Finding the right interactional temperature: Do colder patients need more warmth in physician communication style?
Introduction
Some patients are more difficult to interact with and more difficult to treat (e.g., Breeze and Repper, 2002, Elder et al., 2006, Haas et al., 2005, Steinmetz and Tabenkin, 2001, Strous et al., 2006). Patients are considered as more difficult, for instance, when they do not adhere to treatment recommendations, when they are especially demanding (e.g., in terms of staff, time, or resources), when they are disruptive, when they are rude, or when they are hostile (Breeze and Repper, 2002, Schwenk et al., 1989, Steinmetz and Tabenkin, 2001). When such difficult behavior in the patient does not relate to an underlying psychopathology (e.g., psychosis, borderline personality) or to the complexity of the diagnosis (e.g., patient with multiple complaints), it often relates to personality characteristics represented by the lower end of the agreeableness dimension of Costa and McCrae’s (1992) Big Five model of personality (Schwenk et al., 1989).
Research has shown that patients lower on the agreeableness dimension can be difficult patients in that they typically have a poorer alliance with their physicians (Burns, Higdon, Mullen, Lansky, & Wei, 1999), report more suspicion and mistrust with their healthcare providers, and show less adherence to the treatment (Christensen, Wiebe, & Lawton, 1997). Moreover, less agreeable patients report less satisfaction with medical care than people high in agreeableness (Hendricks, Smets, Vrielink, VanEs, & DeHaes, 2006). Qualitative research on difficult patients suggests that physicians can compensate some of the negative effects of patients' disagreeableness on the interaction outcomes (e.g., low satisfaction, mistrust in the physician, non-adherence to the treatment) by being especially attentive, empathetic, tolerant, non-judgmental – in other words by being particularly affiliative with those patients (e.g., Breeze and Repper, 2002, Elder et al., 2006, Haas et al., 2005, Steinmetz and Tabenkin, 2001, Strous et al., 2006). For instance, in summarizing previous research done on difficult patients, Haas et al. (2005) recommend that physicians improve listening behaviors and interrupt patients less, avoid blaming the patient, and express empathy. Such research suggests that conversely, when physicians adopt a communication style low in affiliativeness, less agreeable patients – maybe because they are more demanding and critical with others (Amitay, 2007, Costa and McCrae, 1992) – react more negatively than agreeable patients do. Research conducted outside the physician-patient context has shown that less agreeable individuals respond with greater quarrelsomeness to quarrelsome behavior (e.g., not responding to questions or comments, criticizing, raising one's voice, showing impatience) in others than more agreeable individuals do (Moskowitz, 2010). In sum, because less agreeable individuals are less tolerant and lenient with others (Amitay, 2007, Costa and McCrae, 1992) and more reactive to unfriendly behaviors (Moskowitz, 2010) than agreeable individuals, we expected them to show negative consultation outcomes particularly when the physician adopts an unfriendly communication style. More specifically, we predicted that less agreeable patients would react more negatively than agreeable patients to a relatively low level of physician's affiliativeness (i.e., to a physician behaving and communicating in a colder, more distant, and less friendly way) in terms of satisfaction with the medical visit, trust in the physician, and determination to adhere to the treatment. Identifying a physician communication style that negatively affects more difficult patient encounters can help guiding physician communication training. Being aware of which communication style to avoid when facing a more difficult patient is important for a physician in order to provide these patients with the same quality of care as patients who are easier to deal with.
Section snippets
Physician affiliativeness
Physician affiliativeness is signaled by behaviors that convey warmth, friendliness, interest, empathy, a desire to help, honesty, a nonjudgmental attitude, and/or humor (Buller & Buller, 1987). It can be expressed through nonverbal behaviors such as smiling, nodding, facial expressiveness, vocal backchannels (e.g., “uh-uh”, “mmh”), soft touch, face-to-face position, forward lean, bodily relaxation, close interpersonal distance, or interactional synchrony (e.g., Andersen & Andersen, 1999). It
Patients lower on the agreeableness dimension
The dimension of agreeableness represents the degree to which an individual tends to act and to communicate in an affiliative way (Costa & McCrae, 2007). Agreeableness is characterized by cooperative behaviors, a desire to create positive and warm relationships, and by trust in others. Disagreeableness represents the negative pole of this dimension and it is characterized by the opposite behaviors (e.g., non-cooperative behaviors, no or less of a desire to create positive and warm
Participants
Physicians were general practitioners working in the French-speaking part of Switzerland who were contacted by phone and asked for their voluntary participation. Seventy-two were contacted and 39 of them agreed to participate (54% of the contacted physicians). For three of them, it was not possible to recruit patients that fulfilled the inclusion criteria (see below) resulting in a total of 36 physicians (20 male physicians and 16 female physicians).
For each physician, the first female patient
Results
With respect to patient satisfaction, results showed that the interaction between physician affiliativeness and patient agreeableness significantly predicted patient satisfaction, b = −0.27, p = .035, f2 = 0.21. According to Cohen's (1988) norms for f2 values, this indicates a medium to large effect size. None of the control variables (i.e., physician gender, patient gender, patient age, gravity of the medical problem, and physician dominance) was a significant predictor of the satisfaction
Discussion
The goal of this study was to test whether patients who are lower on the agreeableness dimensions react more negatively (i.e., less satisfaction, less trust, and less adherence) than agreeable patients to lower levels of affiliativeness (i.e., warmth, friendliness) in their physician's communication style. Results confirmed our predictions for satisfaction and trust: in less agreeable patients, the outcomes of satisfaction and trust were lower when physician affiliativeness was lower, whereas
References (42)
- et al.
Agreeable patient meets affiliative physician: how physician behavior affects patient outcomes depends on patient personality
Patient Education and Counseling
(2013) - et al.
Concordance between physician communication style and patient attitudes predicts patient satisfaction
Patient Education and Counseling
(2012) - et al.
Beliefs, personality, and person perception: a theory of individual differences
Journal of Research in Personality
(1980) - et al.
Integrating measurement of control and affiliation in studies of physician-patient interaction: the interpersonal circumplex
Social Science & Medicine
(2003) - et al.
Physicians' communication and perceptions of patients: is it how they look, how they talk, or is it just the doctor?
Social Science & Medicine
(2007) - et al.
The hateful patient revisited: relevance for 21st century medicine
European Journal of Internal Medicine
(2006) - et al.
Multiple regression: Testing and interpreting interactions
(1991) Supportive and undermining relational patterns in individuals vulnerable to major depression
Dissertation Abstracts International: Section B. The Sciences and Engineering
(2007)- et al.
Measurements of perceived nonverbal immediacy
- et al.
Participants' ratings of male physicians who vary in race and communication style
Psychological Reports
(2002)