gaps in doctor-patient communication: doctor-patient interaction analysis
TRANSCRIPT
Pcdiat. Res. 5: 298-311 (1971) behavioral patterns doctor-patient relationscommunication gap pediatric community
Gaps in Doctor-Patient Communication:Doctor-Patient Interaction Analysis
BARBARA FREEMON, VIDA F. NEGRETE, MII.TON DAVIS, AND BARHAHA M. KORSCH'271
Department ofl'ediatrics, Childrcns Hospital ofl.os Angeles, University of Southern CaliforniaSchool of Medicine, I.os Angeles, California, USA
Extract
As one of several approaches to scientific analysis of doc tor-patient communication,285 visits to a pediatric walk-in clinic were scrutinized using an expanded version ofBales' Interaction Process Analysis. Data analysis consisted of individual case studiesand computer programs for descriptive summaries of cases and index scores. Factoranalysis and chi-squarc calculations were among the methods used to test significantrelations between attributes of the doctor-patient interaction and the dependentvariables, patient satisfaction, compliance, and demography.
As hypothesized, a distinctive behavior pattern emerged for doctor, parent, andchild. Doctors were found to talk more but show less emotion than mothers. Almosttwo-thirds of the mother's communication related to medical history, while the doctordiscussed history and treatment but gave little attention to cause, prognosis, and seri-ousness. Although the physician expressed relatively little reassurance or friendlinessto the mother, almost half of his conversation with the child consisted of friendly state-ments. In general, outcome of the medical consultation was found to be favorably in-fluenced by having a physician who was friendly, expressed solidarity, took some timeto discuss nonmedical, social subjects, and gave the impression of offering informationfreely without the patients having to request it or feeling excessively questioned.
Speculation
Because of the complicated nature and limited methods available for study, the doctor-patient relation has rarely been subjected to scientific inquiry or attempts at quantifi-cation. It is hoped that the present effort as well as other ongoing studies will con-tribute to a body of scientific information which in itself may have application forpediatric education and practice and which ultimately might contribute one approachin urgently needed studies of the quality of medical care.
Introduction
The art of interviewing patients has been the subjectof many books and articles by health professionals andbehavioral scientists. Most experienced physicians bc-licvc themselves ex]>crt in "medical history taking,""bedside manner," and the "art of medicine/' and they
cherish the patterns of doctor-patient relation thatthey have evolved. The teaching of students and youngphysicians is usually done by their more experiencedcolleagues on the basis of intuition, precept, and per-sonal preferences. Advice to the inexperienced inter-viewer tends to stress the importance of creating afriendly atmosphere, taking plenty of time to establish
29a
Doctor-patient communication 299
Dnr.tnr —=» Patient's ,
Mother
I Interaction
Independent Variable
> Pnst VUlt
Interview
Mothers' Perceptionsof V is i t
; , Follow-UpInterview
Outcome(Satisfaction and
v Compliance) j
Dependent Variable
Fig. J. Research design.
rapport with the patient, not being too directive andauthoritarian but being willing to listen to the pa-tient's concerns. All these seem reasonable tenets onthe basis of humanism, common sense, and clinicalexperience, but one is tempted to ask the question thathas come to be legendary in respect to the rest ofmedical knowledge, namely, "What is the evidence?",that these approaches to interviewing are the ones thatlead to the most effective medical care.
This third in a series of papers [12, 17] from a 3-yearresearch project on doctor-patient communication willfocus on role enactment [13, 22]—how the doctor andpatient (in pediatrics, the parent) behave in relation toeach other—and the types of behavior that relate topatient satisfaction and compliance. It was postulatedthat a distinctive behavior pattern would emerge fordoctor, parent, and child and that a relation would befound between the nature of the communication andthe outcome of the visit.
Method
The methods used in this investigation and the find-ings concerning outcome, as determined by interviewswith the parent, have been reported previously [12, 14,17]. Two hundred eighty-five patient visits were stud-ied by means of tape recording the medical consulta-tion, by chart review, and by follow-up interviews withmothers (Fig. 1). Two control groups were obtained tomeasure possible effects of tape recording and inter-viewing so that the entire sample totaled 800.
The findings presented must be considered in lightof the fact that the unit for study was an initial visitfor an acute illness in the outpatient department of achildrens hospital and the pediatricians observed wereusually members of the house staff with 1-4 years pedi-atric experience.
Interaction Categories
For analysis of the tape-recorded interaction Bales'Interaction Process Analysis [3] was chosen because itallowed for quantification of the interaction into dis-
Table I. Modified Bales categories for interaction analysis1
Positive afTcct 1. Friendliness, shows solidarity.2. Shows tension release, jokes, laughs.3. Agreement and/or understanding.
3a. Simple attention.
Neutralstatements
Neutralquestions
Negativeaffect
4. Gives instructions.5. Gives opinion.6. Gives information.
6a. Introductory, parenthetical expressions.
7. Asks for information.8. Asks for opinion.9. Asks for instructions.
10. Disagrees.11. Shows tension.12. Shows antagonism, hostility.
1 For clarity the description of Bales categories has been simpli-fied. The index in Interaction Process Analysis [3] contains thecomplete definitions.
tinctive units designed to capture the nature of thecommunication process itself. In addition, this methodenabled the interaction data to be compared withother variables in this study as well as with otherstudies [10, 11]. Besides process analysis, records werekept of the content being discussed: history, physicalexamination, diagnosis, cause, seriousness-prognosis,treatment, or nonmedical conversation.
As shown in Table I, the Bales categories divideconversation into statements of positive, neutral, andnegative "affect"; because of the medical nature of thevisits, slight modifications were made in those origi-nally proposed by Bales. Highly positive statementsexpressed warmth, friendliness, solidarity, and empa-thy; e.g., "Hello, Don't worry, She'll be all right,"and/or raised the other's status by means of praise orrespect; e.g., "You're doing a good job with Mary."Tension release usually occurred in the form of jokes,laughter, and humor. The speakers showed simple at-tention by a yes or hum-hum which only indicatedlistening to what was said; strong agreement included
300 FREEMON, NEGRETE, DAVIS, AND KORSCH
-Child to Doctor
-Doctor to Child
2.1%
10.5%
fig. 2. Speakers' participation (N = 285).
signs of genuine understanding, agreement, or inten-tion to comply and was coded mostly by the stronglyaffirmative tone of the voice.
Both questions and statements were divided into in-formation, opinion, or instruction categories. Conver-sation having a negative tone was coded under one ofthe following areas: mild disagreements—coolness, de-tachment, withholding of help, interruptions; antago-nism—anger, threats, discourtesy, criticism, and hostil-ity; or tension—worry, nervous laughter, anxiety, ask-ing for help, showing distress or pain.
Coding
Because of the interpretive nature of the codes, ateam of two persons audited the tape recording butcoded each interaction on transcribed copies independ-ently and then came to mutual agreement on the mostsuitable codes. Coding reliability was checked periodi-cally and averaged 81% interteam agreement on themodified set of Bales categories and 84% when thesewere collapsed to the original 12. For the content,coding reliability was 85%. From the code sheets alldata were keypunched, stored on magnetic tape, andcompiled by computer.
Satisfaction and Compliance Ratings
Since this report relates compliance and satisfactionratings to interaction data, the derivation of these rat-ings will be explained briefly. A detailed descriptionhas been published elsewhere [12, 17]. Satisfaction rat-ings were based on a combination of "global" impres-sions recorded by experienced interviewers in the field,responses to questions in the interview that addressedthemselves directly to satisfaction ("How satisfied wereyou with your visit?"), and questions that indirectlysought out satisfaction ("What were some of the thingsyou did not like about your visit with the doctor?").Of the 800 mothers, 7G% were satisfied and 24% dis-satisfied. Likewise, patients were placed in one of threecategories depending on their compliance with thedoctor's prescriptions or in a no regimen category. Forty-two percent of the patients carried out all the doc-
tors instructions (high compliance), 11% carried outlittle or none (low compliance), and 38% followed themedical regimen in part (moderate compliance).
Results
The 285 interactions ranged in length from 22 to 1206statements with an average of 229. As illustrated inFig. 2, doctors talked more than mothers, 48.8 and38.6%, respectively. Considering each case individu-ally, 14% of the mothers talked more than the doctor,27% the same amount, and 59% talked less than thedoctor. Communication between the doctor and childconsumed, on the average, 12.5% of the total interac-tion units.
Role Profiles
Although the most common patterns of behavior formother, doctor, and child are represented in compositeprofiles summarizing the 285 interactions, it must beemphasized that there were also individual patternswhich differed dramatically. Discussion betweenmother and doctor (Fig. 3) included little warm,friendly, positive affect; i.e., those statements which, ineffect, attempt to bring solidarity to the interaction.More of the mothers' conversation expressed agree-ment with, acknowledgement, and understanding ofwhat was being said than did the doctors'.
Differences between the mother and doctor role areevident in the neutral categories: making statementsand asking questions (Fig. 3, categories 4-9). The doc-tor gave most of the instructions and the mothersasked for some but not as many instructions as mightbe expected. Perhaps the medical consultation itselfrepresents an implicit request for help from mothersand therefore specific requests are not often verbalized.Although the traditional role of the doctor is to giveadvice and suggestions about what to do, it had beenthought that doctors might encourage mothers more totake an active role in solving the medical problem, butevidently this docs not occur frequently. The doctorasked for suggestions from the mother in only 6 of the285 cases. Since the mother has to provide the medicalhistory, it was primarily the doctor who asked for in-formation. In general, giving information and orienta-tion was the most frequent type of communication forboth mother (46.9%) and doctor (35.5%) in the medi-cal visits. In effect, this exchange of information meetsthe "task goal" of planning for the care of the sickchild.
The last three categories in Figure 3 depict negative
Doctor-patient communication 301
1
2
3
3a
4
5
6
6a
7
8
9
10
11
12
BALES CATEGORIES
. Friendliness
. Tension Release
. Strong agreement
. Simple attention
. Gives instructions
. Gives opinion
. Gives information
. IntroductoryPhrases
. Asks forinformation
. Asks for opinion
. Asks forinstructions
. Disagrees
. Shows tension
. Shows antagonism
0
yN. i
r"\ J^0
51 10 '
• ^ _ _ _ _ _ _ _ _ _ _ ^
15 ' 2o' 25 ' 301 35 ' 40' 45 ' 50
Motherto
Doctor
2.9%
1.9
12.7
8.5
.2
8.3
46.9
.8.
2.9
.5
1.9
1.7
10.2
.8
Doctorto
Mother
5.67
.7
6.8
6.4
8.0
6.4
35.5
4.8
20.3
3.0
0
1.5
.2
.9
Mean PercentFig. 3. Mean profile of niothcr-tloctor communication in the Bales categories. O — O: Mother to doctor. (— • : Doctor to mother.
affect. In general, mothers expressed a much higherpercentage of negative affect than doctors and it wasmainly passive in the form of tension, feai% or helpless-ness, rather than in direct attack or rejection of thedoctor, the latter being more incongruous with theirpatient role. In contrast to doctors, expressions of ten-sion by mothers were quite frequent, averaging 10.2%of the total statements and ranging from none to asmuch as 45%.
The Bales category scores for mother and doctorwere also studied by means of a factor analysis com-puter program to identify those combinations of cate-gories which occurred spontaneously and consequentlyto check these against the dependent variables. Thethree major factors that were isolated included moth-er-doctor arguments-disagreements; friendliness-jok-ing; and information requesting and giving. Findingssuggest that a two-way exchange was necessary for anovert disagreement or argument to occur; not only wasovert negativity shown to be associated for mother anddoctor in the factor analysis, but the role profile (Fig.3) points out similar mean percentages for both.
To estimate the degree of the two speakers' emo-tional involvement in the medical visit, the proportionof affectual statements to neutral statements was calcu-lated. On the average, the scores were twice as high formothers as for doctors.
The profile for the doctor-child process analysis (Fig.'1) shows the communication to fall consistently into afew categories. Almost one-half of the doctors' conver-sation with their child-patients consisted of warm,friendly statements while another quarter was con-cerned with giving instructions (mostly regarding thephysical examination). The child talked to the doctorlargely by answering his questions; by showing pain,anxiety, or anger; and by complying with his instruc-tions.
Content Categories
The mother-doctor composite content profile (Fig. 5)illustrates that the most common subjects for discus-sion were history and treatment. In fact, it was duringhistory-taking that mothers spoke the most; almosttwo-thirds of their communication to the doctor was
302 FREEMON, NEGRETE, DAVIS, AND KORSCH
BALES CATEGORIES
1. Friendliness
2. Tension Release
3. Strong agreement
3a. Simple attention
4. Gives Instructions
5. Gives opinion
6. Gives Information
ja. IntroductoryPhrases
7. Asks ForInformation
8. Asks for opinion
9.
10.
11.
12.
Asks forInstructions
Disagrees
Shows tension
Shows antagonism
0 5| 10| 15l 20 I 251 3o| 351 401 45I 50Mean Percent
Childto
Doctor
4.77.
3.8
21.1
.3
.1
2.6
31.9
.7
4.2
0
.4
1.2
14.5
14.4
Doctorto
Child
46.07.
3.8
2.6
.4
26.5
.4
4.7
4.5
8.1
.9
Fig. 4. Mean profile of doctor-child communication in the Bales categories. Q—O : Child to doctor. • — • : Doctor to child.
CONTENT CATEGORIES
History
PhysicalExamination
Cause
Diagnosis
Treatment
Seriousness andPrognosis
Nun-medical
0
cflol 20 1
*•
30 1 401 50l 601 70lMean Percent
80| 90 100
Motherto.
Doctor
60.3%
4.9
1.9
6.1
16.4
2.0
8.4
Doctorto
Mother
34.17.
9.1
2.4
12.6
30.1
3.9
7.7
Fig. 5. Mean profile of doctor-mother communication in the content categories. O —O: Mother to doctor. • — • : Doctor to mother.
Doctor-patient communication 303
CONTENT CATEGORIES
History
Physical
Examination
Cause
Diagnosis ,
Treatment
Seriousness andPrognosis
Non-medical
0
{I
K10' 201 301 40l 50 1 60 1 70 1 80l 901100
Child
to
Doctor
14.77.
68.4
.4
.4
3.2
0
12.7
Doctorto
Child
3.77.
86.7
.1
.7
1.2
0
7.6
Mean PercentFig. 6. Mean profile of doctor-child coiniiuinication in the content categories. G — O : Child to doctor. • — • : Doctor to child.
45
40
35
30
25
20
15
10
b-pi
3,3a 6,6a 11 12 3,3a 6,6a 12
(Positive)
Bales Categories
(Negative) (Positive) (Negative)
Bales Categories
lug. 7. Hales interaction profile for mother and doctor. Left: Case A, 244 statements by mother and l'JH statements by doctor. Right: Case II,4G statements by mother and 184 statements by doctor. Shaded areas: Mother—percentage of total. Unshaded areas: Doctor—percentageof total.
devoted to the medical history. The doctor, on theother hand, had nearly an equal amount of discussionrelated to history and treatment. The doctor devotedthe least amount of discussion to cause and prognosis
of the child's illness, yet interviews have indicated thatan explanation of cause is especially important to thepatients' parents and is strongly associated with theirsatisfaction [17]. In the doctor-child interaction (Fig.
304 FREEMON, NEGRETE, DAVIS, AND KORSCH
Case A
32 40
Statement Number
I'ig. 8. Sequence interaction profile for mother and doctor. Heavy line: Mother. Thin line:
48
Doctor.
56 64 72
6), practically all the discussion (86.7%) was related tothe physical examination with a small amount devotedto history-taking (3.7%) and to general nonmedicalsubject matter (7.6%).
Case IllustrationsTwo cases will be briefly described and contrasted to
give a clearer understanding of how this analysis canbe useful in understanding an individual case. Foreach case there are graphs illustrating the Bales analy-sis (Fig. 7) and sequence of statements (Fig. 8) bymother and doctor. Case A illustrates active two-waycommunication, with the mother's participationamounting to 55% of the total. The sequence profile(Fig. 8) shows a freely moving, back-and-forth ex-change between speakers. As shown in Figure 7, themother was especially able to verbalize her opinionsand give information (categories 5 and 6) to the doctorwhile the doctor continually indicated interest, atten-tion, and understanding (category 3). There was a mix-
ture of positive and negative affect during discussionsof history and treatment, indicating a high degree ofemotional involvement by both mother and doctor.The mother on interview was very satisfied and com-pliant. She described the doctor as being friendly andreassuring, felt his attitude really indicated that heunderstood her concerns and that he was especiallyhelpful with his treatment instructions.
The pattern of conversation in case B is quite incontrast to case A in that of 72 statements illustratedin Figure 8 there were few exchanges between speak-ers. The doctor clearly dominated in this instance.The Bales analysis (Fig. 7) also illustrated that themother's contribution amounted to only 20% of thetotal statements. The mother told the interviewer atfollow-up that she felt the doctor was "lousy," that heshowed no interest, and did not relieve her worries atall. Satisfaction with this visit was rated very low, and,although she received an adequate amount of informa-
Doctor-patient communication 305
tion relating to treatment (category 4 and 6), themother was only partially compliant with the regimen.
Analysis of large numbers of individual cases usingthis technique of Bales analysis and sequence of state-ments has not been completed as yet so generalizationsmust be made with caution. Some fairly straight for-ward comparisons, however, have been completed be-tween Bales categories, content categories, and out-come variables.
Correlations
Only the most significant results (chi-square value of0.05 or less) of the analysis of the interaction data inrelation to patient satisfaction, compliance, and pa-tient background are presented in this paper.
Patient satisfaction was not found to be related tolength of interaction as measured in terms of the totalnumber of units. Shorter interactions, however, wereassociated with higher compliance than long interac-tions (Table II). Also, mothers who tended to domi-nate tlie conversation and talk more than the doctorexpressed less satisfaction with their visit and werelower on compliance ratings (Table III). Whether doc-tor or mother dominated the conversation did notseem to be related to the social class or education ofthe mother or the nature of the illness.
The tone and process of the interaction as measuredby the Bales categories were also compared with theoutcome variables. The degree of emotional involve-ment (ratio of affectual to neutral statements) showedno correlation with outcome in that a similar percent-age of highly compliant and satisfied patients werenoted following interactions with little, or with a lotof affect. More affect, however, was expressed by doc-tors to mothers having some college education than tothose with less education.
The type of affect that was expressed by doctor andmother was found to be highly relevant to outcome. Ingeneral, the data support the view that expression ofpositive affect, i.e., being nice, is associated withgreater satisfaction and compliance in the patients. Asseen in Table IV, the greater the friendliness and soli-darity expressed by the doctor, the more likely theparent will be satisfied and highly compliant.
It was postulated that the doctor's conversation withthe sick child would also influence satisfaction, espe-cially since so many of the doctor's statements to thechild were warm and friendly; however, there was onlya slight increase in satisfaction and follow through onmedical advice when the doctors devoted more time tothe child (Table V).
Bales proposed a way of studying the structure of
Table II. Length of interaction and outcome
No. of statements *&& ^cenUge No. of P e ^ l n , l . a R e
patients
22-149250-1206
94100
7876
8595
5341
1 In the tables throughout this paper the extremes are usuallycompared; therefore, the number of patients will not total 285.
1 able III. Speaker dominance ;i
Speaker dominance
Doctor speaks more than or thesame as the mother
Mother speaks more than doctor
md outcome
No. of c eP « "
patients s a t i s f i e d
243 77
40 60
Table IV. Positive affect and outcome
Percentage of doctors' *. t t>
0-2.9 847.5-36.4 68
Table V. Doctors' conversation
Percentage doctor-child Xo.'ofconversation visits
0-*.7 150Over 12 59
6687
with child an
Percentagesatisfied
56.064.5
No. ofpatients
224
35
Per-centage
55.5
34.0
r » t Percentageti'ent highly <
8089
3858
d outcome
No. ofvisits
11178
3949
interaction by combining individual categories intomeaningful units labeled "indices." For each of fiveindices he suggested, three scores were computed percase (mother and doctor alone and in combination),and by computer program these were tested for associa-tions with the dependent variables. It is noteworthythat an index measuring the proportion of negativealfect (disagreement, tension, antagonism) to the totalamount of affect expressed between the doctor andmother had an inverse relation to both satisfactionand compliance (this is the index of malintegretivc-ex-pressive behavior proposed by Bales [3]) (Table VI).An increasingly negative tone for either mother ordoctor was associated with increasing dissatisfactionand less high compliance. Strongly negative state-ments, such as hostility and antagonism, and to a lesserextent disagreements, were also associated with de-creased parent satisfaction although the mother's ex-pression of tension was not. The group of motherswho expressed tension but no open disagreement orhostility seemed to be distinctive in that, on interview,
306 FREEMON, NECRETE, DAVIS, AND KORSCH
Table VI. Negative affect and outcome
Per-Percentage ofstatements No. of " v
with negative patients .•affect
Pcr-No. of centagc
patients highlycompliant
Doctors'affect
Doctors'
Mothers'
negative
hostility
tension
0
0
0.9-690-0.7.7-21.3GMi
12-45
11711022400,r)H
7G
826376577972
105103206
548592
533248.5304942
Table Vll. Mothers' expression of negative affect as tension andoutcome of visit
No. of Percentage No. of P e fo e $ g e
patients satisfied patients com*Ua*n t
Mothers expressing ten- 104 82 94 53sion
Remainder of sample ll!0 G5 166 40
Table VIII. Agreement and outcome
Percentage ofmothers' statements,
agreement, andacknowledgments
No. ofpatients
Percentagesatisfied
No. of P e K C h l J 8 'V^> coolant
0-1524-87.5
10697
6782
9995
4047
Table IX. Questions during the visit and outcome
Percentage No. of Percentage No. of PeK'nlt"BC
questions patients satisfied patients co™|j.fnt
Mothers'
Doctors'
0-26-220-33
45-87
8711193
110
79667568
74818698
494353.538
Table X. Nonmedical, general
Percentage of generalnonmedical statements
0-4.4•J-37
No. ofpatients
9485
content and
Percentagesatisfied
6686
outcome
£uen(s
8981
Percentagehighly
3555
they also expressed less dissatisfaction and reportedless noncompliance than the remainder of the sample(Table VII).
As illustrated in Table VIII responses from themother showing agreement with and understandingand acknowledgement of what the doctor was sayingwere correlated with satisfaction but contrary to thefindings of Davis [10, 11] were not correlated with
compliance. It would seem that no matter how muchthe mother verbally agrees to comply or shows under-standing, this is no criterion for predicting compli-ance. The relation of so-called "yes" mothers (thosehigh in agreements) to high satisfaction ratings maysuggest a limitation of interview technique. Motherswho express a lot of agreement, acknowledgement, andunderstanding during the interaction also may find itdifficult to express dissatisfaction on Interview.
In general, the way mother and doctor phrased theirquestions and statements was not related to the out-come variables. Furthermore, whether the doctor gaveinstructions in a permissive or authoritarian wayseemed to have no relation to the degree to which themother followed through. On the other hand, itseemed that receiving information made for patientsatisfaction and compliance because mothers who wereasked more questions, or had to ask for more informa-tion had a less favorable response to the visit (TableIX). There was increased compliance by parents whendoctors gave more information than when doctorsasked a greater proportion of questions. (The difficultyof communication index proposed by Bales [3] is de-fined as number of questions per number of questionsand number of statements.)
In general, it appeared that the doctor largely con-trolled the subject matter; it was the number of state-ments by the doctor in the various content areas thatproved most related to outcome variables.
A consistent finding in the study was that visits con-taining some conversation of a general or nonmedicalnature were associated with more satisfaction and com-pliance (Table X). This "nonmedical" content cate-gory was designed to include any general conversationnot specifically related to the medical problem, such asgreetings, talking to or about other children in thefamily, and other purely social interchange. Sincemany of the statements in this category also showedpositive affect, however, it cannot be determined atthis time whether outcome is influenced by the socialconversation or by the warmth and friendliness of thedoctor, expressed in relation to all subject matter.
An original hypothesis was that a longer, more thor-ough history-taking period, in which the mother wasallowed to "get everything off her chest," would resultin greater satisfaction and compliance. Also, many doc-tors believe the history to be the most important partof the interaction and the one with which they takethe greatest care. In this study, however, the time de-voted to history taking was found to correlate nega-tively with satisfaction and compliance; generally,
Doctor-patient communication 307
cases with longer histories were associated with moredissatisfaction and lower compliance (Table XI). Thismay mean that a long history-taking process reflectsdifficulty in communication as perceived by themother.
Consideration was given to the relation between thesubject matter discussed and the most frequent diag-noses represented in the sample—ear infections, colds,skin problems, and gastrointestinal upsets. Although itmight be thought that longer histories would necessar-ily be associated with more complicated diagnoses, thiswas not found to be the case. Rather histories of alllengths were recorded with each type of illness.
Increased satisfaction seemed to be associated withthe extent to which the doctor discussed the cause ofthe illness (Table XI), but this association could notbe documented statistically since in 110 of 284 casesthere was no discussion of cause whatsoever. Theamount of discussion regarding the examination, diag-nosis, treatment, or seriousness and prognosis did notcorrelate significantly with satisfaction, although therewas a trend toward higher compliance in cases havingmore discussion devoted to diagnosis. Contrary to ex-pectations, the amount of discussion about treatmentby the doctor was not related to compliance.
The only content factor which bore a highly signifi-cant relation to social class was the doctor's discussionof diagnosis; more discussion was directed by doctorsto patients in the middle and lower classes than to thehigher social classes.
Discussion
The findings presented in this report are one of severalattempts by the present research team to document thefactors that contribute to effective communication be-tween physicians and patients. Some of the results ofthe studies presented here are of interest primarily inthat they describe the process of interaction moreobjectively. These descriptions are sufficiently clear sothat comparisons can be made between different kindsof communication. For instance, in the case of pediat-ric practice, the physician's conversation with the childpatient himself can be compared with his manner inrespect to the patient's mother. It can be noted thatfriendly, warm conversation makes up almost half ofthe pediatrician's interaction with the child, butamounts to less than 6% of his conversation with themother. When it is considered that so much of theeffectiveness of pediatric care of ambulatory patients isdirectly dependent upon cooperation and understand-
Table XI. Content and outcome
Percentage N o o ( , . c r c e n t a K e
statements P a t i e n l s s a t i s f i e d
Percentage
History
Cause
0-2G39-830-0.91-25
9193
124KiO
78646577
8383
11385
523!)5040
ing on the part of the mother, this absence of warmthexpressed to the mother herself is alarming. The tend-ency for pediatricians to identify with the child pa-tient and to consider the parent as a somewhat unwel-come intruder in relation to his patient is well known,but the present report is one of the first instances inwhich this trend is documented and quantified.
Another descriptive finding related simply to thecontent of the conversation between the doctor andthe patient's parent. Very few words are devoted toanything but strictly medical discussion, yet there is astatistically significant relation between the amount ofsocial, nonmedical conversation and the outcome ofthe consultation, not only in respect to patient satisfac-tion but also in follow through on the medical advicereceived from the doctor.
Some common concepts concerning doctor-patientinteraction are challenged by the results of the investi-gation on which this report is based. Most doctorsbelieve that they do more listening to their patientsthan talking. Yet, admitting that there are some ex-tremely garrulous patients whom all remember but toovividly, it was found in the present sample that physi-cians did more talking than did the mothers. No rela-tion between longer consultation and favorable out-come of the medical visit was demonstrated. This initself came as a surprise to many because it has so oftenbeen said that all health professionals would be moreeffective, "if only they had more time to spend withtheir patients." In earlier reports by this research teamit has been stated that the time of interaction in min-utes, as such, did not influence the outcome. Now itcan be added that the amount of talking by the doctoror patient, as such, also could not be shown to influ-ence the results of the medical visit. Does this meanthat, "listening to the patient," in itself, is not as help-ful as it always has been thought to be? Not necessar-ily. All that can be claimed on the basis of this study isthat the length of time that the doctor is in the sameroom with the patient, while the patient is talking,does not influence the patient's responses. True listen-ing probably involves more than that. This also ap-
308 FREEMON, NEGRETE, DAVIS, AND KORSCH
plies to the findings obtained in respect to the contentcategory in the analysis referred to as "medical his-tory." It might have been assumed that the presence of:i long history in itself would indicate that the patienthad had a chance to express her concerns more fullyand would consequently leave her more satisfied andlikely to follow the advice. This was not the case. As amatter of fact, if anything, excessively long historiestended to be associated with dissatisfaction, nor didextra long interactions lead to more satisfaction. Al-though this cannot be backed up statistically, in look-ing at individual cases it would appear that perhapslong histories reflect difficulty in communicationrather than being a sign of effective communication.
In this study, the amount and kind of affect ex-pressed during the consultation by the physician wascompared with the amount voiced by patient's mother.There was found to be a significant relation betweenthe type and amount of emotion expressed by doctorand mother and the outcome of the consultation.Larger amounts of hostility and expression of othernegative affect were associated with negative outcome.More positive affect and greater friendliness and soli-darity were generally associated with greater satisfac-tion and better follow through on medical advice. Insome ways this seems a documentation of the obviousexcept for some earlier suggestions by other workers [7,9] that increased social distance and less friendlinessbetween physician and patient might lead to betterfollow through on advice given, perhaps, owing to thegreater authority vested in the physician.
It is also noteworthy that, in general, the mothersexpressed significantly more negative affect than do thephysicians, and that this negative affect tends to bemore in the direction of tension than out-and-out hos-tility and antagonism. Expressions evidencing tensionconstitute, on the average, about 10% of the mother'sstatement and may contribute as much as 45% of themother's statements in individual cases. The doctor, al-though he shows a certain amount of disagreement withthe mother, shows very little tension and only a smallamount of hostility and antagonism, which incidentallyis equivalent to that of the mother. In simple summaryit would appear that both mother and doctor occasion-ally express reciprocal antagonism with each other butthat the outstanding negative feelings experienced dur-ing a consultation involving a sick child are experiencedand expressed by the mother. It is she who is uncom-fortable and tense. This becomes especially noteworthyin light of the fact that there is so little solidarity or re-assurance to her, expressed by the doctor.
A related finding is that the percentage of totalstatements expressing alfcct of any kind is definitelyhigher for the mother than for the physician, suggest-ing that a medical visit with a sick child generally is amore emotionally charged experience for a motherthan for her doctor.
Initially, it had been expected that the opportunityto ask many questions of the physician would makepatients feel more satisfied with their consultation;however, the study showed that those mothers who didask many questions tended to be less satisfied. Simi-larly, one might have assumed that a patient wouldperceive that a physician who asks her many questionswas evincing interest in her and this might make herfeel satisfied. Inspection of individual cases offeredsome insight into the basis for these findings. It wouldappear that patients prefer a "giving" doctor whofreely offers information to one who makes it necessaryfor them to ask for it specifically; that is, being askedquestions by the physician tended to be associated witha doctor-patient relation where the mother felt thatshe was doing the giving and did not get as much fromthe physician for herself.
Aside from the descriptive and correlative findingspresented here, the implications of applying a methodsuch as Bales Interaction Process Analysis [3] to thesituation that is represented by a medical consultationneeds to be considered. The Bales method was notdesigned primarily for elucidation of an interactionbetween just two persons who are addressing them-selves to the solution of one specific medical problem.Instead, there was more emphasis on subtler, affective,interpersonal relations: hence the highly detailed, de-scriptive categories and the sometimes baffling indicesand analytical approaches which have not been com-pletely detailed here. As anticipated, only portions ofthe methodology proved relevant to the data underconsideration. Still, the Bales method was one of thefew prior attempts at quantifying and measuring whathad heretofore been subjected only to intuitive ap-praisal. It also made possible some comparisons be-tween the interaction process as perceived by the inter-actors and as analyzed with these more objective meth-ods. Having documented [12, 17] that in many respectsthe interaction process was quite appropriately mir-rored in the mother's perceptions, there would be noneed for such detailed coding in the future. There arca limited group of significant variables, however,which were isolated and noted for the first time byapplication of the Bales method that should justifiablybe searched for in future attempts to describe and
Doctor-patient communication 309
measure the verbal communication between doctorand patient.
Literature Review
The subject areas most related to doctor-patient behav-ior are role theory and communication theory, espe-cially Bales Interaction Process Analysis and its appli-cation.
Doctor-Patient Roles
Sociological views of the doctor-patient relation con-tribute greatly to the general theoretical frameworkfor the present research. The concept of role has beenespecially useful "because it offers a means of studyingboth the individual and the collectivity within a singleconceptual framework" [13]. Although the consulta-tion between physician and patient can be consideredwithin the realm of small group interaction, it is atypi-cal of most other small groups in that the membershave certain predetermined roles or patterns of behav-ior as well as a common goal. As characterized byParsons [22], the doctor is sought out by the patient tomake a diagnosis and to indicate what treatment isnecessary for "wellness." In return, the patient is ex-pected to cooperate by giving information to the doc-tor and by following his recommendations. The sickperson, in playing the "sick role," is unable to fulfillhis social obligations, and the physician, in applyinghis knowledge to cure the condition, helps restore thisimbalance in society. The physicians' acts are of twotypes, "instrumental," having to do with technical as-pects of treatment, and "expressive," having to do withthe emotional and psychological aspects of patientcare.
Since Parsons' original application of role conceptsto illness behavior, numerous contributions have beenmade to elaborate doctor-patient behavior patternsand role theory in general. Certainly one of the finestresumes of the history, structure, and properties of roletheory is the work of Biddle and Thomas [6]. Notuntil 1966, however, were Parsons' assumptions aboutthe sick role, as well as possible sociocultural varia-tions, tested empirically [13]. In that study, Gordondistinguished two types of roles relating to illnessbased on behavioral expectations, whether the pa-tient's prognosis is serious and uncertain (the "sickrole") or whether the prognosis is nonserious and cer-tain (the "impaired role").
Bloom [7] and others [16, 19] also inferred certainexpectations from the social roles of the physician and
patient. Both doctor and patient are seen as beinginfluenced by their respective subcultures and by thesocial status ascribed to them by the larger society.Doctors and medical students themselves view the doc-tor as the one in charge, deriving authority from thepatient's consent and from societal expectations [21].Most satisfaction-dissatisfaction and problems wereseen as part of the affective side of the doctor-patientrelation, and the doctors most frequently reported dis-satisfaction from lack of control over difficult patients.
Social distance between doctor and patient is a com-monly noted source of communication difficulty. Alsosome believe the doctor's role to be particularly struc-tured and stereotyped [15].
The Study of Communication
There have been numerous attempts to study doc-tor-patient communication. One of the more indirectapproaches has been the use of follow-up interview. Aserious limitation of this method, however, is the lackof recorded interaction for more direct analysis. Such astudy by Ambuel [2], consisting of 97 interviews withmothers after clinic visits for their sick children, re-vealed that inadequate information was given regard-ing cause of illness, reason for the return appointment,expected cost and action of the prescription given.The mothers were able to give more specific informa-tion when it related to something they must do ratherthan why they should do it.
The need for and lack of explanations have alsobeen reported by Reader [23], who found that patientsseemed to have a great need for explanations but madeno particular effort to get information from the doc-tors nor criticized doctors for not giving information,perhaps suggesting that they in fact did not expectsuch explanations. Hospitalized patients in Cart-wright's study [9] reported that information was diffi-cult to obtain, especially regarding the cause or natureof illness and the likelihood of recurrence. More dissat-isfaction was expressed by patients who said they hadto ask than by those who said people gave them infor-mation freely. Those who neither asked nor were toldwere the most dissatisfied. Diffidence by patients inasking for information was attributed to problems oflanguage and doctor-patient social distance.
Another investigator [20] attempted to relate doc-tors' feelings, as reflected in their speech during aninterview, to the degree of success in referring alco-holic patients for continued treatment. The analysisinvolved auditing of tape recordings, content-filteredtape recordings (tone only), and transcripts of the in-
310 FREEMON, NEGRETE, DAVIS, AND KORSCH
terviews. Those doctors who were judged to be lessangry and more anxious were more effective.
Other attempts have been made to analyze interac-tion more directly through observation or tape record-ings. An article by Weick [24] contains a careful elabo-ration of problems and techniques of observation. Hediscussed settings and methods for observation, prob-lems of observer interference, and the various types ofobservable verbal and nonverbal behavior. The studyby Lennard and Bernstein [18] of structure and proc-ess of verbal interaction between psychotherapist andpatient using a system of categories (e.g., (7) indicateslistening, passively encourages more; (2) actively en-courages more; or (3) limits patient to single subjectarea) showed patient satisfaction to be associated withtheir expectations and the absence of strain duringcommunication. Zabarenko [25] developed methods ofdirect observation of doctor-patient interaction butthese were purely descriptive.
Davis [10, 11] applied a modified form of the Balesinstrument to tape recordings of patient visits in ageneral medical clinic. His study of doctor-patientcommunication was similar to the present one exceptthat he used an adult population, only one outcomevariable (compliance), and two visits per patient. In-teraction categories were found to be related to com-pliance on the second visit only. The giving of infor-mation by the doctor and patient agreement, tensionrelease, and questions seeking the doctor's opinionwere those aspects of communication associated withcompliance. Noncompliance was observed more oftenin patients who expressed tension or who gave theiropinions, and in response to doctors who disagreed orasked for information without giving any feedback, liymeans of factor analysis 10 types of doctor-patient com-munication were described, e.g., "active patient-passivedoctor."
Other adaptations of Bales' analysis include that ofAdlcr and Enelow [1], who designed a scale to fit thespecial characteristics of the communication between apatient and a psychotherapist. Also, Borgatta [8] reorg-anized the Bales categories to allow for the intensity ofresponses and for greater differentiation of the commu-nication process. His system limits the neutral catego-ries while expanding the positive and negative ones(from 8 to 14), making for a more accurate and specificanalysis of interaction.
The literature stresses the increased attention givento the study and scientific evaluation of interactionamong people. Although development has been ham-pered by the lack of measuring techniques, advances
have been made in this area. At this time certainly themost basic and most generally applicable approach isBales analysis [3]. Although this procedure was origi-nally designed for analyzing interaction within smallgroups by having observers watch, listen, and code theprocess through one-way windows, it has been morewidely adapted and utilized than any other. More re-cently, Bales further developed the original categoriestheoretically, in terms of how an individual is rated byothers on three dimensions: power, affection, and con-tribution to the group [4]. There has also been someattempt to set up norms for the Bales categories [5].
Conclusion
In summary, the application of the complex method ofBales to analysis of the verbal communication betweendoctor and patient yielded a wealth of descriptive,qualitative, and quantitative data and made possible afew clinical correlations. Outcome of the medical com-munications, in terms of the patient's satisfaction andfollow through on medical advice, was favorably influ-enced by having a physician who was friendly; ex-pressed solidarity with the mother; took some time todiscuss nonmedical, social subjects; and showed an in-terest in her and gave her the impression of offeringinformation freely, without her having to request it, orfeeling excessively questioned by him. More total af-fect, and especially most negative affect, was experi-enced and expressed by mothers during a medical visitthan by doctors and the total amount of negative affectexpressed by both could be correlated with an unfavor-able outcome of the consultation.
References and Notes
1. AUI.HR, L., AND ENELOW, A. J.: A scale to measure psycho-therapy interaction (Department of Psychiatry, University ofSouthern California School of Medicine, Los Angeles, 1964,unpublished.)
2. AMIIUEL, J., CEHULI.A, J., WATT, N., AND CROWNE, D.: Doctor-mother communications, a study of information communi-cated during clinic visits for acute illness (Ohio State Univer-sity, Columbus, 1961, unpublished.)
3. HAI.ES, R. F.: Interaction Process Analysis (Addison-WcslcyPress, Cambridge, 1950).
4. HAI.ES, R. F.: Interaction process analysis. In: D. L. Sills:International Encyclopedia of The Social Sciences, Vol. 7,p. 405 (Crowell-Collier and Macmillan, New York, 1908).
5. HALES, R. F., AND HARE, A.: Diagnostic use of the interactionprofile. J. Soc. Psycho!., 67: 239 (19G5).
6. HIDDLE, B., AND THOMAS, E.: Role Theory (John Wiley kSons, New York, 19GG).
7. HI.OOM, S.: The Doctor and His Patient—A Sociological In-terpretation (Russell Sage Foundation New York, 19G3).
Doctor-patient communication
8. BORGAITA, E. F.: A systematic study of interaction process 21.scores, peer and self-assessments, personality and other varia-bles. Genet. Psychol. Monogr., 65: 219 (1962).
9. CARIWKIGIIT, A.: Human Relations and Hospital Care (Rout- 22.ledge ft Kegan, Paul, London, 1964).
10. DAVIS, M. S.: Physiologic, psychological and demographic 23.factors in patient compliance with doctors' orders. Med. Care,6: 115 (1908). 21.
11. DAVIS, M. S.: Variations in patients' compliance with doctors'advice: Empirical analysis of patterns of communication.Amer. J. Public Health, 5S: 274 (1908).
12. FRANCIS, V., KORSCII, B., AND MORRIS, M.: Gaps in doctor-pa- 25.
tient communication: Patients' response to medical advice.New Engl. J. Med., 2S0: 535 (1909).
13. GORDON, G.: Role Theory and Illness (College and UniversityPress, New Haven, Conn., I960).
14. Gozzi, E., MORRIS, M., AND KORSCII, B.: Gaps in doctor-patient
communication: Implication for nursing practice. Amer. J.Nursing, 69: 529 (1969).
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16. Koos, I,.: The Health of Rcgionvillc (Columbia UniversityPress, New York, 1954).
17. KORSCII, II., Gozzi, E., AND FRANCIS, V.: Gaps in doctor-patient
communications: Doctor-patient interaction and patient sat-isfaction. Pediatrics, -12: 855 (1908).
18. LENNARD, II. L., AND BERNSTEIN, A.: The Anatomy of Psycho-
therapy (Columbia University Press, New York, 1960).19. MECHANIC, D.: Role expectations and communication in the
therapist-patient relationship. J. Health Hum. Bchav., 2:190 (1961). -9.
20. MlLMOE, S., ROSENTHAL, R., BLANE, I I . , ClIAFETZ, M. , AND
WOI.F, I.: The doctor's voice: Post dictor of successful referralof alcoholic patients. J. Abnorm. Psychol., 72: 78 (1967). 30.
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ship as described by physicians and medical students. J.Health Hum. Behav., 5: 25 (1964).PARSONS, T.: Illness and the role of the physician. J. Ortho-psychiat., 21; 452 (1951).READER, G. G., PRATT, L., AND MIDD, M. C: What patients
expect from their doctors. Mod. Hosp., 89: 88 (1957).WEICK, K. E.: Systematic observational methods. In: G. Lind-zey and E. Aronson: The Handbook of Social Psychology,Vol. 2, p. 357 (Addison-Wcsley Publishing Company, Read-ing, Mass., 1908).ZAHARENKO, L.: Some thoughts on educational evaluation, p.19 (A.P.A. Committee On Psychiatry and Medical Practice,Proceedings of The Third Collegium For Postgraduate Teach-ing of Psychiatry, Miami Beach, 1964).Supported by US Children's Bureau Grant no. 11-10; De-partment of Health, Education, and Welfare Grant no. IIS00381-02; and the California State Department of PublicHealth.Dr. Korsch is the recipient of National Institutes of HealthResearch Career Development Award no. 5-K3-HO-28, 297.We arc indebted to Elaine Aley and the other research teammembers for valuable assistance in coding of the data, to thestart of Childrcns Hospital of Los Angeles for cooperation,and to Ray Mickey, PhD., and Miss Coralcc Yale for collab-oration in data processing. Computing assistance was ob-tained from the Health Science Computing Facility, Uni-versity of California, Los Angeles, sponsored by NationalInstitutes of Health Grant no. FR-3.
Requests for reprints should be addressed to: BarbaraKorsch, M.D., Childrens Hospital of Los Angeles, 4650 Sun-set Boulevard, Los Angeles, Calif. 90027 (USA).Accepted for publication October 0, 1970.
Copyright Q 1971 International Pediatric Research Foundation, Inc. Prinltdin U.S.A.