is to relieve, reassure, and restore him-as would seem to be increasingly the case-the quality of communication assumes instrumental importance and anything that interferes with it needs to be noted, and if possible, removed.
REFERENCES 1 . Daly, M. B., B. S Hulka, and L. L. Knpper. “Assessment of the Doctor-Patient Relationship: 11. Communication as a Function of Patient Satisfaction.” Unpublished paper, 1975. 2. David, M. S . “Variations in Patients’ Compliance with Doctors’ Advice: An Empirical Analysis of Patterns of Communication.” A.P.H.A. 58 (2), 1968, pp. 274-288. 3. Duff, R. S . , and A. B. Hollingshead. Sickness and Society. New York: Harper & Row, 1968. 4. Francis, U., B. Korsch, and M. J . Morris. “Gaps in Doctor-Patient Communication: Patients’ Responses to Medical Advice.” New Englnnd Journal of Medicine 280 (lo), 1969, pp.
535-540. 5. Hrilka, B. S . , and J. C. Cassel. “The AAFP-UNC Study of the Organization, Utilization, and Assessment of Primary Medical Care.” A.P.H.A. 63 (Z), 1969, pp. 494-501. 6. Hrilka, B. S . , L L. Kripper, J. C. Cassel, and F. Mayo. “Doctor-Patient Communication and Outcomes Among Diabetic Patients.” Journal of Community Health, in press. 7. Korsch, B., E. Gozzi, and U. Francis. “Gaps in Doctor-Patient Communication: I. Doctor-Patient Interaction and Patient Satisfaction.” Pediatrics 42 ( 5 ) , 1968, pp. 855-871. 8 Korsch, B , and V. Francis Negrete. “Doctor-Patient Communication.’’ Scientific American 227, 1972, pp. 66-75. 9. Plaza, A. O., L. M. Cohen, and J . Samora. “Communication Between Physicians and Their Patients in Outpatient Clinics.” 10. Reader, G., L. Pratt, and M. Mudd. “What Patients Expect from their Doctors.” The Modern Hospital 89, 1957, pp, 88-94. 1 1 . Samora, J., L Sannders, and R. F. Larson. “Medical Vocabulary Knowledge Among Hospital Patients.” Journal of Health and Human Behavior 2, Summer 1961, p. 92. 12. Viiori, H., T . Aakri, E. Aine, R. Erkko, and R. Johansson. “Doctor-Patient Relationship in the Light of Patients’ Experiences.” Social Sdence and Medicine 6, 1972, pp. 723-730.
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