The interaction between physician and patient communication behaviors in Japanese cancer consultations and the influence of personal and consultation characteristics

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Abstract

The communications of physician and patient vary with the characteristics of patient and consultation, as well as the communications of the counterpart. The purpose of this study is to explore the interaction between physician and patient communications in Japanese cancer consultation in view of the influence of patient and consultation characteristics. One hundred and forty cancer outpatients and 12 physicians were included in this study. The Roter Interaction Analysis System (RIAS) was used to analyze the physician–patient interaction. Patient information giving was positively related to physician facilitation, while patient question asking and emotional expression were associated with the warm and empathetic attitude of the physician. On the other hand, the encouraging statements of the physician were greater in shorter consultations, which implies physicians might have interrupted patients with encouragement before thoroughly listening to the patients concern. Further investigation is needed to confirm the causal relationships of these interactions.

Introduction

Over the past few decades, the physician–patient relationship has been transforming with the changing medical environment, such as increases in chronic illnesses and the rise of consumerism [1], [2]. It has also attracted the attention of researchers to the communication between physician and patient in the medical consultation. Communication is a major component of medical encounters and a key to establishing a favorable physician–patient relationship [3], [4], [5], [6]. Various studies have demonstrated that physician–patient communication has a significant influence on the outcome of patient care, including patient satisfaction, compliance to treatment, recall and understanding of medical information, coping with disease, and even actual state of health [7], [8], [9], [10], [11].

With growing interest in physician–patient communication, several observation instruments, so-called interaction analysis systems (IAS), have been developed for the systematic analysis of physician–patient interaction in the consultation [12], [13]. They have made a great contribution to revealing the content and structure of the interaction in the medical consultation. The Roter Interaction Analysis System (RIAS) is one of the most widely used IAS in Western countries, and has some notable features. It has been specifically developed for the assessment of physician–patient interaction, and captures both types of important behaviors in the interaction, namely instrumental and affective behaviors. Coding is carried out directly from audiotapes rather than transcripts, which allows evaluating nonverbal as well as verbal communication. Moreover, it has been examined on its validity and reliability in Western countries [14], [15], [16], [17], and rated favorably in a comparison study [18].

Until recently, most of the studies on physician–patient interaction have been conducted in primary care settings, and there are relatively few studies that specifically examined the interactions in cancer consultations [14], [16], [19]. In the case of life-threatening illness, such as cancer, which requires continuing care and complicated decision making, the physician–patient relationship may become even more critical in the treatment process, since patients are likely to experience greater uncertainty and anxiety [20], [21]. It is, therefore, necessary to examine the physician–patient interaction specifically in cancer consultations.

Further, it is often indicated that social and cultural background underlying physician–patient relationship is considerably different between Western and Asian countries. Historically, the physician–patient relationship in Japan has been often described as more hierarchical and paternalistic compared to Western countries [22], [23]. It has been a tradition in Japan that physicians do not discuss much about treatment choices and do not explain the details of procedures to patients [24]. Feldman has pointed out that less is overtly communicated during a typical medical visit in Japan than in the United States but less may need to be said in a society where trust and dependency more strongly influence social interaction [25]. Recently, however, following the changes in the physician–patient relationship in Western countries, a similar transformation has been noted in Japan. Various concepts and models developed in Western countries have been introduced, including “informed consent”, “decision making”, and “patient autonomy”. Yet, there have been few systematic studies that objectively evaluate the contents of physician–patient communication in Japan. It is necessary, as well as of much interest from a cross-cultural viewpoint, to explore physician–patient communication in the social and cultural context in Japan.

The purpose of this study is to explore the interaction between physician and patient communications and the influence of patient and consultation characteristics in Japanese cancer consultations.

Physician–patient interactions are “processes of personal and mutual influence that unfold according to the characteristics of the individuals and to interactive processes related to how interactants adapt their communication to one another” [26]. That is, communications of physician and patient are influenced by the communications of their counterpart as well as by their personal characteristics.

It has been indicated that patient information giving and question asking are associated with their age, education, and anxiety, and that partnership building statements by physicians increase patients information giving and question asking [26], [27]. Also, based on their findings that the length of interaction, patient’s diagnosis, and purpose of visit had an important impact on patient information seeking behaviors, Beisecker suggested that such situational characteristics of the consultation must be considered in the analysis of physician–patient interaction [27].

Similarly, it has been reported that physician communication varies with patient characteristics, such as age, sex, and preference for participation [28]. Also, Labrecque reported that physicians provided more information when patients were accompanied by family members [29]. It has been indicated that patient question asking and emotional expressions are positively related to information giving by physicians [30]. Further, more negative emotional expressions by patients lead to more positive socio-emotional statements by physicians [26].

Based on the findings of previous studies in Western countries, we hypothesized that physician and patient communication patterns vary with the characteristics of patient and consultation, as well as the communication pattern of the counterpart. Specifically, (1) patient information giving is positively associated with physician’s partnership building communication; (2) patient information seeking is positively associated with physician’s partnership building communication; (3) patient emotional expression is positively associated with physician’s affective communication; (4) physician information giving is positively associated with patient information seeking behavior and emotional expression; and (5) physician emotional responsiveness is positively associated with patient emotional expression.

Section snippets

Sample

The original data were collected for the study on the relationship between physician communication style and patient anxiety level in cancer consultations [31]. The subjects of this study were 200 outpatients who visited the National Cancer Center Hospital in Tokyo during 3-month survey period. Patients were eligible for the study if they had been diagnosed with cancer, had seen their physician before, and their cancer was not too debilitating for them to participate in the study. Details of

Inter-coder reliability of the RIAS

The median difference of the total number of utterances per consultation identified by two coders was 5 (0–23). The identification of each segment per consultation was 88.2% (76.1–100.0%) congruent between two coders on average.

In order to examine inter-coder reliability of categorization, we calculated the Spearman correlation coefficients between two coders for the categories with a frequency >2 per consultation. The 13 out of 38 physician categories and 12 out of 34 patient categories met

Discussion

This study applied the RIAS to the analysis of physician–patient interactions in Japanese cancer consultations. Inter-coder reliability of coding was examined in terms of the congruence in identifying and categorizing the utterances, which seemed to be acceptably high. Also, inter-coder reliability of global affect ratings for physician was on an adequate level.

Acknowledgements

This research was supported by Grant-in-Aid for Scientific Research (B) 11410042 on “Practitioner–Patient Relationship and Patient’s Autonomy” from Japanese Ministry of Education, Science, Sports and Culture. We are grateful to Dr. Hideki Hashimoto for his helpful suggestions and comments, and to Dr. Debra Roter for her instruction concerning the RIAS and valuable advice. Special thanks are due to Dr. L.M.L. Ong and Dr. Sarah Ford for providing the information on the clusters of the RIAS used

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