Interpersonal Communication Processes Within the Provider-Patient Interaction
Summary and Keywords
The degree to which patients are active and communicative in interactions with medical providers has changed in recent decades. The biomedical model, a model that minimizes patient agency in the medical interaction, is being replaced with a model of patient-centered care, an approach that prioritizes the individual patient in their healthcare and treatment decisions. Tenets of patient-centered care support that patients must be understood within their psychosocial and cultural preferences, should have the freedom to ask questions, and are encouraged to disclose health-relevant information. In short, this model promotes patient involvement in medical conversations and treatment decision-making. Research continues to examine approaches to effective patient-centered communication. Two interpersonal processes that promote patient-centered communication are patient question-asking and patient disclosure. Patient question-asking and disclosure serve to inform medical providers of patient preferences, hesitations, and information needs. Individuals, including patients, make decisions to pursue or disclose information. Patients are mindful that the act of asking questions or disclosing information, particularly stigmatized information such as sexual behavior or drug use, could make them vulnerable to perceived negative provider evaluations or responses. Thus, decisions to ask questions or share information, processes essential to the understanding of patient perspectives and concerns, may be challenging for patients. Various theoretical models explain how individuals consider if they will perform actions such as seeking or disclosing information. Research also explains the barriers that patients experience in asking questions or disclosing relevant health information to providers. A review of pertinent research offers suggestions to aid in facilitating improved patient-centered communication and care.
Managing one’s health can be laden with uncertainty, the cognitive state that occurs when “details are ambiguous, complex, unpredictable, or probabilistic; when information is unavailable or inconsistent; and when people feel insecure in their own state of knowledge or the state of knowledge in general” (Brashers, 2001, p. 478). Individuals may be unsure of how to understand and evaluate health-related concerns, such as what a symptom or pain could mean. Patients may be unsure if symptoms are associated with a health problem, such as signaling the recurrence of a chronic health issue. Or they may be unsure of how to make sense of and interpret the myriad of health messages available online, on TV, and from friends and family, among other sources. There are numerous illness-related stimuli and events that can create a sense of confusion, ambiguity, or lack of clarity (Mishel, 1981). Patients may ask themselves, “Should I try out that medication that I heard about in the commercial? Would it be right for me?” or “Should I tell my doctor that the pain returned?” Patients often attempt to gain a sense of clarity and understanding about health-related issues by visiting a medical provider. Individuals’ uncertainty, however, is not limited to their health experiences. It influences how they communicate with their healthcare providers (henceforth referred to as “providers”). Patients and their companions contemplate which questions to ask, how to frame those questions, which information to share, and which information to conceal. Although companions can play an active role within the medical interaction with the provider (Street & Gordon, 2008), this article is limited to provider-patient interactions.
Two interpersonal communication processes prominent in the healthcare context that aid in understanding how patients manage their uncertainty are patient information-seeking and patient information-sharing, or disclosure. Certainly the act of information-seeking is associated with uncertainty, as one goal of question-asking is to gain information in efforts to manage uncertainty. Disclosure is also grounded in uncertainty (Greene, 2009), particularly as patients struggle with determining what to share or withhold. They may contemplate what information is relevant or superfluous to the provider. Further, in efforts to minimize potential threats of sharing stigmatized information, they may determine what health-relevant information to conceal from providers (e.g., number of sexual partners; Lewis, Matheson, & Brimacombe, 2011). Current standards of quality medical care, referred to as patient-centered care, stress that patients should be able to participate in their visit and be active in medical decision-making. Thus, interpersonal processes of information-seeking and disclosure are central to patients achieving optimal patient-centered care.
This article begins by describing the model of patient-centered care and identifying two interpersonal processes that contribute to patient-centered communication, patient question-asking, and disclosure with providers. Patients experience uncertainty about how to communicate with their providers, and they consider if they should ask specific questions or avoid asking. Similarly, they contemplate implications of disclosing information from their providers. In an effort to understand barriers to patient engagement in the medical interaction, more specifically question-asking and disclosure, this article examines two theories that illuminate the multiple considerations that individuals contemplate when determining if they will engage in a communicative behavior. The theory of motivation information management (Afifi & Weiner, 2004) provides an understanding of how patients determine if they will seek information from their providers. Multiple studies serve to support the relationship between challenges faced by patients and decisions to ask or to refrain from asking questions. The article then considers the potential benefits of patient question-asking and examines the diversity of the types of questions patients may ask. Turning to disclosure, the disclosure decision-making model (Greene, 2009) provides a description of how individuals determine whether to reveal or conceal health-related information. The article highlights how research has identified instances in which patients experience uncertainty and hesitation in disclosing to their providers. Finally, it examines strategies for fostering a climate that facilitates patient-centered communication and care.
The degree of participation that patients are expected to have in their medical visit has changed over time. Expectations of reasonable patient involvement within the medical context have shifted from active participation to passivity and minimized patient involvement, and has returned somewhat to active patient participation. In the early 1700s, providers regarded patients as experts in terms of experiencing their own illness. For example, providers elicited patients’ extended descriptions of their illnesses in their own terms, and often in the context of their homes and family (Reiser, 1978). However, throughout the 1800s, with the proliferation of diagnostic technologies (e.g., stethoscope, X-ray) (Reiser, 1978), providers decreased their reliance on patients’ experiences, instead prioritizing the knowledge provided by the advancing technology. The healthcare model of the time, now referred to as the biomedical model, was a style of healthcare in which diseases, not individuals, were treated (Sharf & Vanderford, 2003). Within the biomedical model, disease is conceptualized as a metaphorical breakdown in the body-machine, and providers served the role of fixing broken parts (Engel, 1977). Considered to be independent entities, disease diagnosis and treatment were generalizable across populations according to strict scientific methods (Sharf & Vanderford, 2003). The biomedical model leaves little room for patients’ personal identities, fears, opinions, questions, emotions, and narratives (Engel, 1977; Reiser, 1978). Thus, patients’ thoughts, experiences, and input are minimized in the task of improving health. When guided strictly by the biomedical model, providers have little incentive to consider patients’ perspectives and environments (social, economic, relational, religious, etc.) when diagnosing and treating disease (Engel, 1977; Mishel, 1981), to create personal/relational bonds with patients, or to facilitate patients’ participation (Emanuel & Emanuel, 1992) in the medical interaction. As such, patients reduced engagement, limiting question-asking and disclosure.
As an alternative to the biomedical model of medical practice, researchers have proposed a number of conceptually similar models, including the biopsychosocial model (Engel, 1977), relationship-centered care (Roter, 2000), and patient-centered care (Beach & Inui, 2006; Bensing, 2000). This article refers to this medical model as patient-centered care and recognizes that goals are consistent across models. Contemporary research and medical practice currently prioritize patient engagement and patient-centered care rather than prior models of provider paternalism (e.g., Epstein et al., 2005). Patient-centered communication, within the larger understanding of patient-centered care, strives to provide optimal care for individual patients while building interpersonal relationships with providers. This model acknowledges the critical relationship between patients and their providers that can improve or hinder patient well-being.
Tenets of patient-centered communication encourage the recognition of patients as unique individuals within their cultural frameworks, elicit patients’ perspectives of their health and well-being, and facilitate the shared decision-making of possible treatment options. These goals can be accomplished via active patient participation (Epstein et al., 2005). Patient participation has been operationalized as “the extent to which patients produce verbal responses that have the potential to significantly influence the content and structure of the interaction as well as the health care provider’s beliefs and behaviors” (Street & Millay, 2001, p. 62). Although research has adopted various approaches to measuring patient (and provider) participation (e.g., Brown, Stewart, & Ryan, 2001; Roter, 1977; Street & Millay, 2001), for the purposes of this article the focus is on patient information-seeking (i.e., question-asking) and patient disclosure, as two processes that enable patient participation. Both interpersonal processes allow patients to assert themselves and be an active agent in the medical interaction. By virtue of patient question-asking, providers are informed of issues important to the patient, the patient’s level of clarity, or thoughts concerning diagnosis and treatment options. Similarly, patient disclosure can enhance provider understanding of patient perspective, lived experiences, and treatment preferences.
Much research has identified various individual-level features that influence patients’ proclivity to seek information from their medical provider. Younger patients (e.g., Butow, Dowsett, Hagerty, & Tattersall, 2002; Butow, Dunn, Tattersall, & Jones, 1994; Eggly et al., 2006), women (Butow et al., 2002; Butow et al, 1994), Caucasian patients (Gordon, Street, Sharf, & Souchek, 2006), patients in urban versus rural settings (Dean et al., 2017), racially concordant patient-provider pairings (Gordon et al., 2006), and those with higher education (Dean et al., 2017; Eggly et al., 2006; Venetis, Robinson, & Kearney, 2013), among other characteristics, often ask more questions. While valuable, this research does not address how communication scholars may approach improved interpersonal processes or improved patient-centered care. This article now turns to exploring the theoretical rationale for patient question-asking as a mechanism for understanding how the interpersonal communication process of information-seeking or question-asking may facilitate improved patient-centered communication.
Research has examined processes in which individuals determine whether or not to ask questions. Literature on interpersonal information-seeking describes processes in which they consider how to manage their uncertainty and information needs. For example, uncertainty management theory (Brashers, 2001) explains that individuals may experience moments, particularly at times of illness, in which they are unclear about what is happening to them. The theory explains that information may be unclear, complex, unreliable, or unavailable. Individuals have to determine how they feel about this uncertain information. They may feel neutral about it, but they may also feel encouraged or, alternatively, frightened, anxious, or upset. The evaluation of how the uncertainty makes them feel, known as their appraisal of the uncertainty, will likely determine how they manage it. Management could include attempts to reduce or increase uncertainty, often resulting in information-seeking, and extensive research has documented information-seeking behaviors of patients and their loved ones (see Anker, Reinhart, & Feeley, 2011 for a review of measures and methods). Patients and their loved ones report using the internet as the most common channel of information-seeking (Mendes, Abreu, Vilar-Correia, & Borlido-Santos, 2017), but they also obtain information from family and friends, particularly from others who have experienced the same health condition (Hovick, 2014; Venetis et al., 2016). Despite numerous channels for information acquisition, information received from medical providers is consistently evaluated as most preferred, trustworthy, and reliable (Mendes et al., 2017; Ramírez et al., 2013). What follows is a review of contemporary literature that includes how patients determine to ask questions, the types of questions asked, barriers to patient question-asking, and question-asking outcomes.
Although the uncertainty management theory recognizes that individuals may manage uncertainty in various ways, another theory, the theory of motivated information management (TMIM; Afifi & Weiner, 2004) describes uncertainty management in an exclusively interpersonal context. The theory details how individuals progress from recognizing uncertainty to selecting strategies to manage it. Although a full description of the theory is beyond the scope of this article, a broad description is provided to aid in the understanding and organizing of empirical research on patient question-asking in the healthcare context.
TMIM explains that individuals experience an uncertainty discrepancy when they recognize that their degree of uncertainty exceeds the degree with which they are comfortable. For example, individuals experience an uncertainty discrepancy when they recognize that what they know about their partner’s sexual health is less than they would like to know (Afifi & Weiner, 2006). Uncertainty discrepancies can contribute to a variety of emotions, such as fear, anxiety, or hope (Afifi & Morse, 2009), and those emotions can influence individuals’ information-seeking decisions. For example, in a study of young adult women aged 18–25 who had not received the HPV vaccination, those who experienced uncertainty-discrepancy anxiety, or anxiety that resulted from the uncertainty discrepancy concerning their unvaccinated state, were more likely to report that they intended to seek information about the vaccination (Wong, 2014).
Uncertainty discrepancy and consequential emotional reactions encourage individuals to consider various issues in the evaluation phase of TMIM. In this phase, individuals contemplate issues such as who they could ask for information (e.g., friend, medical provider), if that person would or could give them the information they seek, how they may be evaluated if they seek that particular information, and their confidence in their own ability to seek the information or ask questions. Such considerations are referred to as outcome and efficacy assessments. In an examination of patient information-seeking, Dahm (2012) explored patients’ rationale for avoiding question-asking, and results support that patient expectation of negative outcome assessments deterred information-seeking. Patients reported that they would avoid information-seeking if they perceived that their medical provider would evaluate them as ignorant for asking specific questions (Dahm, 2012). Thus, when patients anticipate that there could be a negative evaluation from asking a question, this perceived evaluation hinders question-asking. Further, patients reported that they avoided asking questions when providers acted rushed or used medical jargon. Participants interpreted providers’ acting rushed as a signal that they did not have time to address patient concerns or questions and thus would not supply the requested information. Similarly, if providers used medical jargon, patients were reluctant to ask questions for fear they would not understand the provided information.
Several studies support the role of efficacy, or confidence in one’s ability to seek information, in contributing to interpersonal information seeking. Wong (2014) reported that the relationship between uncertainty-discrepancy anxiety and information-seeking intent was partially mediated by participants’ efficacy. That is, although anxiety largely contributed to the intention to seek information, individuals were less likely to ask questions if they did not feel confident in their ability to know how to ask the questions or approach the topic. Similarly, in another study of patient information-seeking about HPV, oral cancer patients reported that a lack of efficacy of how to discuss an illness, or their knowledge about the illness, limited their ability to seek information about it (Inglehart et al., 2016).
Taken together, individuals’ evaluation of their uncertainty discrepancy, discrepancy-related emotions, outcome assessments, and efficacy contribute to the selection of various information management strategies. In the decision phase, individuals may select among options including cognitive reappraisal, such as deciding that information is not important or that they are not uncertain about it; information avoidance, such as avoiding medical visits; or seeking information, such as asking questions. Rather than cognitive reappraisal or avoidance, most research to date examines predictors of patient question-asking.
In summary, the literature points to recommendations encouraging increased patient participation via increased patient question-asking. First, to address concerns about health literacy, providers should attempt to limit medical jargon and select accessible terminology (Hersh, Salzman, & Snyderman, 2015). Doing so may provide increased comprehension to patients and signal providers’ commitment to ensuring patient understanding. Second, despite numerous organizational constraints that limit the time that providers can spend with patients, providers should strive to make the patient feel heard and understood rather than rushed. Patients felt that the use of medical jargon contributed to feeling rushed, which serves as additional motivation to reduce use of advanced medical terminology. Finally, patients reported that they did not know how to approach question-asking. Many communication interventions have introduced a question prompt sheet offering suggestions of plausible questions (e.g., Cegala, Marinelli, & Post, 2000), and research should continue to contemplate when prompts may best assist patients. Recent research aiming to improving health literacy and efficacy in medical disclosure and consent documents recommends alerting patients to their own level of efficacy. Patient awareness of their reduced efficacy encourages patients to make attempts to overcome potential barriers (Donovan-Kicken et al., 2012). Attempts to promote patient-centered care may not necessarily result in increased question-asking, but instead reduce perceptions of provider-imposed barriers to patient information-seeking.
Increased question-asking offers mixed outcomes for patients. Among cardiac care patients, increased question-asking was associated with greater confidence in managing their health condition (Checton, Greene, Carpenter, & Catona, 2017). Breast cancer patients with increased question-asking also reported increased perceptions of decision responsibility (Street & Voigt, 1997). However, increased question-asking is also associated with negative outcomes, such as a reduced sense of collaboration with providers (Takayama & Yamazaki, 2004). Several interaction-based studies that recorded medical interactions and quantified actual, rather than perceived, question-asking reported that increased question-asking is negatively associated with patient satisfaction (Ishikawa, Takayama, Yamazaki, Seki, & Katsumata, 2002; Roter, 1977; Venetis et al., 2013). Thus, the greater the number of questions patients ask, the less satisfied they are with the medical interaction.
Examining Patient Questions
The consistent finding that increased patient question-asking is associated with reduced satisfaction warrants further exploration. Many research articles work to increase patient participation, particularly via question-asking, yet the association between increased questions and decreased satisfaction seems counterintuitive. This relationship calls for an in-depth understanding of the types of questions patients ask. We must consider, in research, what counts as a question. Does a question have to be in an interrogative form to be included? Could a declarative statement such as “tell me about the recovery process” also equate to question-asking? Further, do the patient outcomes, such as satisfaction or adherence, differ according to the type of question patients ask? Prior research has examined question-asking as any form of information-seeking (e.g., Street & Millay, 2001) as well as questions aggregated in categories such as “questions about treatment” or “questions about diagnosis” (e.g., Brown, Butow, Dunn, & Tattersall, 2001). A more nuanced understanding of patient question-asking could determine if some types of questions operate differently for patients than do other types (e.g., Fasulo, Zinken, & Zinken, 2016). Further, in efforts to improve patient-centered care, knowledge of the specific information needs for a particular health condition could allow providers to anticipate and address those needs, ultimately to the patient’s benefit.
To address this gap, one recent study analyzed 2,781 questions that occurred in the context of breast cancer patient question-asking during surgical treatment decision-making conversations with their surgeons (Robinson, Venetis, Street, & Kearney, 2016). Analyses revealed that patients routinely asked one of 15 categories of questions. Over 50% of patients asked for a description of surgical procedures, such as “what happens during a lumpectomy?” and “how long am I under anesthesia?” Another category that occurred in approximately 50% of visits included questions about which surgical procedures were needed or recommended. Patients requested information about when their surgery would occur, descriptions of how lymph nodes are tested, the surgical recovery process, cancer spreading to lymph nodes, how radiation occurs, characteristics about the tumor, the need for chemotherapy or radiation, reconstruction, hormone therapy, and recurrence. As evidenced by the review of some themes, treating all patient questions as “questions about treatment” obscures patient motivations in asking these questions. Subsequent analysis found that individual themes (rather than aggregated question-asking) were associated with different patient coping outcomes (Robinson & Venetis, 2016). Patient questions concerning surgery timing and potential recurrence were associated with positive changes in patients’ hopelessness before and immediately after the treatment decision-making interaction with the surgeon. Alternatively, questions related to hormone therapy were associated with increased hopelessness, or less hope. Authors surmised that providers’ responses to these questions, or information provision, and not the questions themselves, likely contributed to patients’ hopelessness. For example, patients often request immediate surgery dates, and provider responses often comply with such requests, increasing hope. This research underscores the need for additional in-depth analyses of patient question-asking and calls into question how providers may anticipate patient information needs and adjust their interaction script to ensure covering such issues that are consistently asked among patients in a particular health context.
Disclosure is communicative behavior that consists of sharing personal and private information with someone, the disclosure recipient, who would not have otherwise known that information (Derlega, Winstead, & Greene, 2008). Accurate and complete patient disclosure to the provider is essential to enabling the provider to diagnose and make treatment recommendations. Further, patient disclosure facilitates relationship-building and trust between providers and patients. Despite the benefits of disclosure, individuals recognize the potential consequences of disclosing potentially stigmatizing information and consider possible negative reactions (Magsamen-Conrad, 2014). For example, patients report concerns about disclosing certain information that may introduce negative judgment from their provider or could threaten their relationship with their provider (Harvey, Memon, Khan, & Yasin, 2017).
As described in contemporary disclosure theories such as communication privacy management theory (CPM; Petronio, 2002), the disclosure decision-making model (DD-MM; (Greene, 2009), the disclosure process model (DPM; Chaudoir & Fisher, 2010), and the risk revelation model (RRM, Afifi & Steuber, 2009), the decision to disclose personal information involves many considerations. The disclosure decision-making model (Greene, 2009) describes how individuals contemplate the decision to disclose non-visible health information to a relationally close other (rather than a medical provider). The model argues that potential disclosers consider the information to be shared, their relationship with the target recipient, and their efficacy in sharing the information. As with the TMIM, a broad description of the DD-MM is provided as a means for organizing empirical research on patient disclosure practices within the healthcare context. Although the DD-MM focuses on non-visible health information, such as diagnosed illnesses, this article will include examples of health-relevant information that could influence how providers diagnose or treat patients or allow providers to have an improved understanding of patients’ perspectives. The examples provided extend to health-relevant topics disclosed or concealed between patients and their healthcare providers.
Assessment of Health-Related Information as Stigmatized
According to the DD-MM, individuals first contemplate the information to be shared. The model highlights five aspects of the information, including stigma surrounding the information, the individual’s expectation of the diagnosis or health information, visible symptoms of the illness, the prognosis, and the relevance in telling the other (e.g., issues of contagion). This article will focus on the impact of perceived stigma when patients make disclosure decisions. It is known that increased perceptions of stigma are negatively associated with the intention to disclose. In other words, the greater the threat of stigma, the less likely patients will be to share that information with their providers. For example, patients have reported altering or avoiding telling their providers about their smoking history, number of sexual partners, sexual behaviors, domestic abuse, drug use, medication/treatment adherence, use of alternative medicine, and even internet information-seeking behaviors due to potential stigmatization by providers (Boehmer & Case, 2004; Harvey et al., 2017; Julliard et al., 2008; Lewis et al., 2011; Okuyama et al., 2008; Piette, Schillinger, Potter, & Heisler, 2003; Politi, Clark, Armstrong, McGarry, & Sciamanna, 2009; Sankar & Jones, 2005; Shelley, Sussman, Williams, Segal, & Crabtree, 2009; Venetis et al., 2017).
In a study of female patients at birth control clinics, approximately 50% of participants reported having limited complete and truthful disclosure to their providers by altering at least one response (Lewis et al., 2011). Participant open-ended responses offer some insight to their potential motivations for limiting disclosure. For example, one participant said, “I think that I am affected by previous doctors’ treatment of me. Some doctors seem very judgmental, or blame the fact that I need the morning after pill on me exclusively. I’m so used to other doctors’ judgments of me that I find it difficult to be completely honest here even” (p. 511). Thus, patients recognize that sharing their health-related information could result in provider shaming, and may modify their disclosures to limit provider negative response as a result. Similarly, other participants reported withholding or downplaying daily drug or cigarette use in order to achieve medical goals. In another study of female patient disclosure patterns with providers (Sankar & Jones, 2005), participants mentioned several topics that they withheld or altered when disclosing to providers. As in Lewis et al. (2011), study participants explicitly noted that they withhold information, such as lying about habitual smoking habits, to reduce embarrassment and shame as well as to avoid feeling uncomfortable when disclosing (Sankar & Jones, 2005). Participants also noted that they withheld information that they feared could threaten their employment.
Veterans also described limiting their trauma-related disclosures to providers for numerous reasons, including fear of jeopardizing their careers (Jeffreys, Leibowitz, Finley, & Arar, 2010). Healthcare-related trauma included issues from combat, serious accidents, and assault with or without weapons, among others. Veterans additionally said that they withheld information to avoid negative evaluations by providers, including the potential for providers to perceive the veteran as exaggerating. Thus, the threat of being stigmatized is a palpable concern for many individuals.
Hesitation to disclose mental health concerns, even to providers, is experienced by many patients. Among patients experiencing depression, approximately 43% of participants experienced hesitation in disclosing depressive symptoms to their primary healthcare providers (Bell et al., 2011). Patient motivations to withhold telling their providers about their depression include fear of being stigmatized and the belief that individuals should be able to manage depression without medical assistance and medication. In fact, over 20% of participants explained that they did not tell their providers about depression because they did not want medication to be prescribed; others reported that they did not want to be referred to a specialist such as a counselor or psychiatrist. Among lung cancer patients in Japan, patients did not disclose their emotional distress to providers, fearing that disclosure would threaten their relationship with their provider (Okuyama et al., 2008). Fearing the negative repercussions of disclosure was particularly common among patients with higher anxiety and depression scores.
A subsequent consideration in the decision to disclose is the relationship with the recipient. The model says that individuals are more likely to disclose to others who are relationally close (Greene, 2009). However, in the context of the medical interaction, patients and providers often do not share this type of relationship. Instead, patients evaluate their provider using criteria other than relational closeness (Venetis et al., 2014). Patients report greater disclosure to providers they perceive as supportive, compassionate, accepting, open-minded, nonjudgmental, and trustworthy, and who exhibit compassion and respect (DeHart, 2008; Epstein et al., 2005; Jeffreys et al., 2010; Julliard et al., 2008). Further, patients report reduced disclosure when providers are hurried, omit introductions, use technical jargon, or appear judgmental (Jeffreys et al., 2010; Julliard et al., 2008; Lewis et al., 2011). Patients note that female providers often exhibit the personality characteristics and perform the behaviors that serve to comfort patients more readily than do male providers, enabling disclosure to female providers (Eliason & Schope, 2001; Lewis et al., 2011; Politi, Clark, Armstrong, McGarry, & Sciamanna, 2009; Wissow et al., 2003). Research should consider what provider behaviors signal to patients that providers are supportive and trustworthy in order to encourage patient disclosure and promote patient-centered care. Patients have reported that communication that facilitates disclosure is less formal, uses open-ended questions, is direct, and allows patients to complete a sentence without being interrupted (Jeffreys et al., 2010; Julliard et al., 2008).
As in the theory of motivated information management, individuals consider their efficacy in sharing their information in order to achieve the desired response. Research that examined how patients disclosed sexual orientation to medical providers reported various strategies that patients found efficacious in sharing their orientation (Boehmer & Case, 2004; Venetis et al., 2017). For example, patients report that introducing their partner who is with them at the medical visit or casually telling the provider about their partner during the greeting portion of the visit allows patients to share the information. Participants also reported that they were able to disclose during medical history-taking, particularly when providers are asking about condom use and sexual partners; however, this disclosure often occurred in correcting provider misinformation. Additionally, participants described that they contemplated and practiced the disclosure, but they delivered the disclosure casually to minimize provider reaction (Venetis et al., 2017). These studies demonstrate how patients, and in this context lesbian, gay, bisexual, and queer patients, strategize to disclose health-relevant information. Participants expressed a preference for providers to request information on sexual preference to remove the patient burden to inform providers (Venetis et al., 2017).
One study highlights how culture influences degree of efficacy. Julliard et al. (2008) interviewed Latina women about barriers to disclosure. Participants listed content areas in which they would have difficulty disclosing, including sexual behavior, sexual orientation, sexually transmitted diseases, domestic abuse, and genital issues. They said that their culture made it very challenging to talk to medical professionals about these topics because of cultural expectations that such information is private, to be shared only with one’s partner. One strategy Latina patients reported using in order to disclose health concerns or to gain information from the provider is to frame the problem as one happening to “her friend” rather than to the patient herself. Furthermore, patients employed this strategy so that they could acquire medical input while reducing negative judgment from providers for having a stigmatized condition.
There are various reasons why providers may not solicit certain types of information from patients. In some cases, they may not know to request information. For example, one study of complementary and alternative medicine found that providers do not ask patients questions about alternative medical practices if patients do not address them; yet, if patients do not introduce this topic, providers have no way of knowing it is relevant (Shelley et al., 2009). Interestingly, patients reported reserving disclosure of alternative medicine until providers asked. As a result, when both parties expect the other to initiate potential topics, topics may go unaddressed.
Providers also may avoid asking about information that they perceive as stigmatizing, serving to limit patient disclosure. Providers report discomfort and lack of efficacy in how to approach patients about topics such as sexual orientation (Dahan, Feldman, & Hermoni, 2008) and medication adherence (Barfod, Hecht, Rubow, & Gerstoft, 2006). Thus, work is needed to help providers elicit information to enable patient disclosure. Some researchers argue that including questions about a health issue in their script of medical history taking would suffice (Robinson & Roter, 1999). For some topics, such as mental health issues, patients are significantly more likely to disclose their mental health concerns when providers inquire (Robinson & Roter, 1999). However, in many contexts it is not only important that providers elicit information from patients, but how they ask questions also influences patient disclosure. One study that examined how providers ask HIV-positive patients about their antiretroviral medication adherence identified a question style that promoted patient disclosure (Callon et al., 2016). Four categories of provider question styles emerged: broad questions that were open-ended (e.g., “How you been doin’ on taking your medications?” p. 1110); clarifying in which patients confirm which medications they are taking or the timing of medications (e.g., “Now tell me how you’re taking the Epivir?” p. 1111); positively framed, close-ended questions in which patients confirm if they are taking their medications appropriately (e.g., “Do you take your HIV medications every day?” p. 1111), and negatively framed questions that mention missing medications (e.g., “Now, have you missed any?” p. 1111). Of the four types, patients were more likely to disclose medical non-adherence in response to the fourth category, negatively framed questions. Authors argue that patients may have felt more comfortable disclosing their non-adherence when providers used the terms “skipped” or “missed” in the question, thus normalizing non-adherence and minimizing patient embarrassment. Further, questions that avoided leading language that biases patients to agree with providers (e.g., “You haven’t been missing any of the medicine, right?” p. 1111) were more successful in yielding patient disclosure.
Creating a Climate That Facilitates Patient-Centered Communication and Promotes Disclosure
Research highlights that there are several factors that encourage patient participation in the medical interaction. Providers who are perceived as warm, understanding, and nonjudgmental often elicit increased perceptions of patient comfort and acceptance, promoting an environment that fosters patient participation (Anderson, Barbara, & Feldman, 2007). However, provider communicative behaviors foster and contribute to patient evaluations of provider demeanor. This section now examines multiple approaches to accomplishing a task, such as providers asking patients the origin of their medical concern, and how various approaches embody improved patient-centered communication and facilitate greater patient participation.
Although the ideals of patient-centered communication focus on patient involvement and participation, providers, and not patients, often direct the course of the interaction (Robinson, 2003). One study of breast cancer adjuvant therapy examinations documented that providers are agenda-driven, and they proceed from goals of the medical visit in a methodical way (Roberts, 1999). Medical interactions routinely follow the sequence of greeting and opening of the visit, elicitation of patient concerns, collection of medical history, the physical examination, the diagnosis, and the medical recommendation (Byrne & Long, 1976; Roberts, 1999; Robinson, 2003). As providers set the pace of the medical interaction, the opportunity for patient involvement is directed by providers’ communication. For example, within the elicitation of patient concerns, providers could apply one of numerous approaches to soliciting patients’ reasons for the medical visit (Heritage & Robinson, 2006). One style, known as the general inquiry question (such as “What can I do for you today?”), suggests to patients that providers are requesting that patients offer an elaborated description. Consequently, this question style promotes patient responses of approximately 27 seconds in which patients can describe their health concerns on their own terms. Alternatively, providers can seek to accomplish the same goal with a different patient problem elicitation, the symptoms-for-confirmation style. An example of this style would be, “So I see you’ve been feeling weak for five days?” The symptoms-for-confirmation style expresses that providers have prior knowledge of patients’ conditions, minimizing the patient response to an average of 8.33 seconds (Heritage & Robinson, 2006). This study highlights one example of how providers can facilitate and encourage patient participation, particularly patient disclosure.
Another study of antiviral medicine adherence categorized provider questions that yielded patient disclosure of non-adherence (Callon et al., 2016). The authors argue that providers should be mindful in how they phrase questions; for example, “how’s it going with your medications?” makes relevant a “fine” or “pretty good” response rather than a question that normalizes the chances of missing taking medications.
In summary, the literature provides recommendations to facilitate increased patient disclosure, particularly as disclosure helps to accomplish goals in achieving patient-centered care. Disclosure promotes patients being understood within their lived experiences and contributes to greater agency in medical decision-making. How providers ask questions relates directly to how patients provide responses. Certain questions encourage longer responses; other types of questions allow for more truthful disclosures. Thus, providers should consider using open-ended questions that limit the possibility of a patient determining that the question requires a confirmation or short response (Heritage & Robinson, 2006). Additionally, provider questions framed to minimize bias may serve to promote patient disclosure of potentially stigmatizing information, such as problematic medication adherence (Callon et al., 2016). To facilitate the collection of necessary information that patients may not recognize as requested, providers could, at the end of the history-taking phase, ask patients to provide other information that they believe is needed in order to assist providers in diagnosing and advising medical treatment. Furthermore, providers could explicitly ask patients which efforts, if any, patients have already taken to address their medical concerns (Shelley et al., 2009).
Discussion of the Literature
Interpersonal communication in the healthcare context extends well beyond the provider-patient interaction. Recent chapters have addressed interpersonal processes such as disclosure, uncertainty management, stigma management, and social support and how those processes are explored within health-related contexts (e.g., Duggan, 2006; Thompson, Robinson, & Brashers, 2011). Scholars have provided overviews of disclosure and health in risk management (Petronio & Venetis, 2017), stigma in health and risk communication (Smith, Quesnell, & Zhu, 2016), and supportive communication in health contexts (MacGeorge, Feng, & Burleson, 2011), among other topics. Considering relational dyads, many studies examine how patients and partners or significant others communicate about health (e.g., Martire, Schulz, Helgeson, Small, & Saghafi, 2010). Other research examines interpersonal processes between patients and close others, such as adult children and friends (e.g., Rosland, Heisler, & Piette, 2012; Venetis et al., 2016). Furthermore, much health-related research examines how individuals who are not currently managing illness discuss health-related topics, such as weight management strategies, with others (e.g., Guntzvillver, Ratcliff, Dorsch, & Osai, 2017).
Within the narrowed context of interpersonal communication in healthcare contexts, and as discussed in this article, scholars have examined provider-patient interactions (e.g., Arora, 2003; Duggan & Thompson, 2011). Research has paid particular attention to shared decision-making (Joosten, DeFuentes-Merillas, de Weert, Sensky, van der Staak, & de Jong, 2008; Joseph-Williams, Elwyn, & Edwards, 2014), provider disclosure of bad news (Gillotti, Thompson, & McNeilis, 2002; Harrison & Walling, 2010), and end-of-life communication (Parry, Land, & Seymour, 2014). Research is currently actively investigating the provider-patient interaction via mediated channels such as telemedicine (e.g., Lyles et al., 2013). Beyond the patient-provider relationship, interpersonal communication in healthcare contexts has examined other interpersonal relationships such as the role of companions within visits (Laidsaar-Powell et al., 2013), parent-child-provider interactions (Stivers, 2012), and physician-nurse interactions (Matziou et al., 2014).
Methodological trends include patient reports of their communication as well as researchers recording medical interactions and analyzing the talk that occurred within them. Although numerous interaction studies exist, scholars interested in interaction studies are encouraged to refer to RIASWorks.com. This website hosts a collection of interaction studies, many of which are provider-patient interactions, in which the Roter (1977) coding schema has been applied. Although this coding schema is one among various options, it is widely adopted and has been applied across health contexts and internationally.
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