Patient-Provider Communication Research Paper

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Relationships between patients and providers are an inevitable part of everyday life. Throughout the life cycle, humans have fundamental needs requiring care by diverse medical experts, including (but not limited to) physicians, physicians’ assistants, nurses, counselors, and therapists. Medical professionals are trained to address, resolve, and seek healing for a wide variety of health-related biological, social, and psychological problems. Physical and bodily symptoms may be associated with pains, discomforts, and disabilities, restricting full and active participation in daily activities.Variations in lifestyle (e.g., nutrition, exercise, weight, addictions, sleep, and stress) influence both the quality and length of life, as well as behaviors creating and reducing health risks. For example, the American Cancer Society (2008) estimates that more than one-third of cancer deaths could be prevented by changes in patients’health and lifestyle behaviors. Experiences with and the emotional impact of sickness, as well as mental illness, troubled relationships, and the spiritual dimensions of wellness, also contribute in significant ways to overall health. And across family, social, and working relationships, the ongoing presence/absence of comfort, support, alienation, and unresolved conflict affect the delicate (im)balance of mind, body, and spirit. All these dimensions are interrelated, each shaping and shaped by additional factors, such as family medical and genetic history, predispositions toward specific types of disease (e.g., diabetes, breast cancer, depression), and chronic health conditions.

The investigation of communication between patients and providers has focused on diverse types of encounters. For example, a wide array of social activities and distinct patterns of interaction have been examined during medical interviews involving primary, outpatient care (see Beach, in press; Byrne & Long, 1976; Heath, 1986; Heritage & Maynard, 2006; Roter & Hall, 2006; West, 1984), therapy sessions (see Morris & Cheneil, 1995; Peräkylä, Antaki, Vehviläinen, & Leuder, 2008), AIDS counseling (Peräkylä, 1998), patient-centered cancer care (Epstein & Street, 2007), treatment recommendations for breast cancer therapy (Roberts, 1999), and the ways parents and doctors negotiate antibiotic prescriptions for children (Stivers, 2007).

This research paper focuses primarily on communication between patients and physicians during medical interviews. The following issues are addressed: (a) the ideal features of patient-provider relationships; (b) a brief history of “biomedical” versus “patient-centered” approaches to medical care; (c) studying the organization of medical consultations; (d) examples of power and authority as practical achievements (selected transcribed excerpts from actual interviews are included, providing readers with the opportunity to ground their understandings by inspecting interactions and becoming engaged in analysis of key moments); and (e) a glimpse of communication and medical care in the 21st century.

Ideal Patient-Provider Relationships

Patients’maladies require understanding, compassion, diagnosis, and treatment. During medical encounters, ordinary “lay” persons (i.e., nonmedical experts) must somehow report their problems to medical professionals, the authorities whose care is being sought to assist with managing health issues. Ideally, patients are able to clearly describe their physical/bodily symptoms, medical history, and related concerns about everyday life circumstances (e.g., job, family, relationships, finances, exercise, and diet). Patients’ experiences and emotions will also be disclosed and thus made available for providers’ consideration. And when asked questions, patients are able to provide sufficient and informative answers. To ensure their understanding and care, patients will become informed about their medical problems (e.g., through literature, Internet sites, and/or speaking with others who have had similar experiences), seek clarifications, and ask their own questions in assertive yet respectful ways. Patients will also be open and receptive to having their own “lay diagnoses” (Beach, in press) revised, altered, and perhaps even rejected altogether by informed medical experts. So, too, will patients’ family members or significant others work closely with the patients to enhance their comprehension and acceptance of the illness and of strategies for treatment.And patients will follow medical advice, complying with regimens such as exercise, diet, and taking of prescriptions.

In turn (and again, ideally), providers balance two equally important and related capabilities: (1) they are skilled in diagnosing medical problems (alone and with care teams) and technically competent in using appropriate medical technology and prescriptions to treat medical problems and (2) they will not impose their biomedical agendas (described below) at the expense of patients’ concerns but are compassionate in their caring, that is, adept at hearing and being responsive to patients’ reportings, both willing and able (a notable distinction) to work together on problems each perceive as important.

Providers who are particularly gifted continually form active partnerships with patients and their families/significant others. Rather than enacting behaviors contributing to foreign, impersonal, and dehumanizing medical encounters, provider-patient relationships are bound together by mutual respect exhibited through encouragement, reassurance, and the development of trusting communicative environments. Each party is understood and valued as bringing important life-world experiences and knowledge to the encounter. Each possesses unique skills and insights, and each displays recognition that they must work together, effectively and efficiently, to minimize suffering and promote healing outcomes.

To optimize quality patient care and satisfaction, skilled providers also recognize and work creatively when managing the inherent constraints of time and resources. Essential medical jargon is clarified when needed. Bad and good news are not withheld but delivered honestly and with sensitivity (see Maynard, 2003), yet the power of hope is not discounted (Beach, 2009). Patients are not blamed and shamed for lack of medical knowledge or unhealthy lifestyles (e.g., smoking, being overweight, poor diet, or failing to comply with medical advice), but they are heard and understood as engaging in specific types of behaviors in the midst of what are often complex yet (for them) normal daily circumstances. For example, a patient may be wounded from adverse experiences as a child or adult (see Adverse Childhood Experiences Study, https://www.cdc.gov/violenceprevention/aces/index.html) and, relatedly, stressed from multitasking across families, relationships, finances, and jobs. These chronic conditions— “root problems” underlying a significant percentage of adult health problems—can promote unhealthy lifestyles and thus reduce length and quality of life. And when patients attempt to diagnose their illnesses through “lay” knowledge (e.g., personal experiences, speaking with others, media, and/or the Internet), their explanations should not be prematurely discounted. Even if patients’ “lay” diagnoses are inaccurate, they should be rewarded for being involved and active partners in care. If necessary, patients will be educated (not lectured) on how alternative diagnoses are more compelling and suited to the medical problems at hand. When providers do not know what or why something is occurring—medical experts are no more or less infallible than patients—they make timely but appropriate referrals. And, critically, from the inception of care, providers work in close and respectful collaboration with nurses and staff, who work as a team to ensure patients’ health and well-being.

Of course, we do not live in ideal social worlds or relationships, and medical encounters are certainly no exception. How do the social actions listed above, for both patients and providers, get enacted during clinical interactions? Research findings make clear that as patients and providers work together, they produce distinct patterns of human communication that are often less than ideal. Several of these patterns are summarized below, including particular kinds of recurring problems between providers and patients as “biomedical” and “lay” agendas get negotiated interactionally. Selected transcribed excerpts, drawn from naturally occurring interviews, will be used to exemplify these communication patterns by providing readers with opportunities to inspect, firsthand, the kinds of moments that routinely determine patient-provider encounters.

A Brief History: “Biomedical” Versus “Patient-Centered” Orientations to Care

Physicians are traditionally understood as exhibiting “biomedical” orientations to patient care. More than 30 years ago, Engel (1977) described how, in primary care, “the biomedical model . . . encourages bypassing the patient’s verbal account by placing greater reliance on technical procedures and laboratory measurements” (p. 132). Engel’s position is clear: What patients report about their life-world experiences should not be reduced to medical symptoms and their treatments but analyzed “in psychological, social, and cultural as well as in anatomical, physiological, or biochemical terms” (p. 132). Patients should not be reduced to bodies with assorted symptoms but treated as unique persons engaged in daily life circumstances that are, for them, somehow related to the illness experience. An emphasis on bodies and symptoms, stripped of persons’ everyday life-worlds, contributes to derogatory stereotypes that doctors are just “body mechanics,” while patients are only “medical record numbers” trapped in an assembly line of depersonalized medical care (Starr, 1982).

Distinctions between illness and disease are critical for understanding often competing orientations to medical diagnosis and treatment (e.g., see Cassell, 1985; Mishler, 1984). Illness emphasizes the inherently emotional, affective, and experience-based dimensions, while disease focuses on how particular kinds of symptoms give rise to specific diagnoses (e.g., diabetes, cancer, or cardiovascular problems contributing to strokes and heart attacks). In everyday life, these dimensions are tightly interwoven and should not be falsely dichotomized through reductionist and thus dehumanizing medical care. It was for this primary reason that Engel (1977) offered a “biopsychosocial” approach to understanding and treating the rich complexities of the human condition. The key is to promote doctoring centered on patients’ concerns and problems, an integrative focus that has triggered ongoing developments in “biopsychosocial” research, clinical application, and medical training (Frankel, Quill, & McDaniel, 2003). A host of other factors have also been put forward as contributing to reductions in the offering of personalized medical care: (a) because doctors must increasingly adhere to financial restrictions associated with managed care, they struggle with constraints on time, which prohibit patients from fully disclosing their concerns; (b) doctors avoid addressing patients’ emotions not only because they feel inadequately trained as therapists but also because doing so takes time that is not considered to be available during normal interview slots; (c) concerns about malpractice influence the lack of full descriptions about health problems (e.g., see Levinson, Roter, Mullooly, Dull, & Frankel, 1997); (d) increased reliance on sophisticated technology actually distances doctors from patients; and (e) inadequate communication training promotes indifference to what patients treat as important.

But it is clear that patients whose voices are heard and attended to are much more likely to become more actively involved with ongoing care. Increased participation, evident through communicative involvement, promotes enhanced satisfaction, accuracy of diagnosis, reduction of suffering, and improved healing outcomes (see McGee & Cegala, 1998; Street, Krupat, Bell, Kravitz, & Haidet, 2003).

Advances in “patient-centered care” provide viable options to disease-centered or biomedical approaches to diagnosing and treating patients. Priority is given to the therapeutic possibilities of medical consultations (Balint, 1957; see Excerpt 2, p. 362 of this research paper), values and actions that are all too frequently undermined: such as attending closely to patients’affective experiences of their illnesses and their life-world circumstances (i.e., the psychosocial context in which their illnesses occur), building trusting relationships and partnerships, and increasing patients’ involvements in their care through shared decision making (Frankel, Quill, & McDaniel, 2003; Roter & Hall, 2006; Street, Gordon, Ward, Krupat, & Kravitz, 2005). One classic quote is attributed to Hippocrates (470–360 BCE), reputed to be the Father of Medicine: “I would rather know the person who has the disease than know the disease the person has.” Thus, it is clear that the basic idea of treating patients as persons and not diseases reaches back to antiquity and should not be mistaken as solely a result of modern theorizing.

Yet numerous approaches to patient-centered care have emerged in the past several decades, echoed again in the introduction to Cassell’s two-volume set Talking With Patients (1985), where he states, “Doctors treat patients, not diseases” (p. 1). Common priorities given to promoting “humanistic” medical care extend across diverse approaches to ensuring quality of care. Prominent resources such as the Journal of the American Medical Association have for years drawn attention to the importance of not overlooking how providers respond empathically (or not) to “windows of opportunity,” particularly during moments when patients make available their feelings and experiences, often indirectly through hints or cues (e.g., Suchman, Markakis, Beckman, & Frankel, 1997). The long-standing need to enhance skills for communicating effectively has received considerable attention, including areas such as cancer care, where displayed sensitivity to patients’ fears and uncertainties promotes improved outcomes (see Baile et al., 1997; Maguire, 1999). Questions have also been raised about the ways physicians’ gender influences care (e.g., Roter & Hall, 2004), and research that begins to address whether female physicians, for example, exhibit more empathic communication styles. These and related concerns have triggered new accreditation standards for medical education, including a reorganization of the educational programs of residencies in the United States (Accreditation Council for Graduate Medical Education [ACGME], https://www.acgme.org/). These humanistic and relationship-centered medical concerns are also promoted by the National Academy of Medicine (https://nam.edu/).

To summarize, while technical knowledge about disease and treatment options are critical, “biomedical” orientations to care have repeatedly been found to restrict and minimize attention given to patients’experiences and emotions. In contrast, as a primary resource for building trusting and collaborative partnerships, “patient-centered care” attends closely to patients’ needs, offering technically competent diagnosis and treatment options. Questions can then be raised: If and when patients’life-world experiences are disregarded in the midst of diagnosing and treating “bodies,” what factors contribute to how communication shapes medical interviews?

Models Describing the Organization of Medical Interviews

Numerous researchers and clinicians have attempted to generate models of medical consultations. Attention has been given to the opening to closing phases of interviews, as well as to how to have the best impact on patients’ lives—for example, by offering understanding and support, challenging, motivating, and educating patients about healthy behaviors—all during relatively short amounts of clinical time (see Byrne & Long, 1976; Waitzkin, 1991). Among these efforts, the most frequently cited is an extensive study by Byrne and Long (1976), whose analysis of 2,500 primary care encounters yielded a description of six possible phases as well as a range of verbal behaviors and styles routinely used by doctors (e.g., closed attempts to gather information and more facilitative efforts to encourage and counsel patients).The six phases are as follows: (1) openings, during which doctors seek to develop a relationship with patients; (2) patients provide and/or doctors solicit reasons for the clinical visitation; (3) taking a verbal history and/or conducting a physical examination; (4) doctor works alone, and at times in unison with patients, to consider (i.e., diagnose) the patient’s condition; (5) detailing further treatments and/or investigations that may be needed; (6) doctor terminates and thus closes the consultation. These activities are frequently associated with eliciting and elaborating on patients’chief complaints, taking a medical history, performing a physical examination, evaluating other investigations, and offering a diagnosis and treatment plan (Waitzkin, 1991).

While these and other phasic models are conceptually and theoretically intriguing, they are only suggestive and not anchored in specific details about the interactional conduct of both patients and physicians.As a viable alternative, Robinson (2003) describes a “project” including how possible phases—(a) establishing how “new problems” are the “reason for the visit,” (b) interactionally conducting history taking and physical exams, (c) actually delivering/receiving a diagnosis, and (d) offering and accepting/rejecting recommendations for treatment—are replete with a range of detailed, social activities produced by patients and physicians as they work together to coordinate medical encounters. Because “no one has yet demonstrated the internal validity of the proposed project or its consequences for physicians’ and patients’ communication behavior” (p. 32), Robinson (2003) has begun to develop a structural schema involving how new patients raise problems as “first topics” to be dealt with during medical interviews. By closely examining the interactional organization of recorded and transcribed moments from actual interviews, key insights can be advanced that explain (among other primary problems) why and how patients are so passive during medical encounters. A similar orientation is evident in the volume edited by Heritage and Maynard (2006), a collection of studies unpacking the kinds of interactional details that constitute the overall structure of acute primary care visits—encounters most generally described as organized across the following phases: (a) opening, (b) presenting complaint, (c) examination, (d) diagnosis, (e) treatment, and (f) closing (p. 14).

Offering Candidate Explanations About Medical Problems

It has been suggested that patients’ low involvement is a function of passivity in the face of medical expertise, in part because patients lack technical knowledge and experience uncertainty, factors reducing their ability to seek relevant information and even ask appropriate questions (Street et al., 2005). Ongoing research is attempting to clarify how or if these kinds of possibilities get enacted in the midst of patient-physician interactions.

Consider, for example, a patient-physician excerpt from Robinson (2003). The doctor employs an open-ended question to solicit the patient’s description of “thuh problem”:

Excerpt 1. Eye Trouble (Robinson, 2003, p. 36)

11 DOC: What seems to be thuh problem?
12 PAT: .hh I’ve been having a problem: (0.2) mostly with
13 this eye but I’m- with both.
14 DOC: Okay.
15 → PAT: .tch I don’t know if it’s:=uh:- when do I- when I
16 → was=uh: cutting lumber an’ .hh a:nd=uh: thuh
17 → sawdust hit my (eyes),

Patient not only states a reason for his visit but, following the doctor’s acknowledgment with “Okay” (line 14), moves to offer his own diagnosis (lines 15–17). Patients routinely offer contributions about how they make sense of the symptoms they are experiencing and what they consider their problems to be (Gill, 1998; Gill & Maynard, 2006). By so doing, the patient also makes clear that the purpose of the medical encounter is to determine what is wrong, a prerequisite for doctors treating and resolving problems “in the service of diagnosis” (Robinson, 2003, p. 37). But it is also apparent that the patient, by speculating that his eye problems may be a result of “cutting lumber,” displays a need to further establish a valid reason for scheduling an appointment with the doctor. Prefaced with “I don’t know,” however, the patient’s candidate explanation is produced as doubtful, hesitant, and dysfluent. (Notice, for example, that and how the patient searches what to say with three “uh’s” and twice abruptly cuts off (-) and restarts the utterance.)

Gill (1998) has observed that, “when patients exhibit tentativeness and uncertainty about the knowledge they are displaying in their explanations, they also tentatively invite doctors’ assessments” (p. 356). Being tentative displays an orientation to proceeding with caution, downplaying their experiences and knowledge, even though patients’ explanations may (at least for them) seem not only reasonable but also even likely possibilities. And even when patients present unlikely candidate explanations, they have been shown to manage multiple and even conflicting constraints—for example, evidencing their ability to make sense of their condition, yet not advancing worst-case scenarios since it is doctors who are in a better position to make such assessments (Gill & Maynard, 2006; Pomerantz, Gill, & Denvir, 2007). So, too, are doctors in a position not only to grant or reject patients’ requests but also to respond in kind to patients who raise their concerns indirectly and delicately (Beach, in press). These actions further reveal how patients are tentative and cautious when attempting to draw attention to their expectations, needs, desires, hopes, and fears (see Beach, Easter, Good, & Pigeron, 2004; Excerpt 2, below).

To summarize, considerable evidence suggests that when offering explanations amounting to “lay diagnoses,” patients routinely defer and thereby subordinate their knowledge and authority to physicians. Patients display recognition of medical expertise: It is physicians who have not only received technical training but also accumulated experience across years of clinical practice, proficiency amounting to greater knowledge and ability to assess, diagnose, and treat what count as real or imagined problems (at least biomedically). And, as addressed below, there are additional reasons for a basic imbalance or asymmetry of power and authority during medical encounters. So, too, are moments evident when patients initiate assertive actions, at times contesting and resisting the doctor’s authority.

Power, Authority, and Asymmetry During Medical Encounters

Even prior to the outset and through the completion of the medical encounter, “the physician-patient relationship is marbled through with the exercise of authority” (Heritage, 2005, p. 83). Before the interviews begin, patients routinely wait for providers, and on their arrival, it is doctors who initiate greetings, arrange the physical space, and coordinate tasks, such as locating and reviewing medical records (Heath, 1986). When doctors do solicit patients’ opening complaints (e.g., “What can I do for you today?”), Beckman and Frankel (1984) discovered that doctors interrupt patients after they state a single problem, on the average within 18 seconds, moving—frequently with closed questions—to gather additional information about that single issue. And when interrupted, only 1 of 52 patients actually completed their full listing of concerns. By not asking patients if they have additional concerns, which is not uncommon, physicians’ attempt to take control of the interview, which constrains and even halts important information patients could provide about their condition.

In a related study, Marvel and colleagues (1999) examined whether improvements had been made in appropriately soliciting patients’ agendas before redirecting to what physicians treat as important. In only 74 of 199 interviews did patients complete their initial statement of concerns, and in the majority of cases, patients were redirected by their physician after only 23.1 seconds. As with Beckman and Frankel’s (1984) original study—where interruptions occurred after 18 seconds, even though most completed statements occurred in less than 60 seconds and no more than 150 seconds—Marvel and colleagues (1999) concluded that completed statements of concern required only 6 additional seconds. Thus, by investing minimal additional time, physicians could improve their care (and patients’ satisfaction, compliance, and reduction of unnecessary return visits) by attending more closely to information anchored in patients’ concerns. And in both studies, patients who were interrupted at the outset of the interview more frequently raised concerns in the closing phase of the interview, moments when doctors have been shown to be even less receptive to adequately addressing patients’ problems.

The phasic progression of medical interviews is designed to facilitate doctors’ agendas by actions such as asking more frequent questions, delaying or failing to respond to patients’ initiatives, and shifting and closing down topics. Restrictions are also imposed on what reasonably counts as reliable information, knowledge, procedures to be taken, and appropriate utilization of time, prescriptions, referrals, and additional resources (see Beach, in press; Stivers, 2007).

Raising and Responding to Psychosocial Concerns

During particular moments, patients appear to prematurely solicit diagnostic information from physicians before the history-taking or physical examination has been completed (Jones & Beach, 2005). So doing essentially deviates from the typical ordering, where physicians (understandably) offer diagnoses only after relevant information has been gleaned. In Excerpt 2 (below), following an opening introduction and greetings, the doctor’s typical initiation of the patient’s complaint (e.g., “What can I do for you today?”) is preempted by the patient’s “Well I hope you can find out what’s wrong with me” (1→).

Excerpt 2. S14:1 (Jones & Beach, 2005, pp. 107–108)

Dr: H’lo Mister Steen.=
P: =Good morning.
(2.0)
Dr: I’m Physician Krone.
(0.2)
P: Pleased to meet sir.
Dr: Nice to meet you.=
P: 1→ =Well I hope you can find out what’s wrong with me.
Dr: 2→ We(h)ll I hadn’t even seen you yet.
P: 3→ (At’s whuh) I say I still say I hope you can find out what’s wrong [with me.
Dr: 4→ [O:h, okay.
(0.4) Well we will.
P: 5→ Whatever you think whatever yo:- (0.5) u:h (0.3) whatever it is tell me: so I can- (0.7) eh- (0.7) (keepn gih-) get somethin done about it. Cause (.) ma:n (0.4) it’s worrying me.

Rather than respond to the patient’s query as an anxious and hopeful bid for reassurance, in 2→, the doctor responds with surprise by stating the obvious: “We(h)11 I hadn’t even seen you yet.”

But this reply does not ease the patient’s concern. In 3→, the patient restates his need and further pursues what is noticeably absent, namely, an offering of consolation from the doctor. It is only in response to the patient’s second attempt that, and with hesitation, the doctor’s next “Well we will” (4→) is provided. The doctor does not personally assure the patient that whatever is wrong with him will receive the doctor’s full attention and/or that the doctor will work together with the patient to ensure healing. Rather, the doctor invokes “we” to mark institutional affiliation (Drew & Heritage, 1992), in a manner that minimally addresses the patient’s concern yet does not clearly align with the twice-stated “hope” the patient is expressing. Matters of “hope,” then, are not just located in the heart or mind but managed as ordinary interactional achievements (see Beach, 2008).

In 5→ with “you,” however, and with considerable hesitation and dysfluency (i.e., multiple pauses and restarts), the patient squarely focuses attention back onto the doctor. Three times, “whatever” is employed to state, “Whatever you think” and “Whatever it is tell me,” a request that the doctor not be withholding about “it”—an apparent and indirect reference to an illness or disease—and that the reason for his visit is that he wants to “get somethin done about it.” And what is the urgency driving the patient to raise these concerns at the outset of the medical interview? The answer is straightforward: “Cause (.) ma:n (0.4) it’s worrying me.”

By initiating these actions at the outset of the encounter, it is “worry” that the patient is not only experiencing but also seeking solace from the doctor for. No symptoms have yet been mentioned, and no attempt has been made by the patient to offer his own “lay diagnosis” of what “it” might be.

In contrast, a “psychosocial” need is addressed by the patient—albeit prior to the doctor having the opportunity to examine the patient—that seeks not the physician’s impersonal acknowledgment but individual attention to the patient’s anxiety (uncertainty, fear). These moments make clear that and how patients bring their “psychosocial” concerns to the clinic—numerous researchers suggest that a majority of patients’ presenting concerns are “psychosocial”—and that doctors are faced with managing therapeutic (not just biomedical) aspects of care. To adequately address a patient’s “worrying,” at the outset or during any phase of a medical interview, requires that physicians transcend being medically trained bureaucratic representatives and be willing (and able) to offer personalized, therapeutic care that integrates comfort and support with sound diagnostic and treatment skills.

Excerpts such as 1 and 2 (above) are only a small sampling of moments when it is evident that communication between patients and providers occurs at the intersection of professional and lay, authority and subordination, biomedical and psychosocial orientations to providing and receiving medical care. There are inherent and dialectical tensions between these seemingly opposite ways of organizing medical interviews. But, ultimately, they get interconnected, and not only through conceptualizations or theories of medical encounters that stipulate that patients are not sufficiently involved, that when they do initiate actions they are not adequately addressed, or other notions about an imbalance or asymmetry of power in the clinic. Instead, “rather than visits embodying asymmetry, it is actions, activities, and projects of activities, and their constitutive relevancies, that account for asymmetry” (Robinson, 2003, p. 51). The task thus remains to continue explicating the details of actual, naturally occurring contingencies comprising medical encounters and, through close analysis, to advance understandings of routine ways that both patients and providers coordinate often delicate moments of interactional conduct.

Gaining Access to the “Diagnostic Moment”

Considerable attention has been given to what patients want, need, and expect from medical care. Repeatedly, patient surveys have revealed that patients seek to be informed and to receive understandable explanations for their medical condition (Roter & Hall, 2006). Yet patients also report not being well informed and being unable to understand their physicians (e.g., due to complex medical jargon). And by asking few questions, patients subordinate themselves to physicians—who, at times, display a strong dispreference for patient-initiated actions (Beach, in press; Heritage & Maynard, 2006)—even avoiding physicians’ offerings of prescriptive judgments (Stivers, 2007). In stark contrast, however, physicians report investing considerable time informing and explaining to patients their diagnosis and treatment options (Street et al., 2003). So how can these conflicting orientations be accounted for?

Citing what Paul Starr refers to as patients’ “surrender of private judgment” in The Social Transformation of American Medicine (1982, p. 10), a response to dependence on medical expertise and the power of science, Heritage (2005) argues that

when patients get a recommendation from their doctor, they end up abandoning whatever private beliefs, uncertainties, fears, and misgivings they may have about their medical condition, and accept the physician’s diagnosis and treatment recommendation . . . With respect to these moderate, primary care illnesses, preliminary evidence from studies of recordings of medical encounters suggests that patients do indeed abrogate their own judgments and more or less surrender with a blindfold on. (pp. 84–85)

Here again, the management of “authority” is a central issue for understanding how patients and physicians navigate their way through medical encounters. This is especially true during moments when diagnoses are delivered by physicians and responded to by the patient. When reviewing important studies focusing on the relationships between diagnosis and medical authority—from Byrne & Long’s (1976) classic finding that across 2,000 medical visits, physicians were highly authoritarian and did not adequately discuss diagnoses with patients; to Heath’s (1992) primary finding that patients respond passively to diagnoses; to Peräkylä’s (1998) discovery that as physicians assert, provide evidence, and persuade patients about diagnoses, they hold themselves somewhat accountable for their judgments; and finally to both Heritage & Stivers (1999) and Stivers (2007) revealing how patients may contest physicians’ recommendations and, in turn, how physicians can themselves resist patients’ efforts to pressure physicians to prescribe antibiotics—Heritage (2005) makes clear that physicians’ abilities to “name the world,” and thereby exercise medical authority, are fundamental to communication during medical encounters.

And in just the ways physicians claim and assert authority, so too is it inherently problematic for patients to get their needs addressed. This is especially the case when patients raise psychosocial concerns that do not receive adequate attention. Beach and Mandelbaum (2005), for example, examine how a patient discloses “My mom had a stroke” three times over the course of an interview with a physician’s assistant. The additional burdens placed on the patient to care for his ill mother, and also his ailing father, were repeatedly nominated by the patient as reasons for poor health habits, excessive drinking, inadequate exercise and diet, and sleeplessness. In response, and despite the patient’s persistence, however, the interviewer offered only minimal acknowledgment of the patient’s life-world experiences—and shifted attention toward a series of bodily symptoms, namely, blood in the patient’s stools, pancreas and liver damaged by alcohol (and the need for a referral to do other tests), high cholesterol, high blood pressure, and overweight. Excerpts from each of these three moments appear below. Even a brief inspection makes clear how the patient’s focus on his mother’s stroke is disattended by the interviewer rather than pursued as an opportunity to acknowledge, support, understand, and treat the stressful effects related to caregiving.

In Excerpt 3, the interviewer shifts to “blo:od in your stools or bla:ck stools?” rather than address the implications of the patient’s mom having had a stroke:

Excerpt 3. “Do you drink?” (Beach and Mandelbaum, 2005, p. 347; INT = Interviewer)

((The Patient had just reported that he has about three drinks each night before going to bed, and the interviewer is seeking clarification about the amount of alcohol in each drink.))

PAT: 1→ My mom had a stroke (.) five years ago and u:h I have to go every night after work and help (.) my dad out with her. So: = .hh when I come home just ta unwind $I have a few drinks$ and then >go to bed<.

INT: 2→ Have you ever noticed any blo:od in your stools or bla:ck stools? 

In Excerpt 4, the interviewer makes a referral as an alternative to responding directly to the patient’s attempt to explain that daily drinking has only occurred since his mother’s stroke:

Excerpt 4. “mom’s had her stroke” (p. 354)

((The Interviewer has been summarizing the effects of excessive drinking on the pancreas and liver and thus the need to do additional tests to assess the possible damage.))

PAT:       1→ Oh but the daily you know the °drinking° everyday at night has been just since my mom’s had her stroke the last four– four or five years. (.) >The diarrhea’s been< since I really think nineteen years at least [(probably)].

INT:        [ Okay ] sometimes these things-.

PAT:        1→ >But I’ll check it.< I don’t know I $hmph$.

INT:        2→ NOW (.) we’re also going uh to send a referral to Doctor Dorsey who is your designated primary care physician.

And in the final example, the interviewer’s encouragement to cut back on drinking and to exercise more is, once again, countered by the patient: “°Not since my mom got sick°” (1→) has he been able to exercise. The patient next insists that he therefore doesn’t have time (3→) to exercise (i.e., owing to his caregiving responsibilities):

Excerpt 5. “Not since my mom got sick” (p. 357)

((The Interviewer is discussing concerns and future treatment options with the patient.))

INT: Okay. pt .hh Now in terms of um (.) your drinking, .hh need I say (.) you certainly need to cut down. (.) Ideally no more than (.) two ounces a day. pt .hh Um: if that might become a problem area for ya .hh we do have a chemical dependency program.= I’ve circled the name and the phone number and you may call them at your leisure.
PAT: °Okay.°
INT: And I’d like to um (.) talk about some other things which are certainly important. One of tho:se is u::h (.) the need to exercise and I didn’t ask ya are you exercising at all?
PAT: 1→ °Not since my mom got sick.° >I used to bike ride< three miles but I- I hadn’t had time.
INT: 2→ Well exercises (.) even if it’s no more than just walking for thirty minutes non stop three to five days a week .hh is a valuable tool. pt And uh it’s certainly-
PAT: 3→ I- I don’t have thirty minutes <either. $heh$ But what I do is like> when I came here (.) is I took the stairs instead of the elevator. ((INT continues))

Though not included here, the interviewer continues not attending to the patient’s concerns about lacking time in favor of emphasizing the positive health benefits of exercise—raising good cholesterol, managing anxiety and stress, and reducing blood pressure and weight.

The analysis offered by Beach and Mandelbaum (2005) makes clear that the more this patient invited attention to his personal and family dilemma, the more the interviewer avoided aligning with these patient-centered concerns. Yet, and importantly, it was the patient’s own indirectness— hinting and offering clues about his mother’s stroke, rather than directly asking the interviewer to talk about the impact of her stroke directly—that provided the interviewer with interactional grounds for not addressing the patient’s caregiving stressors. At least in this instance, the patient’s indirectness thus facilitated the interviewer’s evasiveness.

A Glimpse of Communication and Medical Care in the 21st Century

It is not news to state that the management of disease— or dis-ease, as is often the case—will continue into and beyond the 21st century. History clearly reveals that human evolution and the growth (or decline) of all civilizations are tightly interwoven with the ability to treat and heal bodily, psychological, emotional, and spiritual problems. And, as this research paper clearly indicates, communication is critical throughout all phases of medical encounters, in which quality relationships, not simply technical knowledge or advanced technologies, shape the overall quality of care and healing outcomes. Nor is it surprising to predict that monumental advancements in medicine will continue to emerge with the completion of investigations such as the Human Genome Project (HGP) in 2003, revealing a mapping of the hereditary codes in the 20,000 to 25,000 genes and 3 billion chemical base pairs constituting human DNA. The HGP has opened new horizons for gene testing and identifying genetic components of diseases, including the ability to locate and alter the hereditary errors in genes that contribute to thousands of diseases that negatively impact humankind. New pharmaceuticals and drug therapies are being generated, along with advanced technologies capable of previously unheard of interventions (e.g., strengthening immunity by inserting genes that suppress tumor growth).

But with the success of the HGP comes a series of moral, ethical, and legal implications bearing directly not only on patient-provider relationships but on families as well. Consider, for example, how genetic counseling involves helping patients and family members assess their inherited susceptibility, make decisions regarding treatment options, and shape their care in the face of an inevitably uncertain future. Below is a written description generated by a genetic counselor I worked on a project with designed to better understand the kinds of communication dilemmas arising in the of genetic counseling:

The woman contacting me has had breast or ovarian cancer, has daughters or sisters or nieces she is worried about, and wants to be tested in order to find information which might help her relatives. The issues here are whether these relatives want the information, and whether the woman realizes that a positive test would mean that she is at greatly increased risk for another cancer.

How do genetic counselors explain hereditary disorders and future health risks to patients? How do patients express their fears about possible but uncertain diseases? In what ways do interviews vary depending on whether family members are present or not? We have only a limited understanding of how these discussions actually occur during genetic counseling sessions. We know even less about how those counseled share this information with their family members, outside of clinics (Beach, 2009), including the positive and negative consequences of talking about the implications of receiving (and/or avoiding) genetic testing. Extending the case study summarized above, what happens when a mother who may be susceptible to BRCA1 or BRCA2 breast cancer (National Cancer Institute, 2008) contacts a physician and requests that both of her daughters be genetically tested? What if only one of the two daughters wants to be tested and the other is vehemently opposed to discovering whether she is predisposed to a future and probable breast cancer diagnosis? How does the family manage potential conflicts arising from alternative stances toward receiving genetic testing (or not)? And if the family itself seeks genetic counseling to address and resolve these problems, what specific kinds of communication interventions are effective (or not)? What, then, are the long-term consequences of seeking genetic testing and counseling (or not) for individuals and families alike?

These questions only begin to address the ways in which communication is critical for managing future quandaries in medical care. Other communicative issues are equally daunting; information is readily available online concerning debates such as those surrounding governmental regulation of stem cell research (Stem Cell Information, The National Institutes of Health, https://stemcells.nih.gov/), privacy associated with online medical databases and access to medical records (Health Communication and Informatics Research, National Cancer Institute, https://cancercontrol.cancer.gov/brp/hcirb), and malpractice associated with the humbling occurrences of death caused by unnecessary surgeries and related medical errors (https://www.medicalmalpractice.com/). As complex as the study of patient-provider relationships seems to be, it is useful to situate medical encounters within these and other encompassing health communication frameworks, such as cancer control, population sciences, and behavioral research.

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