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MODELS OF DOCTOR-PATIENT
RELATIONSHIP
Debra Roter
Objectives
  Explore the theoretical and philosophic basis
defining the therapeutic relationship
  Explore the expression of the therapeutic
relationship in actual practice based on
empirical study
Plato was perhaps the first spokesman for patientcentered medicine
“A physician to slaves never gives
his patient any account of his
illness…The free physician, who
usually cares for free men, treats
their diseases first by thoroughly
discussing with the patient and his
friends his ailment.”
--From Dialogues of Plato
Patient-Centeredness
  Communication in the form of patient-centeredness is
on the national health care agenda
  Patient centeredness broadly defined as a
biopsychosocial approach to medical treatment that
embraces patients’ preferences, experiences and
expectations and in which patients are offered
opportunities to participate in their care in ways that
enhance partnership and understanding
Communication linked to
healthcare quality
  Communication is regarded as key to any
significant improvements in health care
quality -- patient-centered care is included
alongside the core quality requisites of safety,
timeliness, effectiveness, efficiency and
equity.
IOM reports: Crossing the Quality Chasm; To Err is Human; Health Professions Education.
Health People 2010: Objectives for
the Nation
  Health objective 11.6: increase the proportion of
persons who report that their health care providers
have satisfactory communication skills (Surgeon
General 2001).
  These goals are integrated into objectives in
screening, diagnosis, treatment, prevention, and
hospice care applicable to chronic diseases and
cancer.
What is the theoretical and
philosophic basis defining
the therapeutic
relationship?
Prototypes of Doctor-Patient
Relationships
Low
Physician Control
High
Low
Paternalism
Consumerism
Mutuality
Patient Control
Default
High
Roter & Hall, 1996
Core Elements of the Therapeutic Visit
Paternalism
Mutuality
Consumerism
Default
Physiciandetermined
Negotiated
Technical
Information
Unclear
Patient
Values
Assumed
Explored
Unexamined
Unclear
Physician
Roles
Guardian
Advisor
Consultant
Unclear
Goals of Visit
Methods
  Procedure: audiotape of primary care visits
  Setting: urban hospital-based ambulatory
clinics (75%) and private practice (25%) in 11
sites across the US and Canada
  Participants: 127 physicians and 537 chronic
disease patients
Methods
  Physicians: 35 second- and third-year
residents, 63 primary care physicians; 79%
male, 95% white, average age 34.5 years
  Patients: 55% white and 45% African
American, 65% earning < $10,000, 58%
female, average age 60 years (range 21 to
94), 50% with at least 7 prior visits
Statistical Technique
  Cluster analysis based on three physician and
patient communication categories:
–  Biomedical information
–  Psychosocial exchange
–  Question-asking
Cluster Analysis Revealed 5
Distinct Communication Patterns




Paternalistic: Narrowly Biomedical (32%)
Paternalistic: Expanded Biomedical (33%)
Mutalistic: Biopsychosocial (20%)
Mutalistic: Psychosocial (7%)
Paternalistic Patterns: Narrowly
Biomedical
  Physicians are younger and more likely to be
male; patients are older, poorer, and more
likely to be African American.
  32% visits: 68% MD with at least one visit
–  High medical questions (19% MD; 4% PT)
–  High biomedical talk (27% MD, 70% PT)
–  Low psychosocial talk (2% MD, 5%PT)
Paternalistic Patterns: Expanded
Biomedical
  Patients somewhat older than in others
  33% visits: 61% MD with at least one visit
–  High medical questions (17% MD; 5% PT)
–  Mod. biomedical talk (22% MD, 56% PT)
–  Low psychosocial talk (7% MD, 16% PT)
Mutualistic Patterns:
Biopsychosocial
  Physicians are older and more likely to be
female; patients are better educated and
more likely to be white.
  20% visits: 42% MD with at least one visit
–  Low medical questions (11% MD, 4% PT)
–  Mod. Biomedical talk (23% MD, 39% PT)
–  Mod. psychosocial talk(11% MD, 29%PT)
Mutualistic Patterns: Psychosocial
  Patients are more likely to have a
psychological diagnosis
  7% of visits: 19% MD with at least one visit
–  Low medical questions (9% MD; 3% PT)
–  Low biomedical talk (20% MD, 25% PT)
–  High psychosocial talk (19% MD, 39% PT)
Consumerist Pattern
  Physicians are older and more likely to be
female; patients are better educated.
  8% visits: 23% MD with at least one visit
–
–
–
–
Low MD questions (10% MD)
High PT questions (6%)
High biomedical talk (43% MD, 53% PT)
Low psychosocial talk (4% MD, 11%PT)
What do these patterns mean for
the visit content, process, and
outcome?
Communications Patterns and
Verbal Dominance
Pattern
Communication Ratio
Doctor : Patient
Biomedical (restricted)
1.4 : 1
Biomedical (expanded)
1.36 : 1
Biopsychosocial
1.29 : 1
Psychosocial
1.08 : 1
Consumerist
1.62 : 1
Communications Pattern & Patient
Satisfaction
Satisfaction
PT
MD
Biomedical (restricted)
Tied Last
Last
Biomedical (expanded)
Tied Last
Tied Third
Second
Second
Psychosocial
First
First
Consumerist
Third
First
Biopsychosocial
Communications Pattern & Patient
Recall
Pattern Type
Medication Recall
Biomedical (restricted)
67%
Biomedical (expanded)
73%
Biopsychosocial
82%
Psychosocial
89%
Consumerist
92%
Communications Pattern & Length
of Visit
Pattern Type
Length of Visit in Minutes
Biomedical (restricted)
20.5
Biomedical (expanded)
21.8
Biopsychosocial
19.3
Psychosocial
22.9
Consumerist
21.9
How do these patterns inform
conceptual thinking about patientor relationship centered care?
Patient-Centeredness
  A biopsychosocial approach to medical treatment that
embraces patients’ preferences, experiences and
expectations and in which patients are offered
opportunities to participate in their care in ways that
enhance partnership and understanding
Relationship-Centered Care
1.  relationships include the personhood of the
participants,
2.  affect and emotion are important part of
relationships,
3.  relationships occur in the context of reciprocal
influence,
4.  formation and maintenance of genuine
relationships in health care is morally valuable.
Does patient-centeredness matter
for visit outcomes?
Evidence
  There is a growing evidence base linking
communication to direct visit outcomes
(satisfaction, recall, adherence) based on
meta analysis.
  A smaller but very important literature
establishing clinical significance:
–
–
–
–
–
Improved
Improved
Improved
Improved
Improved
HbA1C; BP
functional status
emotional health
anxiety and coping
self-reported health
Visitors Outcomes: Predictors of
Patient Recall
  Meta-analysis of the communication
literature found significant (small to
moderate) ES relationships between recall
and:
1.
2.
3.
4.
More information-giving
Less question-asking
Most positive talk
More partnership building
(Hall, Roter, Katz, 1988)
Visit Outcomes: Correlates of
Patient Satisfaction
  Significant (small to moderate) ES for
patient satisfaction were associated with:
1.
2.
3.
4.
5.
6.
More information-giving
More positive talk (both verbal and nonverbal)
Less negative talk
More social talk
More partnership building
More talk overall
(Hall, Roter, Katz, 1988)
Visit Outcomes: Correlates of
Patient Compliance
  Significant (small) ES for patient compliance
were associated with:
1.  More information-giving
2.  Less question-asking overall BUT more compliance
focused questions
3.  More positive talk (both verbal and nonverbal)
4.  Less negative talk
(Hall, Roter, Katz, 1988)
COMMUNICATION
PATIENT OUTCOME
Patient is given informational
intervention (Kaplan-Greenfield;
Rost; Anderson; Langewitz)
Functional status
HbA1C, BP
Self-ratings of health
Physician is more informative
(Kaplan - Greenfield; Rost)
Self-efficacy
Reduction in distress
COMMUNICATION
PATIENT OUTCOME
Patient expresses affect
(Kaplan-Greenfield)
HbA1C
Patient is given
psychological coping
intervention (Anderson)
Patient feels known
(Beach et al, 2006)
Functional status
HbA1C,
Self-efficacy stress
management; social support
Receipt of HAART,
adherence to HAART,
Undetectable viral load
COMMUNICATION
PATIENT OUTCOME
Patient is empowered to make
Rx decisions (Langewitz,
Anderson)
HbA1C
Provider is patient-centered
(Kaplan-Greenfield; Rost;
Street)
Patient asks questions
(Kaplan-Greenfield; Rost)
Patient is more verbally
engaged (Kaplan-Greenfield;
Rost; Street)
MD-Pt relationship
Functional status
Emotional health
Self-reported health
Is routine medical visit communication related
to the malpractice experience of surgeons and
primary care physicians -- either as a
contributor or result of prior litigation?
Claims were defined as any patient request for
funds, any malpractice suit filed by a patient, or any
contact by an attorney who represented a patient in
an action against the physician, regardless of
outcome. Incidents defined as an event reported by a
physician to the insurance company fearing legal
action was hot included as a claim. (Levenson, Roter,
Mullooly, Dull & Frankel, 1997)
Methods
  65 surgeons and 59 primary care doctors
were recruited to the study.
–  Half of the physicians had 0 lifetime claims
–  Half had > 2 lifetime claims
–  Matched on years in practice and specialty
  10 patients for each physician, drawn as a
convenience sample from the physician’s
daily log, were recruited to the study. Over
1200 primary care and surgical visits were
audio recorded.
Audiotape Analysis
  No-claims compared with multi-claim PC
doctors:
–  longer visits (by 3 minutes—15 vs 18.3)
–  used more partnership exchanges (asked opinion,
cued interest, checked understanding; paraphrase/
interpretations)
–  used more humor and joking
–  provided more orientation – what to expect about the
flow of the visit.
Analysis of Primary Care Visits
  Using communication variables derived from
the audiotape analysis, 80% of primary care
physicians were accurately classified in terms
of their malpractice status based solely on
their communication patterns
  A 30% improvement over chance.
What About Surgeons?
  Trends suggested sued surgeons had shorter
visits, by almost 1.5 minutes, used less
partnership-type exchanges, and patients (but
not physicians) seemed to laugh more.
Physician Voice Tone
  Further analysis, using thin slice techniques
found a relationship between physicians’
voice tone and malpractice history.
  Thin slice relies on very short clips of speech
judged by multiple raters on a variety of
affective dimensions (including concern/
anxiety and dominance) and stripped of
content by passing through an electronic
filter.
Physician Voice Tone
  Surgeons judged to have more dominant
voice tone were almost three times as likely
to be in the sued group
  Surgeons whose voice tone conveyed
concern/anxiety were half as likely to be in
the sued group.
(Ambady et al, Surgery, 2002).
Physician Voice Tone
  Earlier studies using thin slice analysis found
that negative voice tone (anxiety) coupled
with positive words (sympathetic and calming)
was associated with more patient satisfaction
and better appointment keeping over a 6month period
  A second study similarly linked anxious vocal
qualities with patient satisfaction.
(Hall et al 1981; Roter et al, 1987)
Physician Voice Tone
  Anxiety in the physician’s voice tone may be
heard as conveying seriousness,
attentiveness, and concern for the patient’s
well-being and future health.
  Voice tone may act to frame the way in which
the verbal message is interpreted.
What Do These Findings Say About
Clinicians?
  Does communication style and voice tone
heighten a doctors risk of being sued, or does
the experience of being sued change how
doctors communicated (and feel about)
patients?
What Does This Say About
Patients?
  Patients, are looking for cues and clues by
which to judge their relationship; they are
looking to see if the physician cares about
them, will go the extra mile for them, if the
physician likes them.
Mutually Collaborative Models Can
Bridge Medicine’s Art & Science