Beliefs about control in the physician-patient relationship: effect on communication in medical encounters.

The way in which health care providers and patients communicate with one another can have a significant effect on quality of care and health outcomes. Patients often are more satisfied with care, gain a better understanding of their health conditions and treatment options, are more strongly committed to therapeutic regimens, and even experience greater health improvement when they are more actively involved in medical encounters and when their physicians are more informative, supportive, and take into account the patient's perspective on health.1–5 Although few would argue with the claim that quality of care in part depends on the quality of physician-patient communication, researchers and clinicians still know little about the dynamics of communication process in medical consultations. We tackle these issues by adopting the perspective that, like other forms of social interaction, what unfolds during a particular medical consultation is in part a function of personal influences (e.g., the physician's and patient's individual communication styles) and in part a function of mutual influence (e.g., how each responds to the other's communicative actions).5,6 In this investigation, we examined personal and mutual influence on 2 sets of behaviors that are important indicators of patient-centered care,7,8 active patient participation (i.e., asking questions, stating opinions, expressing concerns) and physician partnership building (i.e., utterances that encourage, support, and accommodate patient involvement). Traditionally, researchers have studied physicians' and patients' styles of communicating with respect to personal and social attributes such as gender, ethnicity, personality, and education, to name a few.9–12 While the study of sociodemographic influences on physician-patient communication is a worthy undertaking, more work needs to examine communication as it relates to doctors' and patients' beliefs about health care. A major contribution of the present study was to investigate how physicians' and patients' expectations for their relationship affect their communication with one another. We propose that one's orientation toward control in the doctor-patient relationship will be an important determinant of these patterns of communication. Preferences for control can be placed on a continuum. At one end are those physicians and patients who prefer the more traditional doctor-patient relationship, one characterized by a powerful physician, an acquiescing patient, and a focus on disease and bodily functioning. At the other end is the consumerist perspective where the patient assumes control of health care and the physician serves as a consultant or advisor.4 We predict that physicians oriented toward sharing control with patients will engage in more partnership building than will physicians oriented toward doctor control. For example, 2 studies found that women and younger doctors self-reported more patient-centered orientations than did male and older physicians.13,14 This may explain in part why female physicians tend to use more partnership statements and other forms of patient-centered behavior than do male doctors.9,12,15 Second, we predict that, compared to patients oriented toward doctor control, those preferring shared control will be more active participants, particularly with respect to asking questions, expressing concerns, and offering opinions. Patients with preferences for shared control and involvement in decision-making tend to be female, more educated, and middle-aged.13,16–18 These same patients also are generally more expressive and assertive in medical encounters than are male, less educated, and elderly patients.10–12,19 However, because the interactants must cooperate and coordinate their responses to create a coherent and effective interaction, physician-patient communication is characterized also by mutual influence. That is, the communicative actions of one can significantly affect the response of the other. For example, a passive and uninvolved patient often becomes more participatory after the doctor has explicitly encouraged and shown interest in the patient's views.10,11,20,21 Conversely, prompted by a patient who asks questions and expresses concerns, a physician (even one with a controlling communication style) often will spend more time providing information and discussing issues raised by the patient because the doctor has been alerted to the patient's needs or because the doctor feels obligated to address issues of concern to the patient.5,10 Thus, a third hypothesis is that physician partnership building and active patients participation will have a reciprocal relationship such that increases in one lead to increases in the other. Finally, high levels of partnership building and active patient participation should characterize a consultation in which both doctor and patient are patient-centered, whereas few of these behaviors may occur when both physician and patient prefer doctor control. However, what happens when a doctor-centered physician interacts with a patient-centered patient, or vice versa? Thus, a final research question examines the effect of relational congruence on physician-patient communication.