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MODELS OF DOCTOR-PATIENT RELATIONSHIP Debra Roter
Objectives Explore the theoretical and philosophic basis defining the therapeutic relationship Explore the expression of the therapeutic relationship in actual practice based on empirical study
Plato was perhaps the first spokesman for patientcentered medicine A physician to slaves never gives his patient any account of his illness The free physician, who usually cares for free men, treats their diseases first by thoroughly discussing with the patient and his friends his ailment. --From Dialogues of Plato
Patient-Centeredness Communication in the form of patient-centeredness is on the national health care agenda Patient centeredness broadly defined as a biopsychosocial approach to medical treatment that embraces patients preferences, experiences and expectations and in which patients are offered opportunities to participate in their care in ways that enhance partnership and understanding
Communication linked to healthcare quality Communication is regarded as key to any significant improvements in health care quality -- patient-centered care is included alongside the core quality requisites of safety, timeliness, effectiveness, efficiency and equity. IOM reports: Crossing the Quality Chasm; To Err is Human; Health Professions Education.
Health People 2010: Objectives for the Nation Health objective 11.6: increase the proportion of persons who report that their health care providers have satisfactory communication skills (Surgeon General 2001). These goals are integrated into objectives in screening, diagnosis, treatment, prevention, and hospice care applicable to chronic diseases and cancer.
What is the theoretical and philosophic basis defining the therapeutic relationship?
Prototypes of Doctor-Patient Relationships Low Physician Control High Low Patient Control High Default Consumerism Paternalism Mutuality Roter & Hall, 1996
Core Elements of the Therapeutic Visit Paternalism Mutuality Consumerism Default Goals of Visit Physiciandetermined Negotiated Technical Information Unclear Patient Values Assumed Explored Unexamined Unclear Physician Roles Guardian Advisor Consultant Unclear
Methods Procedure: audiotape of primary care visits Setting: urban hospital-based ambulatory clinics (75%) and private practice (25%) in 11 sites across the US and Canada Participants: 127 physicians and 537 chronic disease patients
Methods Physicians: 35 second- and third-year residents, 63 primary care physicians; 79% male, 95% white, average age 34.5 years Patients: 55% white and 45% African American, 65% earning < $10,000, 58% female, average age 60 years (range 21 to 94), 50% with at least 7 prior visits
Statistical Technique Cluster analysis based on three physician and patient communication categories: Biomedical information Psychosocial exchange Question-asking
Cluster Analysis Revealed 5 Distinct Communication Patterns Paternalistic: Narrowly Biomedical (32%) Paternalistic: Expanded Biomedical (33%) Mutalistic: Biopsychosocial (20%) Mutalistic: Psychosocial (7%)
Paternalistic Patterns: Narrowly Biomedical Physicians are younger and more likely to be male; patients are older, poorer, and more likely to be African American. 32% visits: 68% MD with at least one visit High medical questions (19% MD; 4% PT) High biomedical talk (27% MD, 70% PT) Low psychosocial talk (2% MD, 5%PT)
Paternalistic Patterns: Expanded Biomedical Patients somewhat older than in others 33% visits: 61% MD with at least one visit High medical questions (17% MD; 5% PT) Mod. biomedical talk (22% MD, 56% PT) Low psychosocial talk (7% MD, 16% PT)
Mutualistic Patterns: Biopsychosocial Physicians are older and more likely to be female; patients are better educated and more likely to be white. 20% visits: 42% MD with at least one visit Low medical questions (11% MD, 4% PT) Mod. Biomedical talk (23% MD, 39% PT) Mod. psychosocial talk(11% MD, 29%PT)
Mutualistic Patterns: Psychosocial Patients are more likely to have a psychological diagnosis 7% of visits: 19% MD with at least one visit Low medical questions (9% MD; 3% PT) Low biomedical talk (20% MD, 25% PT) High psychosocial talk (19% MD, 39% PT)
Consumerist Pattern Physicians are older and more likely to be female; patients are better educated. 8% visits: 23% MD with at least one visit Low MD questions (10% MD) High PT questions (6%) High biomedical talk (43% MD, 53% PT) Low psychosocial talk (4% MD, 11%PT)
What do these patterns mean for the visit content, process, and outcome?
Communications Patterns and Verbal Dominance Pattern Communication Ratio Doctor : Patient Biomedical (restricted) 1.4 : 1 Biomedical (expanded) 1.36 : 1 Biopsychosocial 1.29 : 1 Psychosocial 1.08 : 1 Consumerist 1.62 : 1
Communications Pattern & Patient Satisfaction Satisfaction PT MD Biomedical (restricted) Tied Last Last Biomedical (expanded) Tied Last Tied Third Biopsychosocial Second Second Psychosocial First First Consumerist Third First
Communications Pattern & Patient Recall Pattern Type Medication Recall Biomedical (restricted) 67% Biomedical (expanded) 73% Biopsychosocial 82% Psychosocial 89% Consumerist 92%
Communications Pattern & Length of Visit Pattern Type Length of Visit in Minutes Biomedical (restricted) 20.5 Biomedical (expanded) 21.8 Biopsychosocial 19.3 Psychosocial 22.9 Consumerist 21.9
How do these patterns inform conceptual thinking about patientor relationship centered care?
Patient-Centeredness A biopsychosocial approach to medical treatment that embraces patients preferences, experiences and expectations and in which patients are offered opportunities to participate in their care in ways that enhance partnership and understanding
Relationship-Centered Care 1. relationships include the personhood of the participants, 2. affect and emotion are important part of relationships, 3. relationships occur in the context of reciprocal influence, 4. formation and maintenance of genuine relationships in health care is morally valuable.
Does patient-centeredness matter for visit outcomes?
Evidence There is a growing evidence base linking communication to direct visit outcomes (satisfaction, recall, adherence) based on meta analysis. A smaller but very important literature establishing clinical significance: Improved HbA1C; BP Improved functional status Improved emotional health Improved anxiety and coping Improved self-reported health
Visitors Outcomes: Predictors of Patient Recall Meta-analysis of the communication literature found significant (small to moderate) ES relationships between recall and: 1. More information-giving 2. Less question-asking 3. Most positive talk 4. More partnership building (Hall, Roter, Katz, 1988)
Visit Outcomes: Correlates of Patient Satisfaction Significant (small to moderate) ES for patient satisfaction were associated with: 1. More information-giving 2. More positive talk (both verbal and nonverbal) 3. Less negative talk 4. More social talk 5. More partnership building 6. More talk overall (Hall, Roter, Katz, 1988)
Visit Outcomes: Correlates of Patient Compliance Significant (small) ES for patient compliance were associated with: 1. More information-giving 2. Less question-asking overall BUT more compliance focused questions 3. More positive talk (both verbal and nonverbal) 4. Less negative talk (Hall, Roter, Katz, 1988)
COMMUNICATION Patient is given informational intervention (Kaplan-Greenfield; Rost; Anderson; Langewitz) Physician is more informative (Kaplan - Greenfield; Rost) PATIENT OUTCOME Functional status HbA 1C, BP Self-ratings of health Self-efficacy Reduction in distress
COMMUNICATION Patient expresses affect (Kaplan-Greenfield) Patient is given psychological coping intervention (Anderson) Patient feels known (Beach et al, 2006) PATIENT OUTCOME HbA 1C Functional status HbA 1C, Self-efficacy stress management; social support Receipt of HAART, adherence to HAART, Undetectable viral load
COMMUNICATION Patient is empowered to make Rx decisions (Langewitz, Anderson) Provider is patient-centered (Kaplan-Greenfield; Rost; Street) Patient asks questions (Kaplan-Greenfield; Rost) Patient is more verbally engaged (Kaplan-Greenfield; Rost; Street) PATIENT OUTCOME HbA 1C MD-Pt relationship Functional status Emotional health Self-reported health
Is routine medical visit communication related to the malpractice experience of surgeons and primary care physicians -- either as a contributor or result of prior litigation?
Claims were defined as any patient request for funds, any malpractice suit filed by a patient, or any contact by an attorney who represented a patient in an action against the physician, regardless of outcome. Incidents defined as an event reported by a physician to the insurance company fearing legal action was hot included as a claim. (Levenson, Roter, Mullooly, Dull & Frankel, 1997)
Methods 65 surgeons and 59 primary care doctors were recruited to the study. Half of the physicians had 0 lifetime claims Half had > 2 lifetime claims Matched on years in practice and specialty 10 patients for each physician, drawn as a convenience sample from the physician s daily log, were recruited to the study. Over 1200 primary care and surgical visits were audio recorded.
Audiotape Analysis No-claims compared with multi-claim PC doctors: longer visits (by 3 minutes 15 vs 18.3) used more partnership exchanges (asked opinion, cued interest, checked understanding; paraphrase/ interpretations) used more humor and joking provided more orientation what to expect about the flow of the visit.
Analysis of Primary Care Visits Using communication variables derived from the audiotape analysis, 80% of primary care physicians were accurately classified in terms of their malpractice status based solely on their communication patterns A 30% improvement over chance.
What About Surgeons? Trends suggested sued surgeons had shorter visits, by almost 1.5 minutes, used less partnership-type exchanges, and patients (but not physicians) seemed to laugh more.
Physician Voice Tone Further analysis, using thin slice techniques found a relationship between physicians voice tone and malpractice history. Thin slice relies on very short clips of speech judged by multiple raters on a variety of affective dimensions (including concern/ anxiety and dominance) and stripped of content by passing through an electronic filter.
Physician Voice Tone Surgeons judged to have more dominant voice tone were almost three times as likely to be in the sued group Surgeons whose voice tone conveyed concern/anxiety were half as likely to be in the sued group. (Ambady et al, Surgery, 2002).
Physician Voice Tone Earlier studies using thin slice analysis found that negative voice tone (anxiety) coupled with positive words (sympathetic and calming) was associated with more patient satisfaction and better appointment keeping over a 6- month period A second study similarly linked anxious vocal qualities with patient satisfaction. (Hall et al 1981; Roter et al, 1987)
Physician Voice Tone Anxiety in the physician s voice tone may be heard as conveying seriousness, attentiveness, and concern for the patient s well-being and future health. Voice tone may act to frame the way in which the verbal message is interpreted.
What Do These Findings Say About Clinicians? Does communication style and voice tone heighten a doctors risk of being sued, or does the experience of being sued change how doctors communicated (and feel about) patients?
What Does This Say About Patients? Patients, are looking for cues and clues by which to judge their relationship; they are looking to see if the physician cares about them, will go the extra mile for them, if the physician likes them.
Mutually Collaborative Models Can Bridge Medicine s Art & Science