1997). Additional obstacles include discontinuity of care in the absence of a usual source of treatment (Phillips et al 2000). When patients have good access to health care (Shi et al 2002) and when they have better relationships with their health care providers, they have a more positive view of their own physical and mental health status. Therapeutic communication in the care of vulnerable patients Many aspects of physician-patient communication, particularly with older patients, can be affected by patient characteristics. In this paper, we explore the role of patient ethnicity, income level, socioeconomic status, education level, and mental health status as factors contributing to the effectiveness or ineffectiveness of communication between the physician and patient in the medical interaction. We consider how these factors can combine with patient age to further complicate the quality of communication. Ethnicity Communication and ethnicity in physician-patient interaction have been examined extensively in research. In the US, studies suggest that physicians tend to be more empathic and spend more time with White patients than they do with minority patients (Hooper et al 1982; Hall et al 1988; Kaplan et al 1995 ). Minority patients tend to be rated by their physicians as participating less in the interaction than White patients, and this disparity is greater for inter- actions that are race discordant (that is, where physician and patient are not of the same ethnicity) (Cooper-Patrick et al 1999). Research suggests that patients of an ethnic group different from the physician may be less inclined than those in ethnicity-concordant dyads to provide a clear narrative description of their health and current experience to their physician (Ashton et al 2003). Some patients may expect that they will not be understood by physicians who use different terminology and descriptive words than they do; hence, patients may withhold clear explanations of their symptoms and illness experiences. Some patients may feel that they and their physicians have quite different explanatory models for illness, and they may be concerned that the physician will ﬁnd their personal and cultural explanations for illness to be unacceptable (Charon 2001; Ashton et al 2003). Indeed, physicians’ and patients’ explanatory models of illness can play important roles in the medical encounter and can strongly affect how patients and physicians come to understand each other. These explanatory models derive Clinical Interventions in Aging 2007:2(3) Physician-patient communication from culture, education and knowledge, social class, religious beliefs, and personality traits, and may be necessary for trust, satisfaction, patient adherence, and self-management (Ashton et al 2003). In the process of attempting to provide quality care under time pressures and with limited information, physicians may sometimes unintentionally incorporate racial and ethnic stereotypes into their interpretation of patients’ symptoms, their predictions of patients’ behavior, and their medical decision-making (Cooper-Patrick et al 1999). Cultural stereotypes do play a role in health care disparities. For example, studies show differential patterns of prescribing analgesic medication for ethnic minority patients compared with non-minority patients. In addition, ethnic and cultural differences exist in cancer and HIV treatments and in referrals for cardiac procedures offered to patients (Todd et al 1993; Bach et al 1999). The Robert Wood Johnson Foundation has conducted a survey of Spanish-speaking residents of the US and demonstrated that almost 1 in 5 delayed or refused needed medical care because of language barriers with English-speaking physicians (Robert Wood Johnson Foundation 2002). Differences in the use of health services within ethnic groups can be accounted for by the patient’s level of acculturation as well, even after controlling for age, gender, health status, and insurance status (Burnam et al 1987; Anderson et al 1997). Meta-analytic work on physician-patient communication has revealed that White patients receive a higher quality of care in technical, interpersonal, and “positive-talk” domains of communication with their physicians (Hall et al 1988). Key predictors of the quality of doctor-patient communication may, in fact, be patients’ socioeconomic status, income, and education level (Hall et al 1988). Patient income Patients’ experiences in the medical encounter can be affected by their income status and economic vulnerability (Willems et al 2005b) and there can be signiﬁcant income disparities in health care decision-making (Waitzkin 1984; Naumburg et al 1993; Todd et al 1993; Strakowski et al 1995; Feldman et al 1997; Krupat et al 1999). Perceptions of patients as independent, responsible, rational, and intelligent tend to improve their care (van Ryn and Burke 2000), and more educated patients do receive more information and more detailed explanations from their physicians, as do patients from middle to upper socio-economic classes (Waitzkin 1984; Street 1991). While lower income patients tend to ask fewer questions of their physicians, studies show that 459