Doctor-patient (or client-professional, practitioner-patient, lay-professional) communication has been the focus of scholarly study and public concern for several decades. Within medicine, communication is increasingly seen as a critical skill set in the delivery of care. The doctor-patient relationship is a special kind of relationship; while patients may not know their doctors in a personal sense (and often, vice versa) they are nonetheless asked to disclose intimate details of their personal lives and reveal their bodies for examination. This vulnerability is not reciprocated from doctors to patients. There is, therefore, a degree of social imbalance in this relationship (albeit one that is socially sanctioned), which may have a bearing on communication. Barriers to effective communication between doctors and their patients, including such factors as class, gender, race, and health literacy, are discussed.
Keywords: Cultural Competence; Communication; Functionalism; Health Care Disparities; Medical Encounter; Patient Centered Care; Role Format; Sick Role
Doctor-patient (or client-professional, practitioner-patient, lay-professional) communication has been the focus of scholarly study and public concern for several decades. Within the medical field, communication is increasingly seen as a critical skill set in the delivery of care. The doctor-patient relationship is a special kind of relationship; while patients may not know their doctors in a personal sense (and often, vice versa) they are nonetheless asked to disclose often intimate details of their personal lives and reveal parts of their bodies for examination. This vulnerability is not reciprocated from doctors to patients. There is, therefore, a degree of social imbalance in this relationship (albeit one that is socially sanctioned). This may have a bearing on communication; that is, the full range of spoken, facial, bodily, and symbolic expressions that people use when they interact and exchange information with each other.
Classic studies in sociology have highlighted the potential for conflict in doctor-patient communication and identified how assumptions about patients based on class, gender, age and race influence the content and tone of communication. Moreover, research has shown that patients who understand their doctors are more likely to acknowledge their health problems, understand their treatment options, modify their health-related behaviors at their doctor’s recommendation, and adhere to treatment recommendations. Given this compelling evidence, two-thirds of medical schools now provide their students with instruction on how to communicate with patients and how to develop interpersonal skills to support effective communication (Travaline et al., 2005). Such skills, which include listening, explaining, questioning, counseling and motivating patients, are becoming core competencies for medical practice, and in the United States, demonstration of such skills is required for licensure and board certification. Nonetheless, there continue to be many barriers to effective communication between doctors and their patients, including such factors as gender, race, and health literacy.
Physician-patient communication has been central to scholarly research for at least fifty years and the ideal medical encounter (for which effective communication is critical) is increasingly viewed as one that is patient-centered (Mead & Bower, 2000) from obtaining the patient's medical history to conveying a treatment plan. The medical or clinical encounter entails much information sharing about symptoms, diagnosis, and treatment options in what has been historically and is increasingly recognized as a therapeutic relationship that provides the first step toward healing (Travaline, Ruchinskas & D'Alonzo, 2005). However, studies of patient-doctor communication demonstrate that communication is rarely patient-centered and is in fact influenced by many characteristics and ideas.
There is a surprising degree of regularity and ritual associated with communication between doctors and patients, or, more correctly, with the medical encounter. In a classic study of outpatient clinic visits in Scotland, Phil Strong (1979) found that there is an unspoken set of rules and rituals that guide the medical encounter or consultation. These rituals, encoded as role formats (or as sociologist Erving Goffman might put it, social scripts), provide tacit resources that both patients and doctors call upon, depending on their assessment of the encounter (that is, what kind of consultation they consider it to be). Strong identifies four such formats:
- Bureaucratic (doctor and patient are both polite and avoid conflict, though doctors assume patients to be less than competent);
- Charity (doctors draw attention to patients' incompetence);
- Clinical (in which the doctor and patient tacitly agree on the doctor's expertise and authority); and
- Private (in which the doctor focuses on "selling" his competence).
Core to these formats is the way the doctor typically asserts control over the communication process and directs the conversation by the following tactics: interrupting patients or breaking off conversation; excluding the patient by writing while they tell their story; and eliciting information from patients but not explaining why such information was required. Strong (1979) notes that such tactics cement the asymmetry between doctor and patient, and subsequent studies in social psychology have confirmed their use.
Indeed, studies of doctor-patient communication often begin with the observation that the relationship between doctors and their patients is unequal in terms of power, status, and knowledge. For instance, in Talcott Parsons's (1951) discussion of the sick role (a socially deviant state) the patient is entitled to be sick, provided she or he assumes certain obligations, such as making an effort to get well. Accordingly, doctors are obliged to help patients get well. How they interact and communicate with each other is central to how the sick role is negotiated, since doctors occupy a position of authority in relation to the patient (Nettleton, 1992). While such asymmetry is unproblematic in a functionalist view of the social world, it ignores the potential for conflict between doctor and patient, or of the potential for value judgments to influence the process of making clinical decisions.
For instance, doctors may discount information that patients provide and be dismissive toward them. In studies of how patients use emergency rooms, researchers have found that doctors are often dismissive of patients because in their view, based on the symptoms that patients describe, some patients should not be in the emergency room in the first place. That is, patients are judged as being overanxious (especially mothers of young children, see Roberts, 1992) or, in certain situations (such as patients who are injured but who have also been drinking alcohol) may be judged for behaving in ways that are seen as irresponsible. In such cases, patients may be judged as "normal rubbish" (Jeffery, 1979); that is, they are seen as presenting with symptoms that are considered inappropriate or trivial. While doctors usually do not explicitly inform patients of what they are thinking or what their value judgments are, they may communicate disapproval nonverbally by not listening to patients or not demonstrating empathy. More recent research confirms that in situations characterized by prejudice and fear, such as in the case of consultations about HIV risk, doctors may handle communication ineffectively in ways that make patients feel uncomfortable or even stigmatized (Epstein et al., 1998).
Barriers to Doctor-Patient Communication
Social characteristics such as gender and race influence the content and tone of doctor-patient communication, and many studies have demonstrated how the social backgrounds of both patients and doctors create barriers to effective communication. Many studies have found social class, gender, and racial differences in physician communication style, that is, how physicians talk with patients and communicate nonverbally.
First, social class differences are significant in determining how doctors communicate with their patients. Although there have been some changes in medical school recruitment, medicine is largely practiced by members of the middle, upper-middle, or upper class and as such, reflects values associated economic independence and autonomy (Mechanic, 1974). These values influence communication style, especially in terms of the language and the forms of expression used by doctors. For instance, members of the middle class tend to be more verbally explicit, while working class members tend to rely more on nonverbal communication. This means, in doctor-patient encounters between middle-class physicians and working-class patients, physicians may be more likely to talk than their patients (Cooper & Roter, 2003). In addition, patients whose health literacy levels are low (that is, they have difficulties reading and understanding written medical information), which is often associated with social class, are more likely to report poor communication with doctors in face-to-face encounters (Schillinger et al., 2004).
Second, there are differences between male and female physicians in the way they interact with their patients in general (Brody & Hall, 2000). Male physicians have been found to engage less in nonverbal gestures that communicate warmth and empathy, such as smiling, eye contact, nodding, hand gesturing, direct body orientation (facing the patient), and "back-channel responses" (such as saying "mm-hmm" to acknowledge what the patient is saying) (Cooper & Roter, 2003). Similarly, observation...
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