INC532 – Health Communication

 Influence of managed care on physician-patient

interaction
 Role of technological advances (e.g. Internet) on
doctor-patient communication
 State and federal health policies (e.g. patient bills
of rights) influences
 Role of socio-cultural factors (e.g. race, ethnicity,
language)
Positive
 Issues identified implicate the centrality of
communication in the health care process
Negative
 Despite 40 years of research, very little is known
about the mutual influence that the changing
health care landscape and communication
dynamics have on one other. Little attention has
been paid to:
◦ Developing and testing theoretical models of processes
underlying doctor-patient interactions
◦ Explaining role of context in medical encounters
 Ecology – study of interrelationships between
organisms and their environments (p. 63)
 Ecological perspective – interaction between health
care providers and patients across a variety of
social contexts
◦ Helps explain processes germane to provider-patient
interaction
◦ Helps point out gaps in our understanding of these
processes
 Organizational Context
Managed care, Services offered,
Standards of care, etc.

THE INTERPERSONAL CONTEXT

The Health Care Provider The Patient
Predisposing Influences Predisposing Influences Political-Legal
Communication style Communication style Context
Self-concept Self-concept
Malpractice litigation,
Linguistic resources Linguistic resources
Patient bills of rights
Medicaid/Medicare
Verbal & Non- Verbal & Non-
verbal Behavior verbal Behavior

Media Context
Internet Cognitive-Affective Influences Cognitive-Affective Influences
Telemedicine Goals Goals
Mass media etc. Perception of partner Perception of partner
Perception of relationship Perception of relationship
Communicative strategies Communicative strategies
Emotional state Emotional state

Cultural Context
Race/ethnicity, SES, Religion,
etc.
 Patterns of provider-patient communication related
to patient & physician attributes and their
relationship (e.g. rapport, trust)
 Relationship b/w providers’ and patients’
communicative actions & outcomes (e.g.
satisfaction with care)
 While information, the above lines of research have
done little to explain the processes accounting for
the phenomena observed
 In communication research, ontology refers to the nature of
human social interaction (Littlejohn, 2002)
 Medical encounters (ME) – dynamic, creative, and social
constructed
 Primary activity in ME – talk. This talk accomplishes:
◦ Exchange of information related to health concerns
◦ Aids in decision-making about medical care
◦ Helps establish satisfactory patient-physician relationship (as
characterized by rapport, trust, & respect)
 How an interaction unfolds depends on a variety of physician
and patient factors (personality, mutual influence,
adaptation)
 Although each encounter is unique, a wide variety of
recurring patterns of communicative exchange can be
observed
 Predispositions – relatively stable features of a
person’s social behavior
 Communicative predispositions – reflected in one’s
individual communication or self-presentation style
 Examples include: dominant, open, expressive,
attentive
 Communicative style – influenced by objective (age,
sex, education) and subjective (e.g. self-concept)
features of self and socialization
 Communication style – linked to linguistic
repertoire
Communication styles of HCP examined in different ways:
1. How individual clinicians interact w/ diff patients
◦ Patient-centered (elicit and accommodate the patient’s perspective in
consultations) vs. doctor-centered style (focused primarily on
maintaining clinician control)
◦ Even after controlling for participant demographics & degree of
participation, individual physicians varied in frequency of info
provided, partnership building strategies, and displays of positive
socio-emotional behavior
2. Whether certain types of HCP have different styles of
communicating (e.g. gender diff)
◦ Female doctors – longer consultations, give more information, engage
in more r’ship building, & express greater interest in psychosocial
aspects of health
3. Whether a clinician’s communication predispositions are related
to certain beliefs and ideologies (“liberal” vs. “conservative”
doctors)
 General focus on individual differences. Some examples -
◦ Patients w/ more formal education are more expressive and
opinionated than are less educated patients. Reasons?
 Believe more strongly in patient involvement
 Have more knowledge about health issues
 More familiar with medical technology
 More inclined to be verbally expressive
◦ Female patients more likely than male patients to express
their feelings and talk about health in relation to family,
friends, & colleagues (findings inconsistent)
◦ Older patients more likely than younger patients to believe
that: (a) clinician is in-charge of the consultation; (2) primarily
responsible for medical decisions (findings inconsistent)
◦ Personality factors – influence patients’ communicative style
◦ Linguistic repertoire and informational resources
 Communicators generally have a cognitive map of
their encounters – goals, perceptions of partner,
expectations about behaviors & norms, and
possible interactional outcomes
 These maps – guide our initial behavior and how
we interpret others’ behaviors
 These situational influence – mix of strategic (e.g.
goals, purpose), attributional (e.g. stereotypes),
and relational (e.g. trust, familiarity) considerations
 Despite distinctive styles of communicating, HCP will also talk
differently to different types of patients. Reasons –
◦ Clinician’s goals and attitudes toward different patients influence
his or her behavior during the consultation
◦ Clinicians’ communicative adaptation in response to patient health
status may be due to several factors –
 Attitudes about sicker patients
 Their frustration in dealing with complicated health conditions
 Perceived need to focus more on the physiological causes and
consequences of poor health
◦ HCP also vary their behavior depending on patient’s age (e.g.
stereotype of elderly persons as having diminished cognitive
capacity; expectation that older people should be shown greater
courtesy and respect; younger children should be reassured more
than their parents)
 Patient health status – influences amount of information
and concern expressed to HCP during consultation
(poorer health – greater motivation to express feelings
and talk about concerns)
 Patients’ decisions to disclose more about their feelings,
concerns, and issues also influenced by:
◦ Their belief that such topics were part of the doctor’s role
responsibilities
◦ Their perception that it was important not to keep potentially
relevant information from their HCP
◦ Their level of comfort with and trust in HCP
 Influence of HCP gender on patient response – not well
documented (anecdotal evidence of gender and age bias
abound)
 Mutual influence – very important determinant of
medical encounter outcomes
 Norms of communication place constraints on “normal”
conversational flow
◦ Expectation: An answer MUST follow a question
 RESULT: Interactants may feel obligated to answer even if
reluctant or uninterested in doing so
◦ Expectation: Conversational contributions MUST be
topically connected
 RESULT: Interactant expected to incorporate information
introduced by his or her partner in his/her forthcoming
response
 Clinicians – granted greater control over the interaction
– clinicians therefore will have a strong impact on
patient responses
 Because the clinician will ask questions about
biomedical issues and topical obligations will restrict
patient responses, the consultation will focus on
biomedical aspects of health
 However, whether the clinician uses “patient-centered”
or “clinician-centered” approaches will determine the
degree of patient involvement and nature of physician-
patient dialogue during medical encounters
 Active patient participation during consultation can shape the
content and flow of interaction – attenuating clinician control
over the encounter
 Asking questions, expressing concern, and telling health
“stories” – valuable information clinicians use to recommend
personalized treatment recommendations
 Communicative norms obligate clinicians to talk about issues
that the patient raises, regardless of their own preferences
 Studies have found that patients who actively participate in
their medical consultations with clinicians receiver greater
information, support, reassurance, and are more likely to
have doctors accommodate their treatment preferences
 Predispositional, cognitive-affective, and partner’s communication
influences – interdependent and jointly shape communication in
medical encounters
 Difficult to sort of the unique influences of each of the above factors
 Street (1992b) found:
◦ Degree to which a doctor gave information, issued directives, engaged in
partnership building, and provided positive socio-emotional responses –
largely predispositional
◦ Patient influence – doctors gave more info and offered more support to
patients who asked questions and expressed concerns
◦ Only patient education uniquely explained variation in physician’s
communication, among all patient characteristic variables
◦ Physician partnership-building behaviors – associated with patients asking
more questions and offering more opinions
◦ Patients’ communication – uniquely related to their personal
characteristics (e.g. more educated patients asked more questions)
 Provider-patient communication – influenced by a
number of organizational features
◦ Size of health care facility
◦ Types of services offered
◦ Location
◦ Clientele
◦ Standards of care
 Most widely debated health topic in the last two decades
– Managed care
◦ Impact of managed care on patient-provider
communication
 Managed care – traditionally care provided by HMOs or Health
Maintenance Organizations
 Currently – managed care exists on a continuum.
◦ One end – managed indemnity – precertification for elective services and
case management of catastrophic conditions
◦ Other end – staff and group model HMOs – provide care for a fixed
amount per person per year
◦ Between the two extremes – variety of other models of managed care –
hybrids of prepaid plans and contracts for services at a fixed or reduced
cost
 Merits: improve quality of care, strengthen provider-patient
relationship, encourages & rewards clinicians for patient-centered
care, provides patients with health education/disease management
resources
 Demerits: create policies that restrict a patient’s choice of
physician, reduce time spent with physician, restrict access to care,
place medical decision in the hands of business managers rather
than patients and providers, limited autonomy, reduced patient
involvement
 Influence of managed care:
◦ Greater clinician control of the interaction
 Medical encounters typically reflect & reinforce provider control
 Under managed care, providers
 Act as gatekeepers to expensive procedures & specialists
 Feel pressured to see more patients for shorter durations of time
 Have stronger motivation to control the consultation by talking more,
interrupting/rejecting patient requests, and issuing more directives
 Greater clinician control – reduced patient involvement
◦ However, there are some factors that mitigate
organizational constraints
 Provider’s desire to accommodate patient’s individual needs
and preferences
 Active patient participation in the interaction – wresting control
away from clinician – mutual influence
 Patients enrolled in managed care plans – more likely to
have disruptions in their primary care because their
employers changes health plans
◦ Disruptions  threatens trust in HCP
 Media attention to managed care “horror” stories – medical
errors, withheld services  belief that doctors put profits
above patient care
◦ Climate of mistrust or uncertainty – patients less willing to
discuss sensitive, personal topics
◦ Patients – suspicious of their doctors’ motives for recommending
against referrals or tests
 However, trust b/w providers & patients – strongly
influenced by what happens during consultation (initial
(mis)trust may be dramatically altered (positively or
negatively) as a result of interaction
 Benefits of Managed Care:
◦ Emphasis on disease prevention
◦ Disease management education/skills/training
◦ Early diagnoses of life-threatening conditions
◦ Emphasis on health promotion – motivate providers to
spend more time talking to patients about health
maintenance and wellness
◦ Patient satisfaction related to whether their health care
plans offer programs for weight control, smoking
cessation, cholesterol screening, and other types of health
promotion
 HCP and patients – do NOT exist independent of
technology. Examples:
◦ Using telephone to triage a patient’s health concern
◦ Faxing medical information to a clinic
◦ Watching health news coverage
 Internet – different from other media technologies
◦ 40%-70% of Internet users go online for health information
◦ Sheer amount of information users have access to
◦ Speed with which that information can be accessed
◦ Capability it gives uses – interacting with anyone in the
world who has also has Internet access
 Internet may facilitate greater patient participation by:
◦ Expanding patient knowledge base
◦ Giving patient stronger sense of control in managing his or her
health
◦ Hastening the transformation from paternalistic decision-making
to shared decision-making and partnership
 Reasons why the Internet may have little effect on patient
participation
◦ Patients may be reluctant to discuss their concerns with doctors if
they think they are wasting the doctor’s time, are afraid of what
the treatment may entail, or consider the issue outside of the
doctor’s expertise area
◦ Only 37% of 2000 respondents indicated that they discussed
information with their doctors (Aspden & Katz, 2001)
 Clinicians’ attitudes toward information on the
Internet
◦ Clinicians vary greatly in their attitudes
◦ Some of them are threatened by highly motivated
patients who use the Internet to gain more
knowledge about a health topic than a typical doctor
possesses
◦ Some are concerned by the quality of health
information on the Internet – fear patients’ beliefs
may be influenced by ‘quacks’ or that patients may
end up buying unnecessary or dangerous products
◦ Some others see the Internet as having a positive
effect on their interactions with patients - more
productive consultations
 Virtual Consultations
◦ Virtual meetings in addition to or in lieu of FTF meeting
◦ Use of email to answer patient questions, offer advice,
schedule appointments, and follow-up on treatment
 Email – both a limiting and empowering medium
◦ Restrictive – can only type words & symbols
◦ Lacks spontaneity
◦ Increases communicative efficiency – overcomes spatial &
temporal limitations
◦ User motivation to “connect” helps overcome inherent
limitations of the medium – creation of “emoticons”
 Encompasses legislative and judicial actions pertinent
to the delivery of medical care – least studied context
 Reports of malpractice claims resulting from
communicative (in)action in medical consultations
◦ Deserting the patient, delivering information poorly, failing
the understand the patient’s and family’s perspective
 Influence of ‘patient bill of rights’
◦ Provide full disclosure of medical options for patients
◦ Obtain informed consent before performing medical
procedures
◦ Discuss reasonable alternative treatments
◦ Provide timely services to patients in need
 Other political-legal issues to consider:
◦ Patients’ right to know vs. Providers’ goals to keep
consultations short
◦ Providers’ experience, directly or indirectly, with
malpractice claims  influence attitudes towards patients
(trust issues)
◦ Threat of litigation  adoption of more cautious and
guarded style of communication with patients OR more
patient-centered communication, which has been shown to
reduce malpractice risks
 Important to consider medical encounters as
embedded within a number of contexts
 Encounters people have with health care providers
– important part of human experience
 Medical encounters – direct implications for
objective and subjective well-being
 Important to investigate the consequences of
patients’ experiences as they make multiple passes
through the health care system (as in the case of
management of chronic conditions)
 HEALTH ISSUES OF 2018 NEGLECTED ISSUES OF 2018
 Avian influenza  Tobacco
 HIV/AIDS  HIV/AIDS
 Tobacco  Environmental health issues
 Chronic diseases, including
cancer, diabetes and heart
 Chronic diseases, including
disease cancer, diabetes and heart
disease
 Environmental health issues
 Poverty
 Poverty
 Disasters/emergencies  Avian influenza
 Malaria  Malaria
 Malnutrition  Violence
 Inequity in access to health  Malnutrition
care  Inequity in access to health care
 Communications Manager for
Federal Health Agencies
 Drug Rehabilitationist
 Government Positions Related to
Public Health
 Health Communication Analyst
 Health Educator
 Health Facility Fund Raiser
 Health Personnel Educator
 Heath Care Counselor
 HMO’s
 Hospice Manager
 Hospital Director of
Communication
 Medical Center Publications
Editor
 Medical Grants Writer
 Medical Training Supervisor
 Non-Profit Health Organizations
 Pharmaceutical Companies
 Research Analyst
 School Health Care Administrator