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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

“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

Plato was perhaps the first spokesman for patient-centered medicine

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

Default Paternalism

Consumerism Mutuality

Low Physician Control High

Low P

atient Control H

igh

Roter & Hall, 1996

Core Elements of the Therapeutic Visit

Paternalism Mutuality Consumerism Default

Goals of Visit Physician-determined

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 patient-

or 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

HbA1C, BP

Self-ratings of health

Self-efficacy

Reduction in distress

COMMUNICATION

Patient expresses affect (Kaplan-Greenfield)

Patient is given psychological coping intervention (Anderson)

PATIENT OUTCOME

HbA1C

Functional status

HbA1C,

Self-efficacy stress management; social support

Patient feels known (Beach et al, 2006) 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

HbA1C

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