How clinician–patient communication contributes to health improvement: Modeling pathways from talk to outcome

doi:10.1016/j.pec.2013.05.004

Patient Education and Counseling

Volume 92, Issue 3, September 2013, Pages 286-291

https://doi.org/10.1016/j.pec.2013.05.004 Get rights and content

Abstract

Objective

Although researchers have long investigated relationships between clinician–patient communication and health outcomes, much of the research has produced null, inconsistent, or contradictory findings. This essay examines challenges in the study of how clinician–patient communication contributes to a patient's health and offers recommendations for future research.

Discussion

Communication may directly impact outcomes, but more often it will have an indirect effect through its influence on intervening variables (e.g., patient understanding, clinician–patient agreement on treatment, adherence to treatment). For example, a patient communication skills intervention may not directly improve pain control for cancer patients. However, it may do so indirectly by activating patients to talk about cancer pain, which prompts the physician to change pain medication, which leads to better pain control. Additionally, communication measurement is complicated because relationships among communication behavior, meaning, and evaluation are complex.

Conclusion

Researchers must do more to model pathways linking clinician–patient communication to the outcomes of interest, particularly pathways in which the communication effects are indirect or mediated through other variables. To better explicate how communication contributes to health outcomes, researchers must critically reflect on the assumptions they are making about communication process and choose measures consistent with those assumptions.

Introduction

Except in rare circumstances, the delivery of medical care is fundamentally a communicative enterprise in which clinicians, patients, and (when appropriate) families discuss a patient's health, decide on the best therapeutic action, and make plans for follow through on those decisions. This reality begs the question of whether the way in which clinicians and patients communicate with one another can contribute to the patient's health and well-being following the consultation.

In this essay, first we provide a selective review of research of clinician–patient communication (most of which has focused exclusively on physicians) and highlight a number of inconsistencies and contradictory findings in this literature. Second, we lay out two sets of challenges in studying the relationship between communication and outcomes, one centered on modeling pathways through which communication can contribute to improved health and the other on theoretical and methodological issues related to conceptualizing and measuring communication process. Finally, the essay concludes with recommendations for future research aimed at explicating relationships between clinician–patient communication and health outcomes.

Section snippets

Conundrums in communication and health outcomes research

Two of the earliest studies finding relationships between features of physician–patient communication and health outcomes were in the 1980s by Kaplan et al. [1] and Orth et al. [2]. Kaplan et al. found that diabetes patients who were more participatory in their visits (e.g., exerting control, sharing floortime with the doctor) subsequently had lower blood pressure and better metabolic control 8–12 weeks after their consultations compared to more passive patients. In the Orth et al. study,

Challenges for understanding relationships of communication with health outcomes

Our efforts to understand the relationships between clinician–patient communication and health outcomes face two major challenges, one related to modeling communication pathways to improved health and the other to measurement and theoretical challenges inherent in the study of communication processes (see Fig. 1). In the sections below, I discuss each and possible ways to address these challenges.

Conceptual and measurement challenges for studying clinician–patient communication

As noted in Fig. 1, there are a number of conceptual and measurement challenges that must be addressed if we are to better understand ways in which clinician–patient communication contributes to better health. Currently, communication research suffers from a serious lack of integration across different research program both in terms of theory and measurement. Rarely do researchers lay out the theoretical foundation for how they are approaching communication process and, when they do, they often

Conclusion

Communication in medical encounters matters. Yet, it is complex. We as a research community should do more to explain how and why. Toward this end, we need to model pathways through which we identify specific communication features that activate processes that can directly or indirectly contribute to improving a patient's health and well-being. Because these pathways will most often be indirect, we need to account for proximal and intermediate variables that link clinician–patient communication

Conflict of interest

The author report no conflicts of interest.

Acknowledgement

Dr. Street is supported by the Houston Health Services Research and Development Center of Excellence (HFP90-020) at the Michael DeBakey VA Medical Center.

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The findings provide empirical evidence that reveals the underlying mechanism linking clinician-patient communication to patient health information behavior.
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The multiple linear regressions showed that students’ MMI performance upon admission is significantly associated with the communication score (b = 0.32, p = 0.006) but not the clinical score (b = 0.19, p = 0.121), when controlling for gender and cognitive criteria.
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Citation Excerpt :
Completion of the problem presentation typically leads into history taking, physical examination, diagnosis, and treatment discussions, which are doctor-led activities and allow fewer opportunities for patient agency (ten Have et al., 1991). A patient centred approach to communication has been shown to be important for health outcomes by reducing stress, lowering blood pressure, encouraging treatment adherence, and enhancing patient wellbeing (Kaplan et al., 1989; Orth et al., 1987; Street, 2013; Thompson and McCabe, 2012). A study of how people with dementia are engaged in presenting their problem to doctors is therefore of benefit.
People with dementia are often marginalised in health care due to the effects of the condition on short term memory and communication. The problem presentation is a key area of primary care consultations where patients ‘have the floor’, and hence are able to direct the trajectory of the consultation to achieve certain ends. An exploration of how patients with advanced dementia participate in this stage of the consultation can thus demonstrate their participation and subsequent engagement. We used conversation analysis to describe how healthcare professionals (HCPs), people with dementia, and their carers establish the presenting problem in 17 out-of-hours primary care home visit consultations. In all cases, the carer had called the out of hours service on behalf of the patient. Rather than traditional “what can I help you with?” problem solicits, HCPs instead stated their reason-for-visit using information provided by the carer. All the patients showed some misalignment with this presented reason-for-visit, by denying the existence of current symptoms and/or their involvement in the decision to call the doctor. Carers appeared to show respect for the patient's ownership of their experience, only providing input on invitation from doctors or patients. Patient acknowledgement and willingness to engage in examination were needed for progressivity, but agreement with the reason-for-visit was not. In two consultations, the reason-for-visit was not explained to patients, and in both cases this resulted in the person with dementia showing frustration and resistance to examination. People with dementia may resist doctor home visits for many reasons, such as embarrassment for not remembering symptoms, or stoicism in the face of medical ailments. These findings show how the balance of progressivity and intersubjectivity tips towards progressivity in consultations with people with dementia, but this is reversed when the patient is not engaged in the reason-for-visit.
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View full text

How clinician–patient communication contributes to health improvement: Modeling pathways from talk to outcome

Abstract

Objective

Discussion

Conclusion

Introduction

Section snippets

Conundrums in communication and health outcomes research

Challenges for understanding relationships of communication with health outcomes

Conceptual and measurement challenges for studying clinician–patient communication

Conclusion

Conflict of interest

Acknowledgement

Patient Educ Couns

Patient Educ Couns

Pain

J Pain Symptom Manage

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

Soc Sci Med

Patient Educ Couns

Am J Prev Med

Patient Educ Couns

Patient Educ Couns

Assessing the effects of physician–patient interactions on the outcomes of chronic disease

Med Care

Patient exposition and provider explanation in routine interviews and hypertensive patients’ blood pressure control

Health Psychol

Provider–patient communication and metabolic control

Diabetes Care

The impact of patient-centered care on outcomes

J Fam Pract

Participatory patient–physician communication and morbidity in patients with systemic lupus erythematosus

Arthritis Rheum

Change in metabolic control and functional status after hospitalization: impact of patient activation intervention in diabetic patients

Diabetes Care

Patient participation in deciding breast cancer treatment and subsequent quality of life

Med Decis Making

Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. The Diabetes Care From Diagnosis Research Team

Brit Med J

Can 40 seconds of compassion reduce patient anxiety?

J Clin Oncol