Doctor-Patient Interactions: An Analysis of Voices

Doctor-Patient Interactions: An Analysis of Voices

Literature Review

“Medicine is an art whose magic and creative ability have long been recognized as residing in the interpersonal aspects of patient-physician relationship” – Hall, Roter and Rand (1981).

            Originally biomedicine and medicine was ruled by the scientific approach alone, which focussed upon objectivist research in a positivist light. More recently however, the constructivist paradigm has emerged, incorporating ‘objective’ clinical findings and interventions as well as the emergence of recent evidence for the doctor-patient relationship as a contributor to patient outcomes (Wilson, 2000). The rise of social constructivist theories has meant an increase focussing upon the effects of doctor-patient interaction to the extreme. (Greenfield, 2001; Charles, Whelan & Gafni, 1999).

The doctor – patient relationship has been stated as one of the most complex of interpersonal relationships due to the influence on patients’ behaviour and wellbeing (Ong, Haes, Hoos & Lammes, 1995). More specifically influences are on; satisfaction with care, recall, understanding of medical information, quality of life, adherence to treatment and state of health (Bensing, 1991; Higginson & Carr, 2001; Squier, 1990). Continually, Cartwright (1967) stated that patients express the most dissatisfaction with the information they receive from doctors than of any other aspect of medical care and due to the influences it can have on treatment, it is therefore important that communication is as successful as possible to ensure the completed process is successful. Furthermore, Pendleton and Hasler (1983) note that reasoning for the complexity of this interaction means that there is no model or theory that combines the literature and if such an approach was to be created the definition of key terms, methodology and aims would be too confusing. This is due to each study defining aspects of doctor – patient communication completely differently; reinforcing that the concept is such a complex phenomenon. However, much of recent literature has reiterated first and foremost the importance of the doctor’s knowledge and understanding of the patient’s presenting compliant (Gulbrandsen, Fugelli & Hjortdahl, 1998; Hjortdahl, 1992; Magraw, 1958).

Furthermore, the principles of communication in the doctor-patient relationship were listed by Fletcher (1973) as creating a change in the knowledge, attitude and behaviour of the patient, as well as noting that the occasion must be matched to the knowledge, initial background, interests, purposes and needs of the recipient. Fletcher continues to state that only a few can master good communication without special tuition and constant attention to its effectiveness, which gives the impression that the constancy of communication depends on more than just good nature.

Continually, Parsons original role theory suggests that there are two overall aspects of the medical interaction. The first being the instrumental function dealing with technical matters and the second being the expressive function concerning psychological and social skill factors or the ‘art of medicine’ (Parsons, 1937).

Problems with Communication

Fitton and Acheson (1979) noted that patient anxieties about going to see a doctor is mainly the anticipation in making matters clear to the doctor. Furthermore, Pendleton (1979) found that 20-25% of total consultations result in communication difficulties; with 80% of difficulties falling in transmission of information and 13.5% falling when the doctor tries to persuade the patient on a matter.

Pendleton (1981) explored the differences between ‘good’ and ‘bad’ communication. ‘Bad’ communication occurred if the clinical decision making was faulty in anyway, if there was a wrong diagnosis made or inappropriate treatment was recommended. However, ‘good’ communication was not only reported to be dependent on high standards of medicine but also the communication between doctor and patient had to be adequate.

Furthermore, it was found that doctors failed to identify 54% of patients’ reasons for consulting and 45% of their worries. This is due to an overestimation of the extent to which patients are primarily concerned with medical treatment rather than being concerned with gaining information and support (Barry, Stevenson, Britten, Barber & Bradley, 2000). Additionally, (Stevenson et al, 2000; Stewart, McWhinney & Buck, 1979) found that unsuccessful interactions occur when patients have needs and their needs are or cannot be addressed. This evidence therefore demonstrates a need to research the difference between good and bad communication and what constitutes as bad interaction – without researching as such it will be difficult to identify and improve the problems with doctor-patient interactions.

Doctor – patient interaction

The consultation itself is an opportunity for both doctor and patient to identify and choose appropriate actions for each problem presented. There have been many models created to explain the process of the interaction; firstly, doctor – patient communication can be seen as a one way transmission from doctor to patient (Shannon & Weaver, 1949). However, this does not recreate the dynamic interaction that often takes place between patient and doctor and therefore it might instead be more relevant to apply a two-way model. More recently, Ratzan, Payne and Bishop (1996) suggested a two-way transactional model of communication, involving dialogue between two parties where shared meaning and mutual understanding grows.

On the other hand, the more recent social constructivist model of communication (Potter, 1996) suggests that communication in clinical settings is created by the language that is used and doctors build communicative landscapes for the patients. This allows for different types of interaction – it could be dominated by the language professionals use of it may allow the patient to have a voice.

Interactions can depend on the verbal and nonverbal signal sent by both patient and doctor. For example, Barry, Stevenson, Britten, Barber and Bradley (2001) found that doctors switch their communication strategy depending on whether they perceived the patient to be presenting with physical or psychological problems. Furthermore, Byrne and Long (1976) suggested a scale consisting of seven styles of doctor behaviour; from doctor to patient centred.

Voices in the medical consultation

By identifying the doctor – patient interaction as a dynamic / dyadic process it is advisable to further look into the interaction through analysis of the verbal or nonverbal content specifically. A large part of research into the verbal aspects of the interaction has focussed upon the voices shown by both doctor and patient with the development of opposing theories.

Habermas’ theory of communicative action (Habermas, 1981) firstly defines communication as occurring when two or more actors establish a relationship and ‘seek to reach an understanding about the action situation and their plans of action in order to coordinate their actions by way of agreement.’ Furthermore Habermas suggests that there are two types of rationality (value and purposive rationality) which produces two different types of world (lifeworld and the system.) Value rationality involves grounded experiences of everyday events and is therefore inhabited in the lifeworld (real life) whereas purposive rationality (voice of medicine) occurs within formal systems / the system. Furthermore, Mishler (1991) applied this to 20^thcentury western society suggesting that the voice of medicine is used purely in a scientific context; when dealing with patients, the science-based medicine works on hidden assumptions which could be seen as distortions of the lifeworld and are incompatible with the natural undistorted communication patterns of the voice of the lifeworld. Furthermore, results found that when doctors adopted the voice of the lifeworld in the Mutual Lifeworld consultations (where both patient and doctor engage in the lifeworld) for patients with psychological problems it appeared to be a successful strategy, even when patients were also suffering from physical problems (Barry et al, 2001).

More specifically Cordella (2004) suggested that there are three types of voice applied by the practitioner and four types of patient voice. The voices applied by doctors include; the doctor voice, the educator voice and the fellow human voice (which reflects Habermas’s and Mishler’s work); whereas the patient voices include: health-related story telling, initiator voice, social communicator and the voice of competence.

The doctor voice is the most commonly used in an interaction, as it is used primarily to seek information from the patient (e.g. asking questions), complete an assessment, review of the problem and lastly to create alignment of the patient to authority. Furthermore, the educator voice is stated to be the voice of knowledge in the medical field as it is applied to share medical information with the patient to help them understand their health condition and appreciate the benefits of treatment. As well as this the educator voice is used to communicate medical facts, responding to patient discomfort and finally communicating the medical treatment and management. Both the doctor and educator voice work together to maintain the practitioners control in the exchange. The last voice applied is the fellow human voice. This voice is used to show empathy and to facilitate the telling of patient’s stories, assist the telling, create empathy, to show attentiveness and to ask questions about the patient’s general wellbeing. It is used mainly to help patients feel secure, increase patient satisfaction and enhance the medical outcome.

Patient satisfaction

As noted by Ong, et al (1995), the doctor-patient relationship is one of the most complex communication processes, as it involves an interaction which consists of unequal positions and is often non-voluntary. Usually, the patient is forced to give private information about themselves to a stranger, which could cause discomfort for the patient. Certain aspects of doctor-patient communication seem to have an influence on patients’ behaviour and well-being and for example; satisfaction with care, adherence to treatment, recall and understanding of medical information, coping with the disease and quality of life (Carter, Inui, Kukull & Haigh, 1982; Smith, Polis & Hadac, 1981). Specifically, experiencing good doctor-patient communication has a positive impact on health outcomes in previous studies. For example, Roter, Hall, Kern, Barker, Cole and Roca (1995) found that an increase in care associated with the patient’s communication skills was associated with a reduction in emotional distress in patients. Furthermore, a follow up study found that most patients were better after three weeks; but those who were still worried, had unmet expectations and lower satisfaction, were still symptomatic (Kroenke & Jackson, 1998). However, it is hard to define what constitutes good or bad communication so by exploring this relationship and what constitutes satisfactory communication the results can be applied by physicians to try and increase patient satisfaction through application of the voices which are present in the good but not the bad communication clips.

Focus of Investigation

Overall, the communicative action being studied here consists of the doctor – patient relationship; more specifically the verbal discourse forms used by both doctors and patients in a dynamic medical consultation as different kinds of voices. The doctor discourse consists of three voices: a doctor voice (seeking information, assessment, review and keeping authority), educator voice (using medical terminology to communicate facts, responding to patient discomfort, communicating medical treatment and management) and fellow human voice (to encourage the patient to talk to the doctor).  On the other hand, the patient voice consists of four sub-voices: health-related storytelling (informing the doctor of the problem and how the problem came about), competence (complying with the doctor’s demands; rational competence – making decisions, performance competence – performing skills to external standards and reflective competence – actions to internal standards), social communicator (discourse not related to the interaction) and initiator voice (questioning the health professional’s discourse).

In the current video clip two interactions take place, an example of good patient-doctor communication and an example of bad doctor-patient communication; the video clip is used for training purposes to show the student what constitutes a good or bad bedside interaction. The setting is the same for both interactions, the patient is lying in a hospital bed and the doctor is visiting to complete a consultation.

Initially a transcript will be taken of the interaction, as the focus of the investigation will be the verbal content to identify whether the voices suggested in previous research are present in both interactions and whether there are any effects on patient satisfaction.

Two questions will be used to guide the analysis:

1. What is the difference between good and bad communication when identifying voices?
2. Does the absence of a specific voice in the bad communication clip; in either patient or doctor dialect cause less patient satisfaction overall?

Interpretation and analysis

In accordance with Habermas’ (1981) and Mishler’s (1991) theory of voices within the interaction and Cordella’s (2004) theory of specific doctor and patient voices, both transcripts were studied to identify if voices present in the research was reflected each interaction. There are three types of doctor voice identified (the doctor voice, the educator voice and the fellow human voice) and four types of patient voice (health-related storytelling, the voice of compliance and the initiator voice), for further examples please see Appendix one.

Doctor voices: the Doctor voice

The doctor voice is usually employed by the practitioner at the start of the interaction. Primarily the voice is used to seek information from the patient through asking questions to allow them to complete a full assessment review the problem and help create an alignment of the patient to authority. This voice is used intermittently throughout the interaction often to remind the patient their status within the interaction.

The voice is present mainly in the first interaction, for example: “I am Lisa and I am going to be your nurse, so how are you feeling?”(Good communication clip, page 1, line 5) and later: “Is this hurting you? … Are you feeling comfortable?” (Good communication clip, page 2, lines 46-48). However, the second interaction, there are only two examples of the doctor voice including the short question of “what happened?” (Bad communication clip, page 3, line 20).

The Educator voice

            The educator voice is used by the practitioner to convey medical terms and information to the patient to help the patient understand and follow the appropriate treatment and the presenting health condition. However, there is only evidence of this being used in the first interaction: “First of all I am going to take your blood pressure and then I’m going to protect your arm and at the end I am going to remove your bandage and you will be healed OK?” (Good communication clip, lines11-13). There is not however, any evidence in the second clip.

The Fellow Human voice

Lastly, the fellow human voice is used by practitioners to help build a stable relationship between patient and practitioner, which elicits trust and therefore a more truthful interaction. There is again evidence in the first interaction but not the second. For example: “Are you studying or are you working?” (Good communication, page 2, line 38) and later: “if you need something you only have to press the button …. And I will be here in to seconds. So everything is going to be alright. Don’t worry, OK?” (Good communication, page 2, lines 52-54).

Patient voices: initiator voice

The initiator voice is used by the patient to evoke a response from the practitioner to explore or question the verbal content that the doctor provides. For example, “is it going to hurt me?” (Good communication, page 1, line 16) or “What are you doing?” (Bad communication, page 3, line 33).

Health-related story telling

Health-related story telling is used by the patient to explain how the problem was created – “I was practising gym in the garden where suddenly I fell down, so my arm and foot are broken” (Good communication, page 1, line 8). However, the second clips story telling is somewhat limited – “my arm is hurting me” (bad communication, page 3, line 21) as the doctor does not ask for any more detail or confirmation.

Social communicator voice

The social communicator voice provides a forum for patient to discuss personal or emotional difficulties. This is only evident in the first interaction as the conversation is started through the doctor’s doctor voice which is not evident in the second interaction. “I like to practice soccer and I also play in a soccer team.” (Good communication, page 1, line 18).

The voice of compliance

The voice of compliance is used by the patient to follow the practitioner’s requests. Although often this is barely a yes or no answer, it helps the interaction by letting the practitioner know that the balance of power is within their hands. For example “doctor: Can you breathe deeply? Patient: Yes.” (Good communication, page 1, line 19) and later “doctor: I am going to protect your arms with these so can you move?”(Good communication, page 1, line 25).

Discourse Patterns

Discourse patterns are another highly researched area in medicine discourse (Waitzkin, 1989; Davidson, 2002). More recently, Cordella (2004) suggests two forms of discourse patterns in the Doctor voice. The first consisting of the three stop footing pattern. This patterns starts with the doctor voice, followed by the educator voice finishing with the doctor voice, with the patient voices in between; the doctor voice first initiates the interaction and the interaction finishes when the patient responds to the doctor voice, or it may be finished with a question.

This pattern is relevant in the current good communication discourse; switching between doctor and educator voices depending on the patient’s responses (the fellow human voice is also included here). The discourse in the good communication clip follows the pattern of: doctor voice, educator voice, fellow human voice, doctor voice, educator voice, fellow human voice, doctor voice, finishing by giving their farewells in a fellow human voice. Therefore, this is an example of an extended version of Cordella’s (2004) pattern.

However, these patterns are not evident in the bad communication discourse as the doctor chooses to ignore the patient’s questions; in the bad communication clip for example: “patient: What are you doing?” “Doctor: Be quiet, I am listening to your heart beat.” (Bad communication, page 3, line 17) From this it is evident that doctor-patient discourse should follow a certain pattern for it to be deemed satisfactory.

In conclusion, it is evident that there is a vast difference in voices between what constitutes good or bad communication (as asked by the first research question). The concept of bad communication is partly characterised by a lack of diversity in voices. The fellow human voice and educator voice from the doctor were missing, which led to the absence of the social communicator voice in patients and this answers the second question leading the research (whether the absence of a specific voice in the bad communication clip causes a less successful interaction).  Furthermore, within good communication discourse follows a set pattern between patient and doctor whereas the discourse in bad communication does not have a set pattern and the patient’s requests for information are often ignored. Both of these above reasons could therefore be the difference between good and bad verbal communication.

Recommendations and conclusions

From this analysis it is possible to identify the gaps in bad communication when looking at the dynamic / dyadic consultation. When identifying the doctor voices in the good communication condition, it is clear that all three (doctor voice, educator voice and fellow human voice) are present. However, in the bad communication condition the doctor only demonstrates the doctor voice (asking questions about the patient’s condition, giving assessment and review) but there is an increase in the patient initiator voice. This suggests that the educator and fellow human voices are important in raising the patient’s satisfaction levels as the patient is not informed as to what is occurring in the interaction and is left in the dark. On the other hand, when focusing on the patient voices, again in the good communication clip all four voices are used (initiator, social communicator, health-related story telling and compliance) with numerous examples; however, in the bad communication clip only three types of voice are used each with limited examples, not including the social communicator voice.

Also evident is a relationship between the doctoral fellow human voice and the patient as a social communicator. The questions asked by the doctor in the fellow human voice are answered in the voice of social communicator in the good communication clip. However, in the bad communication clip both of these voices are missing. Therefore we can suggest that the first interaction is dynamic, if we believe that evidence of the fellow human voice affects the presence of health-related story telling and social communicator voices in patients. Whereas the bad communication clip has characteristics most like a transmission, as it is mainly one sided; however, the patient does try to make it two-sided with no accomplishment. However, research by Labov & Fanshel (1977) argued that health-related storytelling is most commonly associated with the doctor voice not the fellow human giving motivation to explore the relationship further.

These findings are similar to research already in the subject area – that good communication is a product of all patient and doctor voices shown, the current findings have also taken it further by proposing that bad communication occurs when these voices are not present so discourse patterns cannot be completed successfully – which constitutes as a bad interaction. This could therefore implicate the future of doctor – patient interactions, proposing that doctors must employ the fellow human voice during their interaction to make it successful. Furthermore, if it is made a compulsory part of training for doctors it could lead to the eradication of bad verbal communication completely.

Reflection

As the sole investigator I am constantly aware that the interpretation of the qualitative data may be biased by my experiences and background in relation to the doctor – patient relationship. Luckily, I have not experienced many situations in which doctor – patient communication is utilised, however, this could easily result in a misinterpretation of the interaction taking place.

On the other hand, the method of transcription was a denaturalized approach (focusing on the features of verbal language). However, this meant that the video was transcribed ignoring the non-verbal content. Although, this reflects the nature of the aims (which need focus on the voices within the interaction) it has meant that some socio-cultural features and non-verbal content of the data have been ignored, which could have improved the outcomes of the data and interpretation.

Furthermore, although the interaction was communicated in English, the participants had a very strong Spanish accent. This meant that transcription was particularly problematic, including problems with: challenges with interpreting doctor and patient pronunciation, vocalizations and the use of irregular grammar. This has meant that some cultural clues may have gone unnoticed and the verbal content may have been interpreted incorrectly, without realising. Furthermore, each part of the video clip was clearly marked as either “Good communication” or “Bad communication.” This means that the transcription was written while clearly aware of the participant intentions – this could result in significant interpretative and representational power that could have later affected the analysis and results.

In conclusion, transcription often has competing objectives and interpretation and transcriptions can be subjective or directional due to the researcher’s stance. Furthermore, problems with transcription and interpretation from a sole researcher could have meant that the research outcomes and conclusions may have been interpreted differently than it would have if transcribed or interpreted by a different researcher.

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Appendix 1: Examples of doctor and patient voices.

Appendix 2: Video transcripts – Good Communication

Appendix 3: Video transcript – Bad Communication