Patient Education and Counseling 83 (2011) 73–79
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Communication Study
Identifying transparency in physician communication Lynne Robins a,*, Saskia Witteborn b, Lanae Miner c, Larry Mauksch d, Kelly Edwards e, Douglas Brock a a
Department of Medical Education and Biomedical Informatics, Seattle, WA, USA School of Journalism and Communication, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong c University of Washington School of Medicine, Seattle, WA, USA d Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA e Department of Medical History and Ethics, Seattle, WA, USA b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 29 April 2009 Received in revised form 29 April 2010 Accepted 8 May 2010
Objective: To categorize physician communication demonstrating understanding of what patients want to know and skill in conveying that information. Physicians underestimate how much information patients want and patients rarely seek information during clinic visits. Transparent communication is advocated to facilitate patient understanding and support autonomy, informed decision-making and relationship development. Methods: Analysis and coding of 263 audiotaped interactions between 33 primary care physicians and their patients in eight community-based, primary care clinics in Washington State, USA. Results: Physicians proactively used five types of process transparency to preview speech and actions. Four types of content transparency were used to explicate diagnosis and treatment, demystify medical language and concepts, and interpret biomedical information. Physicians spent the greatest proportion of clinic time explicating medical content. Conclusion: The primacy of information exchange over process-oriented, relational communication was demonstrated. Proactive transparency appears promising to increase understanding and collaboration. Practice implications: In patient-centered care where collaboration is the ideal, transparency in its various forms is a critical ingredient. Without much communicative effort, physicians who proactively communicated that an examination was over, that they were leaving the exam room briefly so patients could dress provided information that appeared to address patient uncertainty and demonstrated empathy and respect. Published by Elsevier Ireland Ltd.
Keywords: Physician–patient communication Transparent communication Patient-centered care
1. Introduction Studies of physician–patient communication have demonstrated over time the primacy of information exchange in clinical encounters [1–3]. When asked to identify competent communication behaviors during a medical consultation, both physicians and patients emphasize information exchange over relational communication [4], though disentangling relational and informational talk can be difficult and even beside the point. Roter has shown that patient adherence improves when physicians convey technical information in ways that imply caring and concern [5,6]. Information gathered from patients during medical history-taking is vital to physicians for making medical diagnoses and treatment decisions; in the majority of cases, it is considered more valuable than information derived from lab results or physical examination [7,8].
* Corresponding author at: Department of Medical Education and Biomedical Informatics, H205 Health Sciences Center, Box 357240, Seattle, WA 98195-7240, USA. Tel.: +1 206 616 9874. E-mail address:
[email protected] (L. Robins). 0738-3991/$ – see front matter . Published by Elsevier Ireland Ltd. doi:10.1016/j.pec.2010.05.004
For patients, the clinical encounter offers a venue in which they can learn about their health conditions and self-care through receipt of medical and treatment information from their physicians [9]. Patients express a strong desire for medical information [10,11] yet, physicians often underestimate how much information patients want about their physical exams, medications, tests, and therapies [12]. And, despite their interest in receiving information, patients exhibit relatively low rates of informationseeking behaviors during clinic visits [11,13,14]. Previous studies have reported that patients are reluctant to ask questions about medications during medical visits [15,16] due to fear of physicians’ reactions to their questions [17]. Noted communications researchers including Waitzkin [18], Roter [19], West [20], and Frankel [21] have suggested that there is a ‘‘dispreference’’ for patient-initiated questions in the medical interview. Ideally, physician–patient communication would exhibit a more ‘‘balanced exchange of information, ideas, and preferences between the physician and patient, with each playing a complementary role during the interaction’’ [22]. Instead, medical communication takes on an asymmetrical shape, deformed by a process of ‘‘collusion’’ that produces only an ‘‘appearance of shared understanding’’ [23].
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As patients are increasingly expected to become informed consumers of medical service, clinicians need to understand that they have a role in helping patients through the process of preference-construction [24]. Yet, patients’ cooperation in carrying out treatment recommendations is often taken for granted [17]. Physicians rarely explain pros and cons, alternatives, or uncertainties [25] nor do they use orienting statements to frame their actions or communications [26,27]. Research that could serve to guide clinicians in how to engage in shared deliberation to achieve mutual understanding and consensus is limited [24]. In this exploratory study we sought to address this research gap by identifying and describing aspects of physician communication that appeared to anticipate patients’ needs and desires for information in its widest sense. Transparency, that is, the ways in which physicians are explicit about their actions and opinions on matters concerning the health of the patient, the encounter, procedures, and the relationship with the patient, is the central concept of this paper. The concept is also a hallmark of patientcentered care [28]. While the concept of transparency in medicine today is more commonly associated with institutional (or macro) level patterns of disclosure and information-sharing, Brody [29] conceptualized transparency as a set of communication strategies for promoting information and power-sharing at the interpersonal (or micro) level of the clinical encounter. He advocated for a ‘‘transparency standard’’ for physician communication with patients, suggesting that when physicians take the lead in communicating in ways that support patient understanding, they promote patient autonomy and informed decision-making and equalize power in the clinical encounter [30]. For example, he recommended using lay language to explain the rationale for diagnoses and treatment recommendations. Silverman, Kurtz, and Draper [31] also promoted transparency, based on evidence that it reduces unnecessary patient uncertainty about their care and increases patient satisfaction, adherence, symptom relief, and physiological outcomes. Like Brody, they encourage physicians to (1) explain their rationale for pursuing a line of medical questioning, (2) share their thinking as appropriate, and (3) use verbal ‘‘signposting’’ to frame important information or signal upcoming transitions, actions, and other aspects of the medical encounter that may be known to the physician but not to the patient. When physicians do spend time educating, informing, and orienting patients, patient health outcomes improve [32]. Provider explanation has also been correlated with patients’ satisfaction with healthcare, understanding of and adherence to treatment regimens, and faster recovery from surgical procedures [33]. Hickson et al. [34] noted that ob/gyn patients were more likely to sue their physicians if they felt they had not received adequate explanations and advice, while Levinson and co-workers found that primary care physicians who used more orienting statements were less likely to be sued and less likely to have problems surface in the closing moments of the interview [35]. The reported benefits of striving toward transparency in communication with patients are compelling. We therefore sought to identify and categorize the full range of verbal behaviors physicians used in routine primary care visits that appeared to increase transparency about the process and medical content components of primary care encounters. 2. Methods 2.1. Participants and setting Study participants included physicians caring for adult patients in eight community-based university-affiliated primary care
Table 1 Characteristics of patients and physicians in sample of audio recordings. Physician
Patient
Variable
n = 33
n = 259
Sex Women Men
17 (51.5%) 16 (48.5%)
143 (55.2%) 116 (44.8%)
Age, mean (range)
43.9 (36–59)
46.6 (18–86)
Ethnicitya White African American Native American or Alaska Native Asian Native Hawaiian or Pacific Islander Hispanic Other Mixed
25 (75.8%) 0 0 5 (15.2%) 0 1 (3.0%) 0 1 (3.0%)
200 (77.2%) 8 (3.1%) 3 (1.2%) 8 (3.1%) 2 (0.8%) 6 (2.3%) 3 (1.2%) 16 (6.2%)
Household income
