investigating the physician–patient relationship: examining emerging themes

Investigating the Physician–PatientRelationship: Examining

Emerging Themes

Kandi L. WalkerDepartment of Communication

University of Louisville

Christa L. ArnoldCenter for Written and Oral Communication

University of Florida

Michelle Miller-DayDepartment of Speech Communication

Pennsylvania State University

Lynne M. WebbDepartment of Communication

University of Arkansas

By extending Millar and Roger’s (1976) relational theory, this study examined howthe physician–patient relationship was negotiated in the context of a clinical visit.Analysis of observational data obtained during the clinical visits of 1 female familypractice physician revealed 5 themes central to the construction of her relationshipswith patients. The 5 themes included control, role negotiation, trust, health care com-mitment, and interrelated issues of time and money.

Research conducted over the last decade, investigating effective physician–pa-tient relationships, has continuously highlighted the role of interpersonal com-

HEALTH COMMUNICATION, 14(1), 45–68Copyright © 2001, Lawrence Erlbaum Associates, Inc.

Requests for reprints should be sent to Kandi L. Walker, Department of Communication, Universityof Louisville, Louisville, KY 40292. E-mail: [email protected]

munication in the development and maintenance of physician–patientrelationships (Ballard-Reisch, 1990; Orient, 1994; Sheer, 1992; Thompson,1994). In particular, health research by communication scholars and cliniciansclearly demonstrated that patients who have satisfactory relationships with theirphysicians have better health outcomes (du Pré, 2000), and show an increasedlikelihood of following their physicians’ advice (Klingle & Burgoon, 1995).Thompson contends that communication affects a number of variables withinthe health care context, beyond the intake interview, “including diagnosis, un-derstanding instructions and subsequent compliance, and openness when com-municating about taboo topics such as bodily functions and sexuality that areoften a part of health care” (p. 698).

Subsequently, health practitioners have heard a resounding call in the literature(Beisecker & Beisecker, 1993; Burgoon, Parrott, Burgoon, Birk, et al., 1990;Kreps, 1988; McNeilis, Thompson, & O’Hair, 1995; Morris & Chenail, 1995;O’Hair, 1989) as well as in the medical literature (Botelho, 1992; Cline, 1983;DeVita, 1995; Konner, 1993; Levinson, 1994; Ong, DeHaes, Hoos, & Lammes,1995; Stewart, 1995) to become more effective in establishing positive relation-ships with their patients.

A recent survey in Consumer Reports (Consumer Union, 1995) concluded thatpatients are generally satisfied with the overall competency of care, but feel thatcommunication is lacking. Patients reported that they were not encouraged to askquestions, not asked their opinions about ailments and treatments, and were notgiven advice on lifestyle changes that could positively affect their health. As pa-tients define communication, it would seem that their interest is in being heard andtreated as a mutual participant in the interaction. In sum, it may be that instead ofpresuming that we know what is effective communication in this setting, and im-posing those views, we should begin our investigation by determining how it isthat patients and their physicians negotiate their relationships and roles throughtheir interaction.

The purpose of this study is to further examine the construction of the physi-cian–patient relationship by concentrating on the negotiation of these interac-tions as they occur in the clinical setting. To achieve this end, this article firstexplores some prevailing notions driving research in this area, as well as thisparticular study.

LITERATURE REVIEW

In the context of physician–patient relationships, communication is rated as one ofthe most important aspects of medical treatment (du Pré, 2000). As a matter of fact,a large percentage of malpractice depositions examined in Consumer Reports(Consumer Union, 1995) attribute communicate issues as significant contributing

46 WALKER, ARNOLD, MILLER, WEBB

factors in lawsuits. A 1973 government report stated that most of the malpracticesuits were due to poor communication skills between physicians and their patients(DeVita, 1995). More recently, studies concerning malpractice litigation revealedthat a substantial number of patients who consider taking legal action do so not be-cause of some actual injury or technically incompetent procedure, but due to a dis-appointing interpersonal experience (Levinson, 1994). In fact, research indicatesthat physicians who have a greater frequency of malpractice complaints and litiga-tion have a greater frequency of complaints about their interpersonal skills(Hickson, Clayton, & Entmann, 1994).

However, lest we begin to see the role of communication as a sort of “hand-maiden,” or second insurance policy, to the practice of medicine (Zook, 1994), wemust address that a lack of interpersonal warmth or expression of empathy doesnot constitute malpractice. In contrast, the role of communication, particularly in-terpersonal communication research, is to explore how patients and physicians cannegotiate the what and how of their interaction to achieve not only greater interper-sonal satisfaction, but also their mutual goals toward the attainment of qualityhealth for the patient. Both popular and scholarly reports have concluded that whatpatients most want from their encounters with physicians is information giving,partnership building, positive talk, and some social talk (Roter & Hall, 1992). Pa-tients are more satisfied with physicians who encouraged questions, explained thepossible side effects of medications, and generally made them feel at ease (Con-sumer Union, 1995). Although the medical outcomes, despite all efforts and de-sires for an egalitarian relationship, remain with the physician, responsibility forpersonal satisfaction and the quality of communication lies with both parties(Cline, 1983).

For example, although Kreps and Thornton (1992) argued that an effective pa-tient interviewer might gain the trust of a reluctant patient by eliciting full disclo-sure of information, clarifying information, and assessing the social andpsychological factors involved in the illness, patient behaviors, such as failing tolisten and failing to comprehend a statement yet not asking for clarification arealso important. As McGee and Cegala (1998) noted, although the majority of pa-tient–provider research focuses on the providers’ communication skills and im-proving them through training, there is also a need to focus on communicationtraining for patients. Indeed, as research by Tardy and Mitchell (1998) revealed, atleast at the entrance of medical training, physicians do not differ greatly from thegeneral population in terms of their communication knowledge and skills. McGeeand Cegala found that training patients resulted in their enhanced ability to askquestions and increased patients’ information-seeking and clarifying behaviors.Moreover, trained patients did not require more consultation time than did thosepatients who had not been trained, thereby debunking the myth that effective inter-action is a factor of time, rather than primarily a factor of ability. Most important,however, this line of research reflects an issue that is integral to interpersonal com-

PHYSICIAN–PATIENT THEMES 47

munication research but has been lacking in health communication research re-garding the physician–patient interaction—it is first and foremost a relationshipwith transactional communication.

The physician and patient together must negotiate how and what will be com-municated during the exam to insure greater satisfaction. The physician–patientrelationship is complex in that, although dealing with a personal issue (health), therelationship must be maintained professionally. The tension between the profes-sional and the interpersonal is salient to our understanding of clinical relationships(Street & Wiemann, 1988). There exists a challenge in the clinical visit to attend tointerpersonal issues of the interaction while attending to instrumental medicaltasks. This tension between the professional and the interpersonal may be negoti-ated in the clinical visit or one may take precedence. Beckman and Frankel (1984)found that physicians often privilege the professional task orientation over an in-terpersonal orientation considering interpersonal communication a luxury in theclinical visit. The physicians in Beckman and Frankel’s study did not allow pa-tients to sufficiently state their concerns in 69% of office visits. On average, physi-cians interrupted patients after 18 sec. More surprising, however, is the fact thatless than 2% of the patients in this study completed their statements. Cline (1983)noted that following physician’s interruptions patients are often too intimidated tocontinue in their dialogue. Not only does this lack of attention to the interpersonalpromote a sterile clinical environment, the physicians involved made diagnosesbased on incomplete information (Beckman & Frankel, 1984; Cline, 1983). Ac-cording to Stewart (1995), when patients are able to complete their statement ofconcerns they feel more comfortable with the interaction and relationship and re-veal important medical information. Thus, managing the tension between profes-sional tasks and the interpersonal communication can be argued as a necessityrather than a luxury when the goal is to develop positive physician–patient rela-tionships. Given the thrust of previous research, it seems prudent that we studyhow both physicians and patients are actively committed to managing professionaland interpersonal tensions to facilitate relational communication.

Relational Communication

The construct of relational communication emanated from systems theory(Watzlawick, Beavin, & Jackson, 1967). The focus of relational communication ison how individuals relate to each other. Simply put,

relational communication assumes that interpersonal relationship patterns willemerge; they are redundant, interlocked cycles of messages, continually negotiatedand co-defined rather than unilaterally caused by personal qualities and/or social roleprescription. (Friederichs-Fizwater, Callahan, Flynn, & Williams, 1991, p. 19)


A premise of relational communication is that relationships are constantly being re-defined and adjusted through interaction. For example, in the context of the clinicalvisit, the physician and patient are not captive to a set dialogue, but rather can adaptto each situation and define their roles accordingly. From a relational communica-tion perspective,

first, relationships are always connected to communication and cannot be separatedfrom it. Second, the nature of the relationship is defined by the communication be-tween its members. Third, relationships are usually defined implicitly rather than ex-plicitly. Fourth, relationships develop over time through a negotiation process be-tween those involved. Consequently, relationships are dynamic, not unchanging.(Littlejohn, 1999, p. 252)

According to this perspective, the physician–patient relationship is not only main-tained and established through communication, but also sustaining ongoing modi-fication as the interactants negotiate new meanings.

Relational theory has contributed to our understanding of the physician–patientrelationship (Friederichs-Fitzwater et al., 1991; Kreps, 1988; O’Hair, 1989), al-though most of these studies have employed a variable analytic approach. Rela-tional communication research “has tended to focus on several small parts of theinterpersonal health communication process without linking these parts togetherinto meaningful configurations” (Kreps, 1988, p. 348). The purpose of this study isto examine how the physician–patient relationship is constructed and adjusted inthe context of a clinical visit. This approach is inductive in nature and ultimatelyseeks to link several parts of clinical interaction into a meaningful configurationthat will contribute to the understanding of how physician–patient relationshipsare constructed and adjusted. To this end, the following research question (RQ)was developed to guide the investigation:

RQ: How do physicians and patients communicatively construct and adjusttheir relationship during clinical interactions?

METHOD

Participants

To gather detailed, descriptive interactional data and provide an in-depth interpre-tation of these data one family physician from a health maintenance organization(HMO) was selected for this study. A family physician from an HMO was pur-posely selected for this study because of the possible range of cases he or she is ex-posed to in any given day. Moreover, a family physician addresses all age groups


and all types of medical cases, and typically has the advantage of being the firstphysician a patient encounters in his or her clinical visit. For this particular study, afemale physician was selected based on these criteria and her willingness to allowthe researcher to observe her interactions with patients during actual clinical visits.The selected physician was White, was 51 years of age, had eight children, and hadbeen in family practice for 21 years.

Seventy-two patients were observed in interaction with the family physician inthis study. Of the 72 patients, 41 were female (54.9%) and 31 were male (43.1%).The age range of the participants was 14 to 86 years old, with a mean of 47. Theethnic breakdown of the patients consisted of White (79%), African American(13%), American Indian (5%), Hispanic (2%), and other (1%).

Data Collection

The principal method of data collection for this research was participant observa-tion. This method allowed the researcher to obtain data situated in the actual con-text of the clinical visit. Participant observation is one of the few research methodsthat can provide the deeper understanding that comes from directly observing andlistening to people. Bernard (1994) states that participant observation

involves establishing rapport in a new community; learning to act so that people goabout their business as usual when you show up; and removing yourself every dayfrom cultural immersion so you can intellectualize what you’ve learned, put it intoperspective, and write about it convincingly. (p. 137)

For this study, the observer wore a white lab coat and was introduced to eachpatient as a student observer who would be recording the patient’s visit, each pa-tient then had an opportunity to accept or reject the observer’s presence in theexam room. Reactivity was minimized by the fact that this physician commonlyhad medical students shadowing her in the exam room. Thus, the observer wasable to effectively conduct the observations and record interaction while standingas unobtrusively as possible in the corner of the room. Rounds were made with thefamily physician for 3 weeks, from mid-October through mid-November. Thetime of day was from 11:00 p.m. to 6:00 p.m., 3 days per week. The total observa-tion time was 63 hr.

In this study, interaction is defined as what occurred during each separate en-counter between the physician and patient. For example, the patient typically en-countered the physician for the first time after the nurse had conducted an intakeexamination and left the room, then the physician arrived. Additional encountersoften occurred if the physician had to leave the room and then return or if the pa-tient returned to the exam room after he or she went elsewhere for tests. Although


there were 72 total patients included in this study, 104 interactions were coded,with an average length of time for each interaction lasting 14.5 min.

Interactions were observed and recorded with a hand-held tape recorder. Ad-ditional detailed notes about the interaction were made after leaving the examin-ing room to supplement the audio-recorded interaction. Audiotapes wereultimately transcribed and the supplemental notes were added to this databasefor analysis.

Data Analysis

The data were analyzed to describe how the family physician and her patients con-structed and adjusted their relationship during clinical interactions. The analyticalapproach used in this study is based on Strauss and Corbin’s (1990) open codingmethod. The steps in the first phase of this coding process are (a) listen to the tape re-cordingsseveral times tograsp thedata, (b) transcribe the information tohaveacom-plete diary of interactions, and (c) code the data into meaningful categories. The sec-ond phase of this coding process required that the data were reduced to meaningfulcategories and then subjected to systematic comparison and reconceptualization.The final phase of this process involved conceptually linking across categories to-ward thedevelopmentofoverarching themes. In thefollowingsections, specificdia-logue is presented. Ph refers to the physician, P refers to the patient.

RESULTS

Discussion of Emergent Themes

Five themes emerged in the relational communication of the physician and her pa-tients during clinical interactions: (a) control, (b) role negotiation, (c) health carecommitment, (d) trust, and (e) time and money.

Theme 1: Control. Research supports the pervasive role of negotiating con-trol in relational communication. Control was conceptualized in this study as be-havior that suggested the “right to direct, delimit and define the actions of the inter-personal system” (Millar & Rogers, 1976, p. 91). Results suggested that patientsdutifully took on a subordinate role in the relationship offering control to the physi-cian during most of the interactions. Cline (1983) identified this as a traditionalone-up one-down power relationship in which the physician has control. The physi-cian’s controlling maneuvers consisted of giving directions and instructions, prob-ing the patient for information, stressing her expertise and authority, and control-ling medical information. The physician monitored her control by asking the


patient a question if he or she was quiet for an extended amount of time or if he orshe leaned forward as if to say something.

In addition, as Pendleton (1983) noted, the seating position of the physi-cian–patient can significantly influence the communication and patients’ level ofrelaxation. The use of standing and sitting were the physician’s most commonlyused nonverbal behaviors to actively take control of the interaction. In this study,the physician employed different body orientations of standing, sitting, or turningof her back to demonstrate different levels of engagement with the patient. AsRobinson (1998) pointed out, this body orientation may suggest that the physicianwas using her body to show the patient when she was ready to engage in certainmedical tasks and when she was not ready to engage in these tasks. Robinson fur-ther suggested that physicians may use their bodies to communicate when they areready to hear the patient’s chief complaint. This explanation may be the reasonwhy the physician sat in the chair when listening to the patients’ personal healthconcerns. She was demonstrating that she was engaging the patient. She stoodwhen giving prescriptions or offering a formal health diagnosis to show that shewas engaging the patient at a different level.

Sheer (1992) contends that the “crucial issue for patients is personal control,that is gaining a sense of mastery over uncertainty” (p. 1). Although the need forpersonal control was evident in some interactions, personal control was typicallyrelegated to secondary status by the patients in this study. For example, one female65-year-old, African American patient preferred to self-diagnose and retain con-trol in the relationship. She was having trouble with her kidneys and with bladderinfections and the following represents the dialogue that occurred in the interac-tion.

P: I know I have a kidney infection. It hurts to go to the bathroom and I alwaysfeel that I need to go [to the bathroom].

Ph: Let me take a look. Since I am the doctor here I should see what’sP: [Interrupting] There really isn’t a need for you to check me out, I know

what the problem is. Can you not just write me a prescription or give mesome medicine?

Ph: Humor me and let me examine you anyway. I just want to make sure thatwe don’t have anything more say

P: [Interrupting] I have had these things before. You’ve given me a pill beforethat cleared me right up. Just give me that again.

Although this example illustrates that the patient was not demonstrating thetypical submissive role in the interaction, the patient otherwise was extremelycompliant during the remainder of the interaction giving the physician the domi-nant role. This example demonstrates that the patient was persistent in wanting tocontrol the relationship in terms of diagnosing her health issue, but was willing to


share that control with the physician as the interaction proceeded. Sheer (1992) ex-plained that sharing control is regarded as a transactional process that occurs be-tween individuals in a relationship and serves to increase patients’ sense of controlover the illness situation as active consumers. Patients in this study appeared will-ing to share control with the physician by allowing the physician to guide the inter-action, but also by engaging in active questioning, giving their opinion, andasserting their status as the informed decision maker in matters of their own health.

Theme 2: Role negotiation. The second theme that emerged from thesedata was the role negotiation that occurred in the relational communication be-tween the physician and patient. Role negotiation is conceptualized in this study ashow the physician and patient construct their communication to perform the rolesof physician and patient and how the physician and patient achieve role congruence(agreement of which role each will play) in the interaction. Results indicate that inalmost all of the interactions both parties in the relationship accepted the role of thephysician as the expert and the patient as the layperson.

Greene, Adelman, Rizzo, and Friedmann (1994) found that patients wanted thephysician to be the medical expert and expected the asymmetric power relation-ship. These patients acknowledged and wanted the physician to be medicallyknowledgeable and have medical expertise. The interactions usually initiated withthe physician indicating interest in the medical problem or the patient with an im-plied promise that she had expert power to solve the problem. In most of the casesshe readily established her authority and role as the expert as in the following ex-ample.

P: You know, I get these headaches all the time.Ph: Do you take aspirin or Tylenol for it?P: I try not to take anything. I hate taking medicine.

Ph: You might try taking some Tylenol for it. It may relieve some of the painyou are enduring. Where do you get these headaches?

P: Here [pointing to the temple area].Ph: Does it hurt back here as well [rubbing the back of her neck]? [Getting a

nod from the patient yes] You are getting tension headaches.

The interaction proceeded into a diagnosis and remedy for the patient’s head-aches. This interaction provided an example of the patient seeking medical ex-pertise from the physician. The physician’s active probing of the patient’s vaguecomments illustrated her involvement with the patient and illustrated her author-itarian role. In this example, the physician not only acknowledged the patient’shealth concerns, but also offered assistance in resolving the situation with a di-agnosis.


Yet, when patients challenged the role of the physician as the sole authority, shewould quickly assert her authorial presence or actively ignore the challenge. In thisexample the physician interacted with a 69-year-old White man with prostate con-cerns.

P: I looked up the medicine you gave me last time in my medical encyclope-dia I have at home. You know, I didn’t have any of the side effects that itsaid I would. I was glad I read it though. Did you know that I am not sup-posed to have dairy products with it?

Ph: I told you that when I prescribed it to you. This [handing a prescription]you can take with dairy products.

P: I read about this last night. I was going through the book to see which medi-cines are given in these kinds of cases.

This example demonstrated the patient’s self-presentation as a knowledgeableman who took an interest in his health. He showed genuine concern for his healthand took an active role in his health care maintenance. The physician did not ac-knowledge the patient’s effort to be an informed patient and actively silenced theimplication that she may not be an authority on the issue. No further discussion ofthe patient’s medical knowledge was discussed in this medical visit. Although thiscase demonstrates the patient was interested in his health care, this example also il-lustrates a missed opportunity for the physician to acknowledge or endorse the ef-forts of the patient for being concerned and actively involved in his healthmaintenance.

In six of the interactions patients did not readily accept the physician’s role ofexpert until relentless probing revealed she was a knowledgeable physician. Forexample, one patient asked seven questions about having back problems. Hewanted to know what could have caused it and how to fix it. The physician an-swered the repetitive questions until the patient seemed convinced she was compe-tent. Although this patient was unconvinced as to the validity of her originaldiagnosis, once he was convinced that she was a competent expert he began shak-ing his head and agreeing with her diagnosis and treatment plan. In the end, of allthe interactions the roles in the relationships were clearly defined with the physi-cian as the expert and the patient as the layperson.

Theme 3: Health care commitment. Although the first two themes can befound in previous health communication literature, the next three themes contrib-ute uniquely to the understanding of relational communication in the physician–pa-tient relationship.

The third theme that emerged in the relational communication of the participantswas negotiating the level of commitment to one’s health care. Health care commit-


ment in this study referred to the amount of involvement each party had towardachieving quality health care. The physician and patient both negotiated how ac-tively involved each was going to be in the relationship regarding the health care ofthe patient. For patients, the level of commitment involved the amount of interestthey displayed in their own personal health (i.e., as one patient commented, “I takevitaminsand try towalkat lunch”)andalsocoming to theappointmentpreparedwithan organized list of questions for the physician. Additional patient commitment wasdemonstrated when the patient came to the appointment well informed about thehealth problem at issue. These patients had clearly conducted research into thehealth issue and were well-informed consumers of health care. For example, one pa-tient inher late20sexplained that sinceshewasdiagnosedwithhypertensionshehadbeen on the Internet to find information about the condition. She came to the interac-tion with a list of treatments to talk about with the physician.

The physician also negotiated her commitment to the patients’ health care inthese interactions. A commitment to care in the physician–patient relationship wasdemonstrated by communicating an interest in the patient’s lifestyle and habits.She asked nonmedical questions to open the lines of communication with the pa-tient. For example, this physician would openly ask “What have you been doingsince the last time I saw you,” and “How are your kids?” These questions were notdirectly related to the physical ailment at hand, but enabled her to develop a posi-tive relational climate. These questions demonstrated a commitment to treat thepatient as a whole person rather than as a set of symptoms.

Rather than sticking to communicating diagnoses and treatment protocols, thephysician also engaged in promoting prevention and encouraging healthy life-styles in the patients. For example, one patient in her early 40s (White) was givensuggestions by the physician for a healthier lifestyle change.

Ph: You seem to have an awful scratchy cough? Are you smoking?P: I hate to say it because I know it’s bad for me but I can’t seem to stop. It is

the only pleasure I get from work and my kids. They drive me crazy.Ph: You’re right, smoking is bad. Old habits are hard to break. You are my pa-

tient and I am here to try to point you in the right path. So how many do yousmoke a day?

P: About a pack. But I’m a lot better than I used to be. I used to smoke a couplepacks a day. But since I can’t smoke at work anymore I have cut back.

Ph: You know what smoking does to your lungs, don’t you? Not to mentionthat smoking increases the aging process. Even though you are not here forthat cough, I am going to get my nurse to give you some information aboutsmoking and different methods to try to stop.

This example illustrated that the physician was not just concerned with the pa-tient’s current health complaint but the overall health of the patient. The physician


seemed to care about the patient as well as provide care for the patient. Althoughthe physician did not immediately ask about her children, the issue was revisitedlater in the examination. Later in the interaction the physician asked more specificquestions about this patient’s family life in relation to her previous comment thatsmoking was her relief from her children. The physician therefore negotiated herlevel of commitment to this relationship by demonstrating active involvement inthe health care of the patient. Although this outcome may be expected of a medicalencounter because commitment to patient health is part of the physician’s job, thedegree of the physician’s interest and involvement in the patients and their overallwell-being was certainly variable in these accounts. This particular physician dem-onstrated interest, involvement, and a commitment to the overall health of her pa-tients throughout most of these interactions, especially if the patient appeared to becommitted as well. For those whom she perceived as committed, there was in-creased positive affect, and increased active involvement in the interaction.

Wherein it is the physician’s job to be committed to the health care of a patient,in this study the patients typically demonstrated equal commitment to their ownhealth care. This negotiation of commitment suggested a construction of the pa-tient and physician as partners striving for a common goal. The following examplewas taken from a White woman in her 30s.

P: I have been trying to lose weight lately one because I knew I was coming tosee you and I hate stepping on that scale and two because I was tired of be-ing overweight. I have been taking vitamins and a herb pill to help me loseweight, can you give me any other suggestions to help me lose this [point-ing at her stomach].

Ph: I highly recommend you taking vitamins and I don’t see any harm in theherbs but as far as a miracle diet or a miracle pill there aren’t any. Do youdrink 8 to 10 glasses of water a day? Do you exercise?

P: I don’t drink as much water as I should but I do exercise. I walk about anhour a night four or five times a week.

Ph: You have got to drink that water. You need to get yourself one of thosethermos cups that have a lid on them, you can get them at any store, fill itwith water and drink until it is empty. Do this twice and you’ve got yourwater knocked out for the day. I’m glad to hear you’re exercising. Now,just eat a low fat diet. You’ve got to eat your veggies!

This example illustrated that the patient was taking an interest in her healthcare. Although this patient acknowledges she was not doing everything that shecould to be healthy, she was making a commitment to his health by trying to loseweight and taking vitamins. The physician reciprocated the commitment by givingher further instructions to help her in her health regimen, expressed empathy at thepatient’s frustration, and smiled encouragingly at the patient. Because the focus of


this health interaction was a routine physical, most of this interaction emphasizedthe patient’s future health.

When both parties were committed to quality health care, each party took an ac-tive role in improving the quality of health care. Thompson (1990) discussed theimportance of the physician and patient coming to the examination prepared towork for the same goal—to attain quality health care. Thompson claimed that theclinical interview should be used as a tool to help achieve “more effectivedata-gathering and relational development” for both parties (p. 37). In the illustra-tions discussed previously, both the patient and the physician asked questions anddemonstrated their involvement and commitment to the overall health care of thepatient. This emerged as significant in the relational communication of the physi-cian and her patients and contributed to the construction of this relationship as apartnership with each pursuing a common health care goal.

Theme 4: Trust. The negotiation of trust was evident in much of the rela-tional communication that occurred in these clinical interactions. Van Servellen(1997) claimed that trust is critical in the provider–patient relationship, and shesuggested that trust should be conceptualized as “an individual’s expectation thatthe communication behaviors of others are reliable” (p. 89). This study appropri-ates that particular conceptualization of trust and the results suggest that trust wasnegotiated in two phases. During the introductory phase of the clinical encounter,trust was established individually; individuals seemed to be struggling with thequestion, “Is this a trustworthy person?” Yet, as the medical encounter progressed,trust was further negotiated in the implementation phase where both enacted be-haviors that constructed shared expectations of a trusting relationship.

The introductory phase of each interaction consisted of the first contact be-tween the physician and the patient. During this phase the negotiation each indi-vidual seemed to engage in was assessing the other as a trustworthy individual.During this phase it was typically the physician who attempted to establish a cli-mate conducive to trust by being sensitive to nonverbal cues, appreciating theuniqueness of a patient, engaging in verbal expressions of positive regard such ascaring and warmth, and being an active listener. For example, this following ex-cerpt is from an interaction with a 38-year-old, White female patient who was hav-ing a yearly physical examination.

Ph: You don’t look very happy. Is there anything bothering you?P: No, I’m fine [looking down; long pause] nothing out of the ordinary, I

guess.Ph: Have you been under more stress than usual? [She sits down.]P: Well, I have been upset more than usual. I, I, I just feel depressed all the

time.


Ph: [Looking through her chart] I know your mother passed away about a yearago and you were upset over her passing. Is this part of the problem?

P: I suppose so. I just feel so stupid saying I am still upset over my mother dy-ing. It was nearly a year ago but I still can’t get over her being gone.

Ph: It is not stupid to be upset. I think that her passing has profound impact onyour health. I know I referred you to a counselor before, are you still going?

P: I haven’t been recently. I suppose I need to make an appointment. I don’tlike going to someone that I don’t know and talking about this stuff.

According to Wood (1999), issues of trust and self-disclosure are important be-cause they illustrate there is a “sense of reliability to each other and sense that dualperspective taking will be involved” in the relationship (pp. 249–250). She furtherexplains that trust is important because it allows people more freedom in disclos-ing personal information. In the previous example, the physician engaged in sup-portive communicative behaviors and the patient responded with disclosure thatwas used to further her diagnosis and treatment. The introductory phase transpiredas the patient was averting her eye contact and avoiding disclosure while the physi-cian elected to patiently probe for information. In this interaction they progressedfrom assessing the trust of the other to establishing a mutual regard and trusting re-lationship during the implementation phase. The mutual trust began to be evidentas the physician confirmed the patient and offered expressions of positive regardwhile the patient began to disclose difficult information.

The previous interaction demonstrated she did not want the prescribed treat-ment of talking with a counselor due to her discomfort with self-disclosure. Shefelt comfortable, however, explaining her depression with the physician and thephysician did not provide negative evaluation about the patient’s discomfort withthe previous treatment recommendation. From this point on in the medical consul-tation, the physician concentrated on the patient’s depression and they set up an-other appointment to check on the depression.

The introductory phase of assessing the other’s trustworthiness seemed to be ofshorter duration or nonexistent in physician–patient relationships that were ongo-ing. The secondary phase in establishing relational trust in these interactions wasidentified by an implicit assumption that trust already existed between theinteractants and therefore the trusting climate need not be reestablished—merelymaintained. For example, the following excerpt illustrated shared expectationsthat the communication behaviors of the other person were reliable. After confirm-ing that the 55-year-old White male patient completed a previous round of medica-tion the following dialogue occurred.

Ph: I am prescribing an antibiotic for the infection you have in your chest. Itmay have some side effects such as drowsiness. In a few people it has theopposite reaction and makes them wide awake. I want you to take all of the


medicine. You may feel better before they are all gone but you still need tofinish the bottle.

P: OK, Doc. I knew you’d know what to give me. I just hope it makes me tiredso I can get some sleep. This thing has been keepin’ me up at night. The lastmedicine you gave me really worked—is this the same kind? You knockedit out of my system last time.

In this excerpt the patient trusted the physician to prescribe the correct medica-tion to make him feel better. This interaction was shorter than many of the otherpatient’s visits, probably because this particular patient had previously visited thephysician with a similar problem, and thus the introductory phase of establishingtrust did not occur. In this case, the trusting relationship was further maintained bypatient disclosure. This patient revealed to the physician that he previously hadcontracted this infection and that he expected to have this infection in the future.He further revealed that she was the only physician he would go to for help becauseshe was the only doctor he had visited who knew what to prescribe. Again, pa-tient’s honest and forthright disclosure emerged as the physician and patientmoved from the introductory phase of establishing trust into the implementationphase of demonstrating and maintaining that trust.

There was possibly a third phase in the process of negotiating trust betweenphysician and patient. The data revealed a few glimpses of this phase, but therewas not sufficient data to support this as a unique phase of developing trust in amedical relationship. In previous phases of negotiating trust, self-disclosure fromthe patient was the primary hallmark of trust, and the physician sustained a trustingclimate to facilitate that disclosure. There were a few instances, however, when anew phase of trust was demonstrated. In this potential third phase of negotiatingtrust in the relationship, reciprocity of self-disclosure was expected from the phy-sician and the physician would engage in that reciprocal disclosure. In the follow-ing example, the physician who had eight children of her own was interacting witha woman who had been a patient for many years. This particular medical examina-tion was a routine examination with no new health problems discussed from thepatient. The patient was a 49-year-old White woman.

Ph: I had a similar situation happen with one of my children. My son has anasthma problem and I had to rush him to the hospital. I knew that if wedidn’t rush him we were going to lose him. This was one of the worst at-tacks he has had. I was extremely scared this time.

Although this disclosure by the physician did not include highly personal infor-mation, she rarely disclosed any personal information about her family or personallife to patients. She did not come across as emotionally distant, nor did she readilyprovidepatientswith informationabouther life.Yet, in this interaction thephysician


and patient discussed their children for most of the examination. As the interactionprogressed the patient continued the maintenance of a trusting relationship by add-ing to the conversation and revealing information about her life and her children.

Therefore, as the physician and patient moved from the introductory phase ofestablishing trust into the implementation phase of demonstrating trust, the physi-cian typically made the effort to sustain a climate of trust encouraging patientself-disclosure. Results also suggested a possible third phase of negotiating rela-tional trust, reciprocal trust, where ongoing medical relationships offer an oppor-tunity for reciprocal self-disclosure.

The implementation phase comprised most of the data in this study. In thisphase patients often responded to the physician as a confidante, a therapist, andeven as a friend. Her skill at active, reflective listening allowed her to be sensitiveto both verbal and nonverbal cues, identify the other person’s feelings, and thuscommunicated empathy (Cline, 1983). The physician was empathic to most of theemotional requests, she would engage in lengthy discussions with her patientsabout their personal problems, yet she also moved the examination forward if theinteraction was getting off track.

Theme 5: Time and money. The final significant theme that emerged inthe relational communication of physicians and patients was issues of time andmoney. Quality health care has its price; therefore, temporal and monetary issuesseemed central to many of the interactions. Time and money could possibly be a di-vision of the theme of role negotiation; however, the frequency of this phenomenonwarranted its classification as a distinct theme.

Sheer (1992) stated consumerism likely leads to increased information-seekingby the patients as well as a commitment to enact health promotion behaviors. Thisframing of health care from a consumer orientation emerged as salient in these inter-actions.Thefollowingexample illustratedasegmentofan interactionoriented to theissue of money. In this interaction the patient was 37-year-old White woman. Shewas concerned because her medical expenses were more than she anticipated.

P: I know I probably need to come back but I just can’t afford to pay anothercopayment.

Ph: I have it here [looking through her charts] that you pay $10 per visit. I knowmoney is tight but I think it would be worth your money and effort to comeback.

P: Is there any way I could come back and get the blood work done withouthaving to pay?

This was an example of the impact of money issues on health care because thepatient was more concerned with the keeping her expenses to a minimum than she


was with receiving the medical attention she needed. The interaction continuedand the physician informed her that she would need to make another appointmentbecause she could not accomplish all the medical tasks in one visit.

Institutional features also impacted the relational communication in this con-text, obligating both interactants to be conscious of time and money. For example,a 28-year-old White female patient who suffered from a chronic sore throat ex-claimed,

P: While you’re writing the prescription for me, could you write me a note soI can show it to my boss. I have to proof that I was here. I can’t afford tomiss any more days. At least this way I won’t get docked.

Ph: I will have my nurse give you a form before you leave.

Possible sanctions from institutions added increased pressure on the patient andplaced the physician in a maternalistic position of protecting the patient from thosesanctions. Moreover, if the patient thought she would not get paid for going to thephysician’s office then she probably would not take the time off time from work.She was placing her health as second priority to her work and pay.

Institutional features also increased physicians’ awareness of temporal issues,especially in HMOs where patient visits are scheduled every 15 min. The physi-cian maintained a constant balance of relational maintenance, instrumental task ef-ficiency, and monitoring of time. Examples of this were most evident in reaction to“doorknob comments.” Stewart (1995) labeled doorknob comments as those pa-tient comments that occur just as the physician reaches for the door to exit. In thefollowing example the patient is a 30-year-old African American woman.

Ph: I have given you your prescriptions. You have a good rest of the day[reaches for the door].

P: I almost forgot. I wanted to ask you about my foot. I am still havin’ troublewith it. I took all the pills you gave me but it just ain’t doin’ any better.

Ph: I really don’t have time to examine your foot since you were just here forthe sinus infection. But let me take a look at it. [Patient extends foot] I re-member referring you to Dr. X have you been to see him?

P: No, I was waitin’ to see if the pills helped any. Boy, it sure hurts.Ph: [Putting the patient’s foot down] I want you to go to Dr. X. I am not a podi-

atrist so I am not an expert on the feet. I recommend you go see him and lethim take a look at your foot, especially if it is still bothering you. [Getschart and walks toward door] My nurse will be in right in here to help youout.

Time was a prime concern for the physician. She was on a strict schedule to seeher patients, establish the course of the examination within the first 5 min, leaving


little time for small talk. She used open-ended questions toward the beginning ofthe interaction and began using closed-ended questions toward the end. Some ex-amples of the beginning and ending scenarios are as follows:

Beginning scenarios:Ph: How are you feeling today?Ph: What seems to be the problem?Ph: What have you been doing lately that may have caused this reaction [aller-

gic]. Anything different than normal? New detergent for your clothes?

Ending scenario:Ph: I’m giving you a prescription for the rash, OK?Ph: If you don’t have any other questions I’m leaving you with [name] my

nurse.Ph: Do you have any further questions? [Looking at her watch and heading to

the door; without a second delay] If not, I’ll see you in 2 weeks.

The physician also used nonverbal leave-taking behaviors such as moving to-ward the door and collecting the charts, and closed body structure to help concludethe interaction. However, no matter what verbal or nonverbal communication thephysician engaged in, the door knob comments still prevailed.

The patient, on the other hand, used the doorknob comments as their methodof saving time. They used doorknob comments, in this study, possibly becauseof fear of wasting the physician’s time over something trivial or experiencingreal anxiety with the possible significance of their symptoms. Also, there was asense that fairness was an issue. Patients suggested that they willingly compliedwith the physician’s schedule when kept waiting; however, it was implicit in thepatient’s behavior that during the visit with the physician it was his or her turnfor undivided attention. Grumblings from patients indicated that patients be-lieved the physician should comply with the patient’s timing preference. The pa-tients also seemed to view doorknob comments as an opportunity to save areturn trip to the physician’s office. These patients received consultation on agreater number of problems in a single visit than those patients who did not usedoorknob comments. In some respects, doorknob comments enabled the patientmore control over their office visit.

Along the same lines of time, is the issue of money. In this study, the physiciansaw her time as money and the patients viewed the interaction as money. Althoughthe two approaches to the relationship were similar they revealed fundamentallydifferent orientations to both the examination and the relationship. The physicianclearly demonstrated a goal to provide quality care for her patients, but she wantedto do it in the limited time allotted. The patients, however, often saw the examina-tion as costing them money and therefore wanted the “most of their money.”


DISCUSSION

The purpose of this study was to examine how the physician–patient relationshipwas coconstructed and adjusted through relational communication. The results re-vealed five themes present in the relational communication of physicians and pa-tients as they manage their unique relationship in the clinical context. Indeed, thephysician and patient have a complex relationship to coconstruct in the small timeallotted for the health interaction; they must incorporate the needed interpersonalaspects while also attending to the medical tasks.

Control was evidenced in this study as salient to the negotiation of the physi-cian–patient relationship. McNeilis et al. (1995) indicated that relational control isan important factor in the cocreation of the physician–patient relationship. Yet, re-sults of this investigation suggested patients assumed a subordinate role in the rela-tionship and offered most of the control to the physician during interactions. Thephysician gained control most often by guiding the conversation verbally (e.g.,asking questions) and nonverbally (i.e., she stood directly in front of the patientwith her chart in front of her and talked in an authoritative voice; displayed indica-tors of expert status such as the chart and lab coat). Her message-related behaviorsserved to metacommunicate her position as expert and asserted control over theclinical relationship. Although the physician was clearly in control of the interac-tion she communicated flexibility by being receptive to patients’ questions andconcerns.

This control positioned her as the expert and the patient as the laypersonseeking assistance. These roles were manifest throughout the interactions andsuggested a willingness from all parties to accept these roles. The patients in thisstudy accepted a one-up, one-down relational structure quite readily. There wasvery little evidence that there were role conflicts in negotiating these relation-ships. In fact, as Greene et al., (1994) suggested, patients may want the physi-cian to be the medical expert and thus they expect asymmetrical control in therelationship.

Although issues of control and role negotiation have been well represented inthe health communication literature in the past few years, several unique themesemerged in this study to describe what occurred in the relational communication ofa physician and her patients. The results suggest that both the physician and patientmust be committed to quality health care to prevent one party controlling the direc-tion of the interaction. If the physician and patient both demonstrated commitmentto health care in the interaction (i.e., patient preparation, physician interest extend-ing beyond the medical problem to how that problem affected the life of the pa-tient) the interactants appeared to construct a relationship based on a shared goaland partnership. The goals in this situation can be tied back to the interpersonal lit-erature on instrumental and relational goals (Dillard, 1990; Hecht, 1984). If bothinteractants shared the primary goal of patient overall well-being and health (in-


strumental goal) then that shared commitment appeared to affect the constructionof a positive relationship. As soon as one interactant perceived that the other hadan equal commitment to health care, he or she appeared to increase their invest-ment in the relationship (i.e., listen more attentively, engage in more direct eyecontact, display more signs of affect). If, in turn, both interactants shared a second-ary goal to develop this positive physician–patient relationship (relational goal)then this commitment to health care provided common ground for the two to nego-tiate this relationship. What emerged was a construction of this relationship as apartnership in pursuit of a common health care goal.

Trust was a dimension of the physician and patient relationship that promotedinformation exchange, a bond between the participants, and a higher level of un-derstanding of each party. As Millar and Rogers (1976) found, trust is an importantcomponent to relational development. Kreps and Thornton (1992) also reportedtrust as crucial in the health care setting because patients are often communicatingabout uncomfortable topics. Trust, in this study, appeared to be negotiated in aprocessual manner. Friederichs-Fitzwater et al. (1991) contend that relationalcommunication assumes that interpersonal patterns will emerge and that messagesare continually negotiated and codefined. This emergent nature of relational trustwas evident in these interactions. The introductory phase of each interaction con-sisted of the first contact between the physician and the patient. During this phaseeach assessed the other’s trustworthiness. This phase typically did not last longand may possibly be tied into the impression management literature. During thisinitial phase of negotiation the physician assumed the responsibility to establish aclimate conducive to trust (i.e., by being sensitive to nonverbal cues, engaging inverbal expressions of positive regard such as caring and warmth, and being an ac-tive listener.)

If, after this introductory phase, trust was tentatively negotiated, the physicianand patient moved into an implementation phase. In this phase the interactantsdemonstrated trustworthy behavior and each assessed that behavior. As each tenta-tively evaluated the trustworthiness of the other, the more comfortable each partyseemed, the more information was shared, thus leading to the construction of atrusting relationship and increased ability to achieve instrumental goals of healthcare.

A possible third phase was hinted at in these data. This third phase, reciprocaltrust, occurred when the physician and patient had an ongoing health care relation-ship. Whereas self-disclosure from the patient was the primary hallmark of trust inprevious phases, during this third phase self-disclosure was expected from thephysician and the physician would actively engage in that reciprocal disclosure.This was an interesting finding that warrants further investigation. Professional re-lationships that require positive personal relational dimensions are unique andpossibly follow differing rules than intimate personal relationships regarding reci-procity, self-disclosure, and the role of trust in relational development.


The final theme that evolved from the data involved issues of time and money.The physician–patient relationship was not immune to the constraints of time andmoney. Time was a direct concern for both parties. In most of the interactions thepatients wanted more time with the physician but the physician stayed on a stricttime schedule. Institutional constraints for physicians regarding spending mini-mum time with each patient for maximum benefit affected her management oftime. Moreover, there appeared to be institutional constraints on patients that sanc-tioned missing work time for medical visits. These constraints led to short officevisits while making the visits maximally beneficial. One interesting aspect of theissue of time was the frequency of doorknob comments in the interactions. Patientsemployed doorknob comments to include everything not mentioned during theprimary interaction. These comments typically consisted of more health questionsand statements. However, the patients appeared to slide these questions into theconversation as the physician walked toward the door. This strategy was appar-ently employed in an attempt to avoid taking a disproportionate amount of the phy-sician’s time.

Money was also a concern that appeared to affect relational communication inthe physician–patient relationship. Money seemed to motivate the physician andpatient differently. The physician needed to keep the flow of patients runningsmoothly to make money, whereas the patient needed to get as much expert servicein the interaction as possible to make it worth the cost (loss of money). The physi-cian saw her time as money and wanted to provide quality care in the time allottedfor each patient. In contrast, the patients seemed concerned the interaction wascosting them money and wanted to achieve maximum benefits for that cost.

DIRECTIONS

The results of this study suggest five areas of importance in understanding how phy-sician and patients negotiate their relationship. Yet, there is still much to know abouthowindividuals in thisrelationshipmanagetobalancetheprofessionalandpersonal.There appeared to be a phasic process of developing trust in these relationships—asin most intimate relationship—however, physicians and patients often must negoti-ate through these phases in a short period of time during a single encounter. Door-knob comments were one area that demonstrated this delicate balance of competingtensions. Additional research is necessary to better understand the complexities thatare apparent in this professional and personal relationship.

Althoughconclusionsdrawnfromthis limitedsamplesizecannotextrapolate toageneral conceptualization of the physician–patient relationship, the conclusionsprovide insight into the types of issues raised during the coconstruction of such a re-lationship. One obvious limitation to this study was that the project examined a sin-gle physician’s interactions with her patients. Moreover, this physician was a


woman, thus limiting these findings to a specific sex. Women are often thought of asmore empathic in their interpersonal interactions than men and there is some evi-dence that this is translated into the health care setting (van Servellen, 1997).

Because the sample of patients in this study consisted of mainly blue-collarWhites, it would be wise to conduct future research efforts with a more diverse sam-ple of patients. In addition, the presence of the observer in the interaction itself mayhave increased patients’ reactivity and affected the level of honesty and openness inthe interactions. Recent research using videotaped observational methods may pro-vide an efficient way to capture interactional data while minimizing reactivity.

The purpose of this study was to examine how the physician–patient relation-ship was negotiated in the context of a clinical visit. The findings illustrate howcontrol, roles, and trust are negotiated in this relationship. Moreover, this study de-scribes how mutual commitment to health care as well as issues of time and moneycontribute to the ongoing renegotiation of this unique relationship. Nevertheless,further research is needed to develop our understanding of these themes and howthey function, in concert, to affect the construction of a positive physician–patientrelationship. Providers and patients often fail to see the necessity of enhancingcommunication skills in the physician–patient interaction. Thus, it is imperativethat this kind of research not only enhance our understanding of the clinical rela-tionship, but offer persuasive descriptions of how this relationship is affected bycommunicative interaction. This kind of qualitative, descriptive analysis contrib-utes to our knowledge base, but also has the potential to enhance the training ofboth physicians and patients to be better relational communicators during medicalinteractions.

ACKNOWLEDGMENTS

An earlier draft of this article was presented at the 1999 Southern States/CentralStates Communication Associations joint conference, St. Louis, MO. This articlewas based on the findings of Kandi L. Walker’s master’s thesis. We thank ThomasDarwin and Rebecca Weldon for their comments and advice with earlier versionsof this manuscript.

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