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Teams, tribes and patient safety: overcoming
barriers to effective teamwork in healthcare
Jennifer Weller, Matt Boyd, David Cumin

Centre for Medical and Health
Sciences Education, Faculty of
Medical and Health Sciences,
Grafton Campus, University of
Auckland, Auckland,
New Zealand

Correspondence to
Associate Professor Jennifer
Weller, Centre for Medical and
Health Sciences Education,
Faculty of Medical and Health
Sciences, Grafton Campus,
University of Auckland, Private
Bag 92019, Auckland 1142,
New Zealand; j.weller@
auckland.ac.nz

Received 5 December 2012
Revised 1 December 2013
Accepted 20 December 2013
Published Online First
7 January 2014

To cite: Weller J, Boyd M,
Cumin D. Postgrad Med J
2014;90:149–154.

ABSTRACT
Modern healthcare is delivered by multidisciplinary,
distributed healthcare teams who rely on effective
teamwork and communication to ensure effective and
safe patient care. However, we know that there is an
unacceptable rate of unintended patient harm, and
much of this is attributed to failures in communication
between health professionals. The extensive literature on
teams has identified shared mental models, mutual
respect and trust and closed-loop communication as the
underpinning conditions required for effective teams.
However, a number of challenges exist in the healthcare
environment. We explore these in a framework of
educational, psychological and organisational challenges
to the development of effective healthcare teams.
Educational interventions can promote a better
understanding of the principles of teamwork, help staff
understand each other’s roles and perspectives, and help
develop specific communication strategies, but may not
be sufficient on their own. Psychological barriers, such
as professional silos and hierarchies, and organisational
barriers such as geographically distributed teams, can
increase the chance of communication failures with the
potential for patient harm. We propose a seven-step
plan to overcome the barriers to effective team
communication that incorporates education,
psychological and organisational strategies. Recent
evidence suggests that improvement in teamwork in
healthcare can lead to significant gains in patient safety,
measured against efficiency of care, complication rate
and mortality. Interventions to improve teamwork in
healthcare may be the next major advance in patient
outcomes.

INTRODUCTION
Modern healthcare is delivered by teams rather
than individuals and requires the cooperation of
healthcare professionals from multiple disciplines.
However, the evidence suggests that these changes
in healthcare delivery have not been supported by
changes in the systems for communication between
health professionals, especially across disciplines.
Approaches that may have been effective in earlier,
less complex and less distributed environments no
longer reliably work.1 We know that failures in
interprofessional teamwork and communication
lead directly to compromised patient care, staff dis-
tress, tension and inefficiency2–7; make a substantial
contribution to medical error8–13; and are a con-
tributory factor in 61% of sentinel events.7

In this review, our focus will be on improving
sharing of important clinical information between
healthcare professionals. We will first describe the
features of effective teams. We will then discuss the
evidence on information sharing between different

members of the team and categorise the challenges
to interprofessional teamwork and communication
in healthcare into three domains: educational, psy-
chological and organisational. Finally, we will
suggest a range of solutions to these challenges,
synthesising these into a seven-point plan to
promote effective healthcare teams. While our
focus is predominantly on hospital-based teams, we
believe lessons can be generalised to wider health-
care settings.

Features of effective teams
Following an extensive review of the factors asso-
ciated with team performance across a range of
industries, Salas14 proposed a model for five key
dimensions of effective teams: team leadership,
mutual performance monitoring, backup behaviour,
adaptability and a team orientation. These are coor-
dinated by the underpinning mechanisms of mutual
trust, closed-loop communication and shared
mental models. Leadership involves not only task
coordination and planning, but development of the
team, motivation and establishing a positive atmos-
phere. Mutual performance monitoring requires
sufficient understanding of the environment to
enable monitoring of other team members to allow
identification of lapses or task overload, while
backup behaviour requires sufficient understanding
of others’ tasks to enable supportive actions to be
taken by team members, such as redistribution of
workload or support. Adaptability enables a team
to respond to changes in the environment and
change the plan for patient management. Team
orientation is the willingness to take other’s ideas
and perspectives into account and a belief that the
team’s goals, which should be aligned with what is
best for the patient, are more important than an
individual’s goals. To achieve these five dimensions
of effective teams, members of the team must
respect and trust each other in order to give and
receive feedback on their performance, must have
good communication skills to accurately convey
information and must have a shared mental model.
Shared mental models have been identified as one
of the critical underpinning mechanisms for effect-
ive teamwork in general15 and specifically in
healthcare.14 16 17 Shared mental models lead to a
common understanding of the situation, the plan
for treatment, and the roles and tasks of the indivi-
duals in the team. This is often described as the
team being ‘on the same page’. A shared mental
model enables anticipation of other’s needs, identi-
fying changes in the clinical situation and adjusting
strategies as needed. Without a shared mental
model, the different members of the team cannot
fully contribute to problem solving and decision

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making.18 A fundamental requirement for developing a shared
mental model, and for effective team performance, is sharing of
information between team members.

Information sharing: a challenge for healthcare teams
A meta-analysis of 72 independent studies (incorporating 4795
teams) across a range of industries showed that information
sharing positively predicted the performance of the team.19

There are multiple interfaces where transmission of information
between members of the healthcare team is needed for safe and
effective patient care. Particular areas where information sharing
has been shown to be inadequate are the interface between con-
texts, such as interdepartmental transfers,20 or transfers from
primary to secondary care21; high-acuity settings, such as the
emergency department22 or the operating room2; patient hand-
overs at change of shift23; and information sharing across pro-
fessional boundaries, for example, between doctors and nurse.24

In a study on medical ward handovers, less than half of resi-
dents felt confident in their patient handovers.23 In an observa-
tional study of operating room communications, Lingard2

classified over a quarter of communication events as failures,
and 36% of these had visible adverse effects, including ineffi-
ciency, waste, delay, tension and procedural error. Mazzocco
et al.25 found that teams who shared information about the
patient less frequently at the start of a surgical case and at the
handover postsurgery had more than double the risk of surgical
complications than teams that shared such information fre-
quently. Observers of postoperative handovers found that much
critical information (eg, allergies or intraoperative problems)
was not communicated from OR doctors to ward nurses.26 27

There is also evidence suggesting that specific techniques to
improve information sharing can improve clinical management,
such as, in the high acuity setting, declaring an emergency and
sharing information about a crisis with the team28 or ‘thinking
aloud’—verbalising observations and decision-making processes
to the team to share your mental model.29

The failures in information sharing described above, so crit-
ical to effective team communication and safe patient care, are
sequelae of educational, psychological and organisational
factors.

Educational factors
While considerable attention has been paid to doctor–patient
communication in the undergraduate medical curriculum, less is
being done to train medical students on how to communicate
with other health professionals.30–32 Each professional group
has different ways of organising information due to their differ-
ent educational programmes. Different professional groups have
different expectations concerning the content, structure and
timing of information transfer33, and may not understand the
role and priorities of other groups.34 Education for health pro-
fessionals remains largely discipline-specific with minimal inter-
action between healthcare disciplines.35 Training occurs largely
within professional ‘silos’, and few healthcare providers receive
specific training in teamwork.36 37 Such separation of disciplines
and differences in education does little to address understanding
of others roles, responsibilities or priorities, and may contribute
to problems when interprofessional teamwork is required.

Psychological factors
While development of a professional identity as a doctor or a
nurse is a key part of professional education, there are some
downsides. Psychologically, the distinction between ‘ingroup’
and ‘outgroup’ is strong38 39 and social identity theory explains

that members of a professional group (eg, medicine, nursing or
the allied health professions) tend to see the attributes of their
group as positive and those of other groups as less desirable.40–42

Certain types of people are also attracted to certain professions
and specialties,43 strengthening this ‘tribal’ phenomenon. These
professional allegiances can lead to tensions when different pro-
fessional groups have different expectations about how things
should be done.44 This is reflected in the findings of The Joint
Commission International, whose international patient safety
goals include improving effective communication among clinical
staff.45 A further psychological barrier to effective communica-
tion is the hierarchical structure in healthcare. Although senior
staff are happy to use commands, less senior staff may not feel
they can challenge decisions or offer suggestions or alternative
diagnoses and so may conceal their concerns.32 46 This hierarch-
ical structure has been proven to have disastrous consequences
in aviation crews where junior pilots failed to challenge mis-
guided decisions of their superiors.47

Organisational factors
The physical geography of a hospital and the geographical loca-
tion of patients within the hospital can affect the efficient sched-
uling activities of the patient care team, such as ward rounds, or
scheduled meetings to discuss patient management plans. These
geographical and organisational factors act as barriers to infor-
mation sharing, with junior doctors describing the difficulties in
coordinating patient care across multiple wards, with multiple
different staff, relying on ‘opportunistic meetings’ with nurses
or physiotherapists to convey important information.1 Likewise,
nurses, who may know the patient best, may not be present
when key decisions are made about their patient. The reality is
that staff may know what sort of communication is required,
but the environment is not conducive to actually doing this.
Additionally, different clinical areas may use different forms or
incompatible software, making it difficult to access or interpret
information.40 The interface between electronic patient notes in
primary and secondary care is one example.

SEVEN INTERVENTIONS TO IMPROVE TEAM INFORMATION
SHARING
Given that there are many challenges to successful information
sharing and the formation of shared mental models among
modern, distributed healthcare teams, no one solution is likely
to be adequate in alleviating the problem. If we are to enhance
effective information sharing and therefore reduce harm to
patients, then healthcare must take a multifactorial approach
that addresses education, psychology and organisational factors.
Rather than specific training, much of this is about creating con-
ditions that prompt, reward or facilitate appropriate behaviours,
such that health professionals actually do what they already
know how to do.

Learning how to improve and enhance their communication is
a priority for today’s healthcare teams. Other industries have
identified effective approaches,48 and these can inform strategies
for helping healthcare teams. Broadly, the barriers to effective
communication in healthcare teams are educational, psychological
or organisational. We have put together the following seven
approaches to overcoming these barriers that should help health-
care teams determined to improve communication (table 1).

OVERCOMING EDUCATIONAL BARRIERS
Teach effective communication strategies
A number of strategies have been suggested to improve informa-
tion sharing in healthcare. Reviews of these exist, arguing that

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health practitioners’ ‘verbal dexterity’ should equal their pro-
cedural dexterity and factual knowledge.32 Some of the more
researched tools are given with references in table 1. One area
where communication strategies may be most useful is at patient
handover.49 Many staff feel that handovers are not effective
enough,23 and data are emerging regarding what factors consti-
tute good quality handover.50 Higher ratings of handover
quality from those receiving the information were found when
the person handing over made more of an assessment of the
patient. This is likely to be because information unknown to the
receiver is highlighted. Staff also feel that handovers are of
better quality when the person receiving the handover needed
to do less information seeking.51 Handover quality can be
improved, self-reported sentinel incidents avoided and unex-
pected deaths reduced by implementing a simple structured
handover tool,23 one version of which comprises the acronym
SBAR or ISBAR 52 (see table 2).

TRAIN TEAMS TOGETHER
Education is one approach and is supported by the U.S. Institute
of Medicine (IOM) recommendation that teams who work

together should train together.36 This is directly related to the
IOM core competency of ‘working as interdisciplinary teams’.
Training together can promote better understanding of others’
roles. Training that includes all members of the team has been
shown to improve patient outcomes. For example, comprehen-
sive team training in obstetrics and in surgery has been shown
to prevent errors and improve patient safety. Merién et al.58

reviewed teamwork training in obstetrics and reported studies
that not only improved team knowledge but improved APGAR
scores and reduced hypoxic ischaemic encephalopathy. Neily
et al.59 reported a 50% decline in the risk-adjusted surgical mor-
tality rate in the team-training group compared with controls
across over 100 hospitals.

TRAIN TEAMS USING SIMULATION
Working together in an immersive simulation can be a powerful
intervention to trigger discussion about roles, responsibilities
and information sharing around patient management.
Simulation, with appropriate postscenario debriefing, provides
insights into how other professional groups think and feel, and
a better understanding of how to support each other and maxi-
mise everyone’s input to patient care. Such opportunities
present a chance for culture change, through developing mutual
respect and trust, an orientation to team rather than individual,
and an appreciation of the value to the patient of a shared
mental model.

Simulation is a safe environment for deliberate practice of
particular communication strategies, for example, those
described in table 1. Learning can be facilitated by structured
debrief with the opportunity for participants to view
video-recordings of their own communication behaviour. Seeing
how you appear to others can be a powerful motivator to
change. A meta-analysis of 609 studies has demonstrated that
simulation can unequivocally enhance knowledge, time manage-
ment skills, process skills and product skills.60

OVERCOMING PSYCHOLOGICAL BARRIERS
Define inclusive teams
To overcome the barriers that ingroup/outgroup psychology
poses, there is a need to redefine the ‘team’ of healthcare profes-
sionals from a collection of discipline-based teams to a cohesive
healthcare team. Salas’ model of teamwork emphasises the need
for a team orientation, but Burford41 explains that staff self-
categorise and identify with different groups at different times.
Where the environment can be manipulated to emphasise and
value the input from all health professionals to the care of a
patient, the importance of belonging to the whole healthcare

Table 1 Seven actions to overcome barriers to team
communication in healthcare

Action Description

Teach effective communication
strategies

Teaching structured methods of
communication, such as ‘SBAR’ handovers,
can improve patient outcomes.

Train teams together Teams that work together should train
together. Training that includes all
members of the team improves outcomes.

Train teams using simulation Using simulation is a safe way to practice
new communication techniques, and it
increases interdisciplinary understanding.

Define inclusive teams Redefine the team of healthcare
professionals from a collection of disciplines
to a cohesive whole with common goals.

Create democratic teams Each member of the team should feel
valued; creating flat hierarchies encourages
open team communication.

Support teamwork with protocols
and procedures

Use procedures that encourage information
sharing among the whole team, such as
checklists, briefings and IT solutions.

Develop an organisational culture
supporting healthcare teams

Senior champions and department heads
must recognise the imperative of
interprofessional collaboration for safety.

Table 2 Strategies to improve communication

Tool Brief description

Step-back (call-out)32 48 Stepping back from and taking an overview of the situation, the health professional who is leading the team calls the attention
of the team and provides an update of the situation, the plan and invites suggestions.

Closed-loop communication40 53 54 This three-step strategy involves; the sender directs the instruction to the intended receiver, using their name where possible;
the receiver confirms what was communicated as a check on hearing and understanding the instruction, seeking clarification if
required; the sender verifying that the message has been received and correctly interpreted.

Structured information transmission
(SBAR/ISBAR)52 55 56

This is a widely used acronym to help structure verbal at handover or patient referral. The original version (SBAR) has been
expanded in some reports to ISBAR, starting with Identify yourself: Identify
→Situation→Background→Assessment→Recommendation.

Structured handover23 57 Simple templates for summarising important patient information at handover
Graded assertion (PACE)48 Escalating concern (Probe, Alert, Challenge, Emergency)

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team will be emphasised over the single discipline subteam.
Such environmental manipulations exist in the chronic care spe-
cialities where multidisciplinary team meetings are well estab-
lished. This model could be extended to acute inpatient care,
for example, scheduled inpatient ward rounds where all relevant
health professionals are able to attend and all have a role, or
whole team briefing at the start of a day’s operating theatre list.
Such interventions could overcome psychological barriers to
interprofessional communication and enhance a sense of belong-
ing to an inclusive patient care team.

CREATE DEMOCRATIC TEAMS
Structured communication strategies can help to create more
democratic teams, where all members are confident of being
heard. Bleakley argues that such a democratic communication
framework is needed in healthcare.61 Every member of the team
needs to be empowered to contribute their information to deci-
sion making. In Salas’ model of teamwork, mutual trust is a
central factor. If all team members are valued, and feel their
contributions are important and acknowledged, then trust can
be established. Structures that encourage open team communica-
tion, such as flat hierarchies or the WHO surgical safety check-
list,62 aim for an inclusive team and work to mitigate barriers to
information sharing and therefore decrease the potential for
patient harm. Graded assertion is a technique for escalating the
force with which information is presented to ensure transmis-
sion, particularly up a hierarchy. The PACE technique (Probe,
Alert, Challenge, Emergency)48 is one such tool. If everyone on
the team is familiar with structured communication techniques
such as time-out or PACE, then their use can be accepted and
welcomed.

OVERCOMING ORGANISATIONAL BARRIERS
Support teamwork with protocols and procedures
Effective information sharing may require support from organ-
isational protocols. Structured operating room briefings that are
timetabled into the day’s activities are an opportunity to share
the mental model and have been demonstrated to enhance
patient safety, for example, by increasing timely prophylactic
antibiotic administration.63 Procedures should be instituted that
ensure all team members (including the patient) are present, and
all information is available, when important decisions are made.
At Emory University Hospital, the structured interdisciplinary
bedside rounds (SIBR) system is a new procedure that brings the
multidisciplinary ward team together routinely in time and
place for rounds.64 This is an organisational procedure that
overcomes the geographical and temporal challenges often faced
by healthcare teams where patients and team members are
spread across the hospital and belong to a number of different
teams. Early findings suggest a significant reduction in patient
complications and mortality. It is likely that the significant
reductions in patient morbidity and mortality associated with
the introduction of the WHO Surgical Safety Checklist similarly
arise partly from the participation of all staff in the same place
at the same time to share patient information, plans and poten-
tial concerns for patient care.31 Other ways of enhancing struc-
tures to make them more conducive to information sharing are
to align paperwork and IT systems so that data are recorded
consistently and in familiar formats, that crucial information is
highlighted and that red flags are identified with mandatory
reporting requirements. An example of this is the New South
Wales Health ‘between the flags’ project, which mandates escal-
ation of abnormal patient observations.65

DEVELOP AN ORGANISATIONAL CULTURE SUPPORTING
HEALTHCARE TEAMS
Organisational culture is an important element in the pre-
vention of error,42 and this culture is established by those in
leadership roles at both institutional and healthcare team
level.66 67 The organisation has a financial interest in
improving information sharing as failures in information
exchange leads to inefficiencies and increased costs. Delays
in treatment, waste of resources and prolonged hospital stays
have been observed as a direct result of communication fail-
ures in the operating room2 and seem likely to occur in all
aspects of healthcare. If healthcare institutions are to evolve
adaptively, then senior champions, department heads and
individual clinicians must recognise the imperative of inter-
professional collaboration and teamwork for safe and effi-
cient patient care.

Self assessment questions

1. A shared mental model is a critical requirement for effective
teamwork. Which of the following is not a component of a
shared mental model?
A. All team members understand the general plan
B. All team members know each other’s roles
C. All team members can perform all of the required tasks
D. All team members are ‘on the same page’
E. All team members know each other’s capabilities

2. Failures in communication in healthcare teams have been
shown to
A. Contribute to 61% of sentinel events
B. Result in visible adverse events over one-third of the

time
C. More than double the risk of surgical complications
D. All of the above
E. None of the above

3. Which psychological and organisational factors are
challenges to effective interprofessional teamwork in
healthcare?
A. Hierarchical structures
B. Colocation of patients and the patient care team
C. Development of professional identities
D. A&B
E. A&C

4. What training strategy has been shown to reduce
risk-adjusted mortality rates by 50% across over 100
hospitals?
A. Teaching effective communication strategies
B. Training together as a team
C. Using simulation-based training
D. All of the above
E. None of the above

5. Which of the following is not an example of a successful
initiative to support teamwork with protocols and
procedures?
A. Using discipline-specific IT systems and paperwork
B. WHO surgical safety checklist
C. Structured daily briefings
D. Emory University Hospital SIBR system
E. New South Wales Health ‘between the flags’ project

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CONCLUSION
With increasing complexity and even more specialisation of
skills, the current healthcare environment demands effective
communication and teamwork to reliably deliver best patient
care. We have perhaps paid insufficient attention to the new
challenges the modern healthcare environment poses to the
effective sharing information between providers. The aim is to
ensure all team members have a shared understanding of the
situation and are working towards the same goals in patient
care. This article has provided a review of these challenges and
presented a range of strategies to address them. Ongoing
research should evaluate interventions to structure communica-
tions and support information sharing. Interventions to improve
team communication may be the next major advance in improv-
ing patient outcomes.

Main messages

▸ Compelling evidence now exists relating reduced patient
complications and death to improved teamwork in
healthcare.

▸ Challenges to effective teamwork arise due to the way
different disciplines are trained, psychological factors
and the culture and administration of healthcare
organisations.

▸ Strategies exist to improve the function of healthcare teams
at the level of individuals, patient care teams and
organisations.

Current research questions

▸ Elucidate the association between patient harm or inefficient
care, and failures in teamwork and communication.

▸ Develop and evaluate interventions to improve teamwork
and communication with safe and effective patient care as
the primary outcome.

▸ Translational research to embed evidence-based teamwork
and communication interventions in clinical and
organisational practice.

Key references

▸ Salas E, Sims DE, Burke CS. Is there a “Big Five” in
teamwork? Small Group Research 2005;36:555–99.

▸ Mazzocco K, Petitti DB, Fong KT, et al. Surgical team
behaviors and patient outcomes. The Am J Surg 2009;197
(5):678–85.

▸ Burford B. Group processes in medical education: learning
from social identity theory. Med Educ 2012;46(2):143–52.

▸ Haig K, Sutton S, Whittington J. SBAR: a shared mental
model for improving communication between clinicians. Jnt
Comm J Qual Pat Saft 2006;32(3):167–75.

▸ Haynes A, Weiser T, Berry W, et al. A surgical safety
checklist to reduce morbidity and mortality in a global
population. N Engl J Med 2009;360:491–9.

Contributors JW conceived the idea and shaped the manuscript. MB and DC
contributed to the writing and revision, reference search and construction of tables
and figures.

Competing interests None.

Provenance and peer review Commissioned; externally peer reviewed.

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Answers

1. A-T, B-T, C-F, D-T, E-T
2. A-T, B-T, C-T, D-T, E-F
3. A-T, B-F, C-T, D-F, E-T
4. A-F, B-T, C-F, D-F, E-F
5. A-T, B-F, C-F, D-F, E-F

154 Weller J, et al. Postgrad Med J 2014;90:149–154. doi:10.1136/postgradmedj-2012-131168

Review
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Quality of doctor–patient communication through
the eyes of the patient: variation according
to the patient’s educational level

Karolien Aelbrecht • Michela Rimondini • Jozien Bensing •

Francesca Moretti • Sara Willems • Mariangela Mazzi •

Ian Fletcher • Myriam Deveugele

Received: 3 February 2014 / Accepted: 12 November 2014 / Published online: 27 November 2014
! Springer Science+Business Media Dordrecht 2014

Abstract Good doctor–patient communication may lead to better compliance, higher
patient satisfaction, and finally, better health. Although the social variance in how phy-
sicians and patients communicate is clearly demonstrated, little is known about what
patients with different educational attainments actually prefer in doctor–patient commu-
nication. In this study we describe patients’ perspective in doctor–patient communication
according to their educational level, and to what extent these perspectives lean towards the
expert opinion on doctor–patient communication. In a multi-center study (Belgium, The
Netherlands, UK and Italy), focus group discussions were organised using videotaped
medical consultations. A mixed methods approach was used to analyse the data. Firstly, a
difference in perspective in communication style was found between the lower educated
participants versus the middle and higher educated participants. Secondly, lower educated
participants referred positively most to aspects related to the affective/emotional area of
the medical consultation, followed by the task-oriented/problem-focused area. Middle and
higher educated participants positively referred most to the task-oriented/problem-focused
area. The competency of the physician was an important category of communication for all
participants, independent of social background. The results indicate that the preferences of
lower educated participants lean more towards the expert opinion in doctor–patient

K. Aelbrecht (&) ! S. Willems ! M. Deveugele
Faculty of Medicine and Health Sciences, Department of Family Medicine and Primary Health Care,
Ghent University Hospital – 6K3, De Pintelaan 185, 9000 Ghent, Belgium
e-mail: karolien.aelbrecht@ugent.be

M. Rimondini ! F. Moretti ! M. Mazzi
Department of Public Health and Community Medicine, University of Verona, Verona, Italy

J. Bensing
Netherlands Institute for Health Services Research, NIVEL, Utrecht, The Netherlands

J. Bensing
Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands

I. Fletcher
Health Sciences Research, Lancaster University, Lancaster, UK

123

Adv in Health Sci Educ (2015) 20:873–884
DOI 10.1007/s10459-014-9569-6

communication than the middle and higher educated participants. Patients’ educational
level seems to influence their perspective on communication style and should be taken into
account by physicians. Further quantitative research is needed to confirm these results.

Keywords Communication ! Doctor–patient communication ! Educational level !
Patients’ perspective ! Quality

Introduction

Equity in health care is a major issue in the health policy debate. The central principle of
the concept is equal access, treatment, and treatment outcomes for people in equal need
(Whitehead et al. 2001). It refers to the fact that personal variables (e.g. age) and social
variables (e.g. income) should not dictate that people with similar needs for health care
enter through different doors (public vs. private providers), are treated differently in terms
of the type or intensity of services provided, are more or less involved in treatment
decisions, or receive more or less information (Aday et al. 1999). Yet, research shows that
doctor–patient communication tends to differ according to the educational background of
the patient. Patients with a lower educational background are significantly less involved in
treatment decisions, are approached in a more directive way during the consultation, and
are less frequently asked to take responsibility for care than patients with a higher edu-
cation (Verlinde et al. 2012).

This social variance in doctor–patient communication seems to indicate that there is
inequity in communication in health care. For example, doctors might be less informative
with less educated and lower income patients, because they assume that these patients are
not particularly interested in learning about their health or do not understand this infor-
mation (Williams et al. 2010; Cerin and Leslie 2008; Baron-Epel et al. 2007; Starfield
2006; Street 1991; Waitzkin 1985). Yet, even though physicians often ground their
behaviour on these perceptions, it is not clear to what extent these perceptions are in
accordance with patients’ needs and preferences.

Studies exploring the patient side of communication merely focus on describing
patients’ actual behaviour. They report that patients from lower social classes are less
likely to ask questions and exhibit their opinions. They also react with less affect and take
less initiative to increase their participation in the decision making process (Verlinde et al.
2012; Longtin et al. 2010; Smith et al. 2009; Bernheim et al. 2008). However, not all
studies confirm these findings; a study conducted by Street did not find a relation between
the frequency of the patients asking questions and his/her educational background (Street
1991). Furthermore, no studies have reported on social differences in patients’ expectations
regarding doctor–patient communication.

More and more, medical students are receiving communication skills training throughout
their medical studies. The content of the training courses, however, is usually derived from
psychological theories and determined by professional experts (e.g. doctors, psychologists,
and nurses) (von Fragstein et al. 2008; Kinderman and Humphris 1995), and patients are
seldom involved in the development of these courses or in the development of clinical
guidelines (Boivin et al. 2010). Moreover, several studies show a low correlation between
patients’ and professionals’ quality assessments, underlining the need for a more direct
approach to tapping patients’ views about the quality of doctor–patient communication

874 K. Aelbrecht et al.

123

(Mazor et al. 2005; Greco et al. 2002; Rothman and Cusimano 2000). Therefore, a multi-
center study was set up in Belgium, the Netherlands, UK, and Italy.

The objective of this study is twofold. First, to analyse whether there is a difference in
the kind of topics participants address when talking about doctors’ communication style
according to their educational level, and to describe these differences, if any. Second, to
examine which participants lean most towards an expert opinion on doctor–patient
communication.

Methods

Background

Data were derived from the GULiVER project, an international, multi-center study in
Belgium (Ghent University), the Netherlands (Utrecht University), United Kingdom
(University of Liverpool), and Italy (University of Verona).

A study design using focus group discussions (FGDs) was adopted. In all four countries
the same procedures were followed according to a detailed protocol, pretested with three
pilot panels. The detailed protocol of the GULiVER study is described in a related paper
(Moretti et al. 2012).

Ethical approval to use the recordings in this study was given by the University of
Liverpool.

Recruitment of participants

To recruit the participants, the research teams applied stratified sampling according to age
(18–30; 31–49; C50) and gender (separate male and female panels). Inclusion criteria were
(a) age over 18 years; (b) at least one GP-visit over the last 12 months; (c) speaking one of
the country’s official languages; and (d) not being involved in a medical lawsuit or formal
complaint with a care provider during the last 2 years. The participants were approached in
a context not related to any medical consultation (e.g. in shopping malls, railway stations,
and market places).

Measurement instruments and data collection procedure

To collect the data, thirty-five data collection sessions were organised: nine in Italy, the
Netherlands, and United Kingdom, and eight in Belgium. In each session 6–9 participants
were included. During these sessions (all lasting around 6 h) different data collection
methods were used. The resulting heterogeneity in the data was intended to generate a
comprehensive view of the participants’ perspectives.

Firstly, the participants filled out a questionnaire on socio-demographic characteristics
including age, gender, and educational level. The latter was based on the highest educa-
tional attainment of the participant and was categorised in three categories: low (no
education or primary school), middle (secondary school), and high (higher education)
educational level.

Then, video-recorded medical consultations were presented. Two sets of four stand-
ardised recordings were used: one set on vaginal discharge after unprotected sex and one
set on severe menstrual pain. Both scenarios referred to clinical problems that can be

Quality of doctor–patient communication through the eyes of the patient 87

5

123

associated with high levels of emotional distress. These recordings were made as part of
the summative fourth year OSCE’s (Objective Structured Clinical Examination; i.e.
medical consultation with a simulated patient) at the Liverpool Medical School to assess
the competency of the medical students’ communication skills in a primary health care
setting. Four video recordings were selected per scenario: one with high ratings from both
examiner (E) and simulated patient (SP), one with a high rate from the examiner and a low
rate from the simulated patient, one with a low rate from the examiner and a high rate from
the simulated patient, and one with a low rate from both the examiner and the simulated
patient. The recordings were dubbed (Italy) or subtitled (Belgium and the Netherlands).
After watching the recordings, each participant was asked to rank them from 1 to 4: ‘‘1’’
being the recording of the consultation done by their most preferred doctor to ‘‘4’’ being
the recording of the consultation performed by their least preferred doctor.

Next, the participants participated in a focus group discussion. Participants were invited
to share their views on the doctors’ performance, and the underlying reasons for their
choices were explored. Because they were not directly involved in the consultations, the
participants could freely judge and comment on the student doctors’ communicative
performance, while still representing a patient perspective. After an hour, the discussion—
if it had not already ended—was summarised and closed.

All focus group discussions were moderated by a native speaker trained in the method
of focus group discussions. The discussions were audiotaped and fully transcribed ver-
batim, including information on the identity of the participant speaking. In order to make
the transcripts accessible to researchers in all four countries, they were translated into
English. Because of privacy issues all references to names (e.g. the participants’ name,
names of children, and doctors) were replaced by anonymous numbers.

Data coding

The four research teams coded one or two transcripts independently. To do so, the prin-
ciples of the framework approach, in which the pre-defined questions and objectives are
used as boundaries for the coding, were applied (Mazzi et al. 2013; Moretti et al. 2011).
Subsequently, codes were compared and differences in coding were discussed in order to
develop a common understanding of all codes. This classification system was then used to
code the transcripts of all the remaining focus group discussions.

The applied coding scheme was divided into six areas of communication of which three
will be discussed in this article—i.e. process-oriented area (i.e. all the comments about the
way a doctor is handling the process of the conversation), task-oriented/problem-focused
area (i.e. all the comments about the overall attitude of the doctor regarding the instru-
mental tasks during the conversation) and affective/emotional area (i.e. all the comments
about the overall attitude of the doctor regarding the affective/emotional components)—,
12 main categories, and 41 subcategories (Moretti et al. 2011). For more detailed infor-
mation about the scheme see Table 1 of Appendix.

Statistical analyses

A total of 7,067 quotes were coded, but 1,598 quotes were excluded from the analyses
because these were not related to the topic of the study (i.e. small talk, e.g. someone asking
for more coffee). The codes were inserted in the statistical software program SPSS (version
20.0.0, IBM) and linked with the information of the participant who was talking.

876 K. Aelbrecht et al.

123

First, the number of utterances according one’s educational level was calculated and
tested using one-way ANOVA. Further, to answer the first research question, a Chi squared
test of independence with adjusted residual analysis was used (Agresti 2002). For the
second research question, the videotaped consultations with a high expert assessment (i.e.
high E-high SP and high E-low SP) were merged and a generalised estimating equation
approach was used to provide a practical method with good statistical properties to model
data that exhibit association, but cannot be modelled as multivariate normal (Johnston and
Stokes 1999).

Results

Participant characteristics

A total of 259 lay people participated in the GULiVER study. UK data were excluded for
this article because reliable information on the educational level of the participants was
missing. As a result, for this paper, the data of 178 participants were analysed: 59 par-
ticipants in the Netherlands, 71 in Italy, and 48 in Belgium.

The sample included 79 male and 99 female participants, all between 18 and 71 years
old. There were 31 participants with a lower educational level, 73 participants with a
middle, and 74 participants with a higher educational level included (see Table 2 of
Appendix).

Discussed topics by educational level

Lower educated participants talked significantly less during the focus group discussions
than middle and higher educated participants: a mean of 15 quotes per lower educated
participant, a mean of 17 quotes per middle educated and a mean of 20 quotes per higher
educated participants. Consequently, lower educated participants were talking for 14 % of
the duration of the discussion, middle educated participants for 40 % of the duration, and
higher educated participants for 46 % of the duration. This was found statistically sig-
nificant as determined by one-way ANOVA (F(2, 3165) = 12.233, p = 0.000).

When asking participants about their perspective in doctor–patient communication
(‘‘Why do you prefer this doctor?’’), lower educated participants mostly referred to the
affective/emotional area of communication (41.1 % of the quotes expressed by this group;
187/454 quotes), followed by the task-oriented/problem-focused area of communication
(40.9 %; 186/454). Only 17.8 % of the quotes (81/454) referred to the process-oriented
area of communication. For the middle and the higher educated participants, the task-
oriented area was most frequently referred to (middle: 40.9 %; 515/1,259; high: 41.8 %;
609/1,455). The affective/emotional area came second (middle: 35.1 %; 443/1,259; high:
30.9 %; 450/1,455), and this group referred to the process-oriented area the least (middle:
23.9 %; 301/1,259; high: 27.2 %; 396/1,455). This was found statistically significant for
the task-oriented/problem-focused area and the affective/emotional area as determined by
Pearson’s Chi square test, respectively v2(6) = 14.9786, p = 0.020 and v2(14) = 84.8600,
p = 0.000.

When looking within the areas, we found an effect of the patient’s educational level in
four categories. Within the process-oriented area, the category ‘‘structuring’’ was statisti-
cally significant, with v2 (6) = 39.9304, p = 0.000, while in the task-oriented/problem-

Quality of doctor–patient communication through the eyes of the patient 87

7

123

focused area, the categories ‘‘attitude of the doctor’’ and ‘‘collecting information’’ were
statistically significant, with v2 (10) = 19.9900, p = 0.029 and v2 (6) = 14.7640,
p = 0.022, respectively. Finally, within the affective/emotional area, the category ‘‘attitude
of the doctor’’ was statistically significant, with v2 (14) = 84.8600, p = 0.000. Higher
educated participants referred significantly more to these four categories.

When looking within these four significant categories, we found differences between the
subcategories. Within the category ‘‘structuring’’, lower educated participants refer more to
‘‘time issues’’ than middle and higher educated participants, while middle educated par-
ticipants refer more to ‘‘opening or closing of the interview’’. Within the category ‘‘attitude
of the doctor’’ in the task-oriented/problem-focused area, lower educated participants refer
more to the subcategories ‘‘business-like/to the point’’, ‘‘other/general’’, and ‘‘competency
(of the doctor)’’ than middle and higher educated participants. The subcategory ‘‘self-
confident’’ is often referred to by the middle educated participants. Within the category
‘‘collecting information’’, lower educated participants refer more to the subcategories
‘‘medical’’ and ‘‘bio-psychosocial’’ than middle and higher educated participants. Within
the category ‘‘attitude of the doctor’’ in the affective/emotional area, lower educated
participants refer more to the subcategories ‘‘inviting attitude (of the doctor)’’, ‘‘showing
interest in the patient/commitment’’, ‘‘facilitating’’ and ‘‘listening’’ than middle and higher
educated participants. Both lower and middle educated participants refer significantly more
to ‘‘pleasant attitude (of the doctor)’’ than higher educated participants. The subcategories
‘‘empathic (attitude of the doctor)’’ and ‘‘reassurance/trust (in the doctor)’’ were often
referred to by the middle educated participants.

The expert opinion versus layman’s opinion on good doctor–patient communication

Participants with a lower educational level preferred the doctors who received a high score
by the experts (i.e. examiner/expert), significantly more than the middle and higher edu-
cated participants. The odds of choosing the expert opinion on good doctor–patient
communication is 1.443 times higher for participants with a lower educational level than
for participants with a secondary diploma (95 % CI 1.030–2.021).

No significant effect was found for the higher educated participants, meaning they do
not have a specific preference.

Discussion

This study shows that lower educated participants expressed their perspectives during the
focus group discussions significantly less than middle and higher educated participants.
Moreover, participants’ perspective on doctor–patient communication differ according to
the participant’s educational level. Lower educated participants emphasised the emotional
and task-oriented/problem-focused area more, while for the middle and higher educated
people the emotional area came second, after the task-oriented/problem-focused area. For
all participants, the process-oriented area was least referred to. The differences in partic-
ipants’ education were found statistically significant. Furthermore, we saw that participants
with a lower educational level preferred the expert opinion on doctor–patient communi-
cation significantly more than the middle and higher educated participants.

First, we found that lower educated participants talked less during the focus group
discussions. Willems et al. (2004) described how these patients often find themselves in a
vicious circle, where their more passive behaviour in a consultation elicits a less-involved

878 K. Aelbrecht et al.

123

behaviour from the doctor. This is not a new result. Lower participation from lower
educated people was also found in other studies (Galea and Tracy 2007; Moorman et al.
1999). It means that the voices of lower educated people are less heard in focus group
studies. However, focus groups discussions are meant to be used to encourage participants
to explore specific issues and attitudes. As stated by Kitzinger in 1994: ‘‘Tapping into such
interpersonal communication is also important because this can highlight (sub)cultural
values or group norms. It also makes them useful in studies examining why different
sections of the population make differential use of health services.’’ Our finding that
participants with low educational levels are less talkative in focus group discussions means
that in studies which are seeking for differential opinions and experiences, special effort is
needed to give these people a voice, either by organising homogeneous groups of people
with the same educational levels, or by targeted invitations by the moderator in hetero-
geneous focus groups.

Lower educated participants seem to attach the most importance to the subcategories
‘‘inviting attitude (of the doctor)’’, ‘‘pleasant attitude (of the doctor)’’, ‘‘showing interest in
the patient/commitment’’, ‘‘facilitating’’, ‘‘listening’’, ‘‘(being) business-like/to the point’’,
‘‘competency (of the doctor)’’, ‘‘collecting medical and bio-psychosocial information (by
the doctor)’’, and ‘‘time issues’’. Participants with a lower educational level also lean more
towards the expert opinion on doctor–patient communication than the middle and higher
educated participants. This is in accordance with the general educational guidelines of
what is generally considered as good doctor–patient communication: doctors need to be
competent, have to know their job, while adopting a patient-centered style (Roter and Hall
2006). At the same time, this result contrasts with what physicians tend to do, namely using
a more dominant communication style when dealing with patients from lower educational
backgrounds (Verlinde et al. 2012; Smith et al. 2009; Kelly-Irving et al. 2009). This means
that doctors often adapt their communication style based only on ingrained prejudices, and
therefore, in the opposite direction.

Moreover, while the lower educated participants described the affective/emotional area
and the invitation of the doctor to participate in the consultation as most important, the
middle and higher educated participants indicated the task-oriented/problem-focused area
as most important. Looking in particular to the middle educated participants, we saw that
they attach the most importance to the subcategories ‘‘opening or closing of the interview’’,
‘‘self-confident (attitude of the doctor)’’, ‘‘pleasant attitude (of the doctor)’’, ‘‘empathic
(attitude of the doctor)’’ and ‘‘reassurance/trust (in the doctor)’’. A possible explanation
could be that the field of affective communication is perhaps the field where lower edu-
cated people feel competent enough to make comments, and feel less secure when more
medical issues arise. Also, people with a higher educational background are perhaps more
aware of the ways in which doctors give direction to a consultation and have more to say
about this.

It appears that the specific needs of the lower, middle, and higher educated participants in
a medical consultation occur on different levels. While lower educated participants explicitly
ask to be invited to take part in a consultation, other elements of a consultation, in particular
about the attitude of the doctor towards the patient, seem to be more important for middle
educated participants. It is possible that the middle educated are asked to take part in the
consultation, and as a result attach more importance to other elements that are perhaps
missing for them in a consultation. None of the subcategories stood out for the higher
educated participants, probably because their expectations were met (Fiscella et al. 2002).

Looking at the concept of shared decision making, McKinstry (2000) found that a lower
educational level was associated with a lower preference for the shared approach. However,

Quality of doctor–patient communication through the eyes of the patient 879

123

it was not found to be an independent predictor and, moreover, specific minorities within
each group had opposite views than the rest. And yet, this is what we often see in practice,
where some physicians assume that they know the patient’s preference, and act on this
without first explicitly testing this assumption. Moreover, both patient and physician have to
be willing to share the process. And as described by Charles et al. (1997), ‘‘It takes at least
two to tango’’ for shared decision making to occur in a medical consultation.

This study has important strengths and limitations. The GULiVER study is one of the few
to research the perspectives of lay people regarding doctor–patient communication. The
importance of this type of research was strengthened by Frenk et al. (2010): ‘‘Health is about
people; thus the core driving purpose of professional education must be to enhance the
performance of health systems for meeting the needs of patients and populations in an
equitable and efficient manner.’’ Furthermore, it is done on a large scale, in four different
countries, applying a strict and well thought out method to ensure the validity of the results as
much as possible. Because of the explicit use of group interaction, focus group discussion is a
widely used technique to explore people’s experiences and perspectives (Kitzinger 1994).

The use of the OSCE’s to record the recordings can be criticised since recordings from
this setting do not necessarily resemble the natural variance observed in everyday medical
practices. However, for the aim of this study, namely to compare lay people’s opinions, we
needed to show all participants the same set of (standardised) recordings, and this could
easily be achieved by using the OSCE stations (Moretti et al. 2012). Also, the use of only
gynaecological scenarios might have been a bias in this study. These specific scenarios
containing levels of emotional distress were used in order to be able to assess the medical
students’ communication skills. Furthermore, in selecting the participants, we stratified on
age and gender, but not on education. While aiming for homogeneity is usually recom-
mended for each group, bringing together a diverse group can maximise exploration of
different perspectives within a group setting (Kitzinger 1994). Taking this advantage and
the research aim into account, we mixed the focus groups in terms of educational back-
ground of the participants. Nevertheless, the results concerning lower educated participants
being less expressive can call this decision into question. Finally, another important lim-
itation for this study is the limited number of included participants; this was due to the
exclusion of the British data.

Conclusion

Patients’ educational level seems to influence their perspective on communication style.
Patients from different educational backgrounds have different needs in consultations, in
particular with regard to doctor–patient communication. However, instead of behaving like
most patients want, doctors must be aware of these specific differences in needs, and take
them into account during consultations. Further quantitative research is needed to confirm
these results.

Acknowledgments We would like to thank all the participants for their significant contribution to the
study. Also, we would like to thank the other members of the GULiVER study, as well as the moderators of
the focus groups for their committed participation in the study.

Appendix

See Tables 1 and 2.

880 K. Aelbrecht et al.

123

T
a
b
le

1
N
u
m
b
er

o
f
ti
m
es

p
ar
ti
ci
p
an
ts
re
fe
rr
ed

to
ea
ch

o
f
th
e
ca
te
g
o
ri
es

an
d
su
b
ca
te
g
o
ri
es

in
d
o
ct
o
r–
p
at
ie
n
t
co
m
m
u
n
ic
at
io
n
(a
cc
o
rd
in
g
to

ed
u
ca
ti
o
n
al

le
v
el

)

A
re
a
o
f
co
m
m
u
n
ic
at
io
n

C
at
eg
o
ry

S
u
b
ca
te
g
o
ry

E
d
u
ca
ti
o
n
al

le
v
el

(n
o
.
o
f
q
u
o
te
s)

L
o
w

M
id
d
le

H
ig
h

P
ro
ce
ss
-o
ri
en
te
d
a
re
a
a
(n

5
7
7
8
)

S
tr
u
ct
u
ri
n
g
(n

=
3
9
4
)

C
h
an
g
in
g
o
f
to
p
ic
s
an
d
si
g
n
p
o
st
in
g

2

2
3

5
1

F
le
x
ib
il
it
y

1
3

4
9

1

0

8

T
im

e
is
su
es

1
6

3
3

2
6

O
p
en
in
g
o
r
cl
o
si
n
g
o
f
th
e
in
te
rv
ie
w

6
3
9

2
8

S
u
m
m
a
ri
si
n
g
(n

=
1
0
5
)

S
u
m
m
ar
is
in
g

1
0

5
0

4
5

P
a
ti
en
t-
in
v
o
lv
in
g
(n

=
1

3
1

)

S
h
ar
in
g
p
la
n
s/
id
ea
s

8

2
1

2
3

A
sk
in
g
p
er
m
is
si
o
n

3
1
0

2
8

V
er
if
y
in
g

2

1
4

2
2

S
p
ea
k
in
g
p
ec
u
li
a
ri
ti
es

(n
=

1
4
8
)

R
ep
et
it
io
n

9
2
4

2
1

F
il
le
rs

5
2

6

2
3

C
o
m
p
re
h
en
si
b
il
it
y

7

1
2

2
1

T
a
sk
-o
ri
en
te
d
/p
ro
b
le
m
-f
o
cu
se
d
a
re
a
b
(n

=
1
,3
1
0
)

A
tt
it
u
d
e
o
f
th
e
d
o
ct
o
r
(n

=
7
9
0
)

S
el
f-
co
n
fi
d
en
t

1
2
5
2

5
8

C
o
m
p
le
te

p
ic
tu
re

2
1
5
8

8
6

B
u
si
n
es
s-
li
k
e/
T
o
th
e
p
o
in
t

1
7

3
0

5
3

O
th
er
/G
en
er
al

7
2
3

1
1

C
la
ri
ty

o
f
in
te
rv
ie
w

3
2

0

3
2

C
o
m
p
et
en
cy

5
1

1

1
8

1
3
8

C
o
ll
ec
ti
n
g
in
fo
rm

a
ti
o
n
(n

=
2
5
2
)

M
ed
ic
al

1
8
3
2
3
0

B
io
-p
sy
ch
o
so
ci
al

1
4
3
0
2
8

P
sy
ch
o
lo
g
ic
al

2
1
3

7

S
o
ci
al

5
2
9

4
4

G
iv
in
g
in
fo
rm

a
ti
o
n
(n

=
1
6
9
)

M
ed
ic
al
1
1

4
0

6
0

B
io
-p
sy
ch
o
so
ci
al

6
1
7

2
6
P
sy
ch
o
lo
g
ic
al
1
1
0

Quality of doctor–patient communication through the eyes of the patient 881

123

T
a
b
le

1
co
n
ti
n
u
ed

A
re
a
o
f
co
m
m
u
n
ic
at
io
n
C
at
eg
o
ry
S
u
b
ca
te
g
o
ry
E
d
u
ca
ti
o
n
al
le
v
el
(n
o
.
o
f
q
u
o
te
s)
L
o
w
M
id
d
le
H
ig
h
S
o
ci
al

0
2

5

P
ro
v
id
in
g
S
o
lu
ti
o
n
(n

=
9
9
)

P
ro
v
id
in
g
so
lu
ti
o
n
s

1
8
5
0
3
1

A
ff
ec
ti
v
e/
em

o
ti
o
n
a
l
a
re
a
c
(n

=
1
,0
8
0
)

A
tt
it
u
d
e
o
f
th
e
D
o
ct
o
r
(n

=
1
,0
8
0
)

In
v
it
in
g
at
ti
tu
d
e

2
2

4
2

4
5

P
le
as
an
t
at
ti
tu
d
e

2
2
5
1
4
4

S
h
o
w
in
g
in
te
re
st

in
p
at
ie
n
t/
C
o
m
m
it
m
en
t

5
3

7
5

1
0
1

E
m
p
at
h
ic

3
4
0

2
1

F
ac
il
it
at
in
g

2
0

3
6

4
6

R
ea
ss
u
ra
n
ce
/T
ru
st

2
3

1
1
2

1
0
9

N
eu
tr
al
/N
o
p
er
so
n
al

re
m
ar
k

8
4
5

6
6

L
is
te
n
in
g

3
6
4
2
1
8

n
=
4
5
4

n
=
1
,2
5
9

n
=
1
,4
5
5

T
h
e
n
u
m
b
er
s
h
ig
h
li
g
h
te
d
in

b
o
ld

re
p
re
se
n
t
th
e
to
p
5
o
f
co
m
m
u
n
ic
at
io
n
su
b
ca
te
g
o
ri
es

m
o
st
re
fe
rr
ed

b
y
ed
u
ca
ti
o
n
al

le
v
el

a
F
o
r
ex
am

p
le
,
w
it
h
in

th
e
ca
te
g
o
ry

st
ru
ct
u
ri
n
g
,
a
q
u
o
te
o
f
ti
m
e
is
su
es

w
as
:
‘‘
Y
es
,
it
is
st
ra
n
g
e
th
at
h
e
(i
.e
.
th
e
d
o
ct
o
r)
w
as

so
fa
st
,
I
h
ad

a
fe
el
in
g
li
k
e,
n
o
w
y
o
u
ar
e
fi
ll
in
g
y
o
u
r

ti
m
e
…

(f
em

al
e,

T
h
e
N
et
h
er
la
n
d
s)
.’
’

b
F
o
r
ex
am

p
le
,
w
it
h
in
th
e
ca
te
g
o
ry

at
ti
tu
d
e
o
f
th
e
d
o
ct
o
r,
a
q
u
o
te

o
f
co
m
p
et
en
cy

w
as
:
‘‘
S
h
e
lo
o
k
ed

p
ro
fe
ss
io
n
al

b
ec
au
se

o
f
h
er

ex
p
re
ss
io
n
s,
b
ec
au
se

sh
e
d
id

n
o
t
k
ee
p
o
n

sa
y
in
g
‘o
k
,
al
l
ri
g
h
t;
o
k
,
al
l
ri
g
h
t’
(m

al
e,

It
al
y
).
’’

c
F
o
r
ex
am

p
le
,
w
it
h
in
th
e
ca
te
g
o
ry
at
ti
tu
d
e
o
f
th
e
d
o
ct
o
r,
a
q
u
o
te

o
f
in
v
it
in
g
at
ti
tu
d
e
w
as
:
‘‘
T
h
ey

(i
.e
.
th
e
d
o
ct
o
rs
)
ar
e
b
eh
in
d
a
la
rg
e
d
es
k
an
d
th
en

y
o
u
ar
e
si
tt
in
g
at

su
ch

a
d
is
ta
n
ce

(m
al
e,

B
el
g
iu
m
).
’’

882 K. Aelbrecht et al.

123

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BE 21 27 6 15 27

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123

D. Riedl, G. Schüßler The Influence of Docto r-Patient Communication on Health Outcomes
The Influence of Doctor-Patient Communication
on Health Outcomes: A Systematic Review

David Riedl1, Gerhard Schüßler1

Zusammenfassung

Der Einfluss der Arzt-Patient-Beziehung auf den Gesundheitszustand:
eine systematische Übersicht

Hintergrund: Für den Einfluss der Arzt-Patient-Beziehung sowie -kommunikation auf den
Gesundheitszustand ist eine weitere empirische Fundierung notwendig. Anhand der Unter-
scheidung zentraler Bereiche (bspw. Beziehungsqualität, Informationsvermittlung, Patienten-
edukation) können spezifische Ergebnisse beschrieben werden. Um die empirische Basis dieser
Annahmen zu überprüfen haben wir einen systematischen Review durchgeführt.
Methoden: In einem systematischen Review der Publikationen in Medline, Embase, Cochrane,
PsychLIt und Psyindex zwischen 2000 und 2015 wurden RCTs, kontrollierte und unkontrol-
lierte peer-reviewte Studien mit erwachsenen klinischen Stichproben identifiziert und analy-
siert. Studien mit psychiatrischen Stichproben, psychologischen oder psychotherapeutischen
Interventionen wurden ausgeschlossen.
Ergebnisse: Siebzehn RCTs, siebzehn kontrollierte Studien sowie acht qualitative Studien er-
füllten alle Einschlusskriterien. Die generelle Studienqualität der RCTs und kontrollierten Stu-
dien war zufriedenstellend. 60% der Studien konnten einen positiven Effekt der Arzt-Patient-
Beziehung auf den Gesundheitszustand zeigen. Die Rolle von Informationsermittlung sowie
-vermittlung (Patientenedukation) wurde am häufigsten untersucht, wobei ein eindeutiger
positiver Effekt gefunden wurde. Auch die Kommunikationsfähigkeit führte zu verbesserten
Ergebnissen sowie zur verbesserten Unterstützung behandlungsbezogener Verhaltensweisen
und Emotionen. Zwei Studien, in denen eine ökonomische Evaluation mit eingeschlossen wur-
de, zeigten verringerte Kosten für das Gesundheitssystem.
Zusammenfassung: Im vorliegenden systematischen Review wurden überzeugende Effekte für
unterschiedliche Bereiche der Arzt-Patient-Beziehung sowie Aspekte der Kommunikation auf
verschiedene objektive und subjektive Gesundheitsparameter gefunden.

Z Psychosom Med Psychother 63/2017, 131-150

Keywords

Doctor-Patient Relationship – Doctor-Patient Communication – Patient Education – Com-
munication – Treatment-Related Behaviors

Summary

Objective: In order to evaluate the influence of the doctor-patient relationship and commu-
nication on healthcare outcomes, further reliable results are needed. More specific results can
be achieved depending on the differentiation of several domains (e.g., relationship, informa-

Z Psychosom Med Psychother 63, 131–150, ISSN (Printausgabe) 1438-3608, ISSN (online) 2196-8349
© 2017 Vandenhoeck & Ruprecht GmbH & Co. KG, Göttingen

! University Hospital of Medical Psychology, Medical University of Innsbruck, Austria.

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y.

Z Psychosom Med Psychother 6 , ISSN (Printausgabe) 1438-3608, ISSN (online) 2196-8349
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tion gathering, or patient education). We conducted a systematic review including publications
from 2000 to 2015 to gather further empirical support.
Methods: A systematic review was carried out (with information drawn mainly from Medline,
Embase, Cochrane, PsychLit, and Psyndex) to identify RCTs as well as controlled and uncon-
trolled studies in clinical adult samples. Studies with psychiatric samples and psychological-
psychotherapeutic interventions were excluded.
Results: A total of 17 RCTs, 17 controlled studies, and 8 qualitative studies met the inclusion
criteria. The quality of the RCTs and controlled studies was satisfying. In the doctor-patient
relationship (building), 60% of the studies showed a positive effect on objective health param-
eters. Information gathering and provision (patient education) were the most investigated do-
mains with unequivocally positive effects. Communication (skills) showed improved results
and enabled treatment-related emotions and behavior. Two studies included an economical
evaluation with reduced healthcare costs.
Conclusions: A systematic review revealed different domains of the doctor-patient relation-
ship and communication with convincing effects regarding different objective and subjective
health outcomes.

1. Introduction

Throughout the history of medicine the doctor-patient relationship has been in the
center of treatment, however evidence for its effects is hard to prove. In the last com-
prehensive systematic meta-analysis up to the year 2000 Di Blasi et al. (2001) iden-
tified RCTs (N = 25) with 19 trials examining the effects of doctor patient-commu-
nication (half of them showed significant positive effects). The general effects of doc-
tor-patient communication and their relationship were described as “emotional and
cognitive care” mainly as “warm, friendly and reassuring manner” and “positive in-
formation about treatment.”

Di Blasi et al. (2001) confirmed the inconsistencies in definitions and measure-
ments and suggested necessary improvements (Epstein et al. 2005; Makoul, 2001).
The two aspects of emotional and cognitive care are dissolved in a set of communi-
cation and relationship tasks: relationship building (with empathy), gathering infor-
mation (with the patient’s perspective), share and provide information (patient ed-
ucation), reach agreement, decisions making (shared decision making). These rela-
tionship and communication tasks are geared to enable treatment-related behavior
and emotions for patients and relatives. Nowadays the economic aspect (“it pays
off”) has to be added. Since the last comprehensive review was published over 15
years ago and, taking into account the different aspects of doctor-patient communi-
cation and relationship, we updated the review with studies from 2000 up to 2015.

2. Methods

2.1. Search strategy

A systematic comprehensive search of databases between 2000 and 2015 was con-
ducted to identify studies eligible for a systematic review and synthesis of the litera-

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ture. The search was carried out by using a large number of medical and psycholog-
ical electronic databases (MEDLINE, Cochrane Controlled Trials Register, PsycLIT,
Social Science Citation Index, Science Citation Index, EMBASE, PsycINFO, PSYN-
DEX, PsycARTICLES). A combination of 64 search terms was used within each data-
base. The search terms described different aspects of the patient-practitioner rela-
tionship, aspects of communication, contextual information, placebo effects, and dif-
ferent major diseases (e.g., cancer, diabetes, etc.). A manual search of the reference
lists from retrieved papers and previous related reviews was conducted to identify
further studies.

2.2. Selection criteria

Studies investigating verbal communication and interventions were included. We
used a broad approach, taking all studies into account which used randomized con-
trolled, controlled or uncontrolled designs2 in clinical adult samples. We excluded
studies examining treatment characteristics (e.g., different medication) and using
psychological-psychotherapeutic interventions or psychiatric samples.

2.3. Data extraction and statistical analysis

Data extraction followed a predefined stepwise strategy. Each step was individually
conducted by two researchers (GS and DR) and conflicting results were discussed
until consensus was reached. Irrelevant studies were excluded based on the studies’
title in a first step and based on their abstract in a second step. Finally, the full text
of all remaining studies was individually rated and cross-checked by both researchers
to be included in the review, if eligible.

A standardized data extraction form was used to collect data. The extraction of
the data comprised (1) reference information (author and date); (2) characteristics
of study population (number of patients and/or practitioners, disease of the popu-
lation) and study design (RCTs, controlled studies, or qualitative studies); (3) char-
acteristics of the intervention (type of intervention, aim, frequency, and duration of
the intervention); (4) main communication function; (5) characteristics of outcomes
(main outcome measures and results). The extracted data is presented as a descriptive
summary of the studies. Furthermore, an assessment of the studies’ quality was con-
ducted. Because of the high heterogeneity of intervention types and outcome vari-
ables among the studies, a quantitative meta-analysis of the extracted data was not
feasible.

We used a modified version of the checklist developed by Downs and Black (1998)
for the quality assessment. The checklist has been cited in over 300 reviews and is
usually used to evaluate randomized and non-randomized studies of healthcare in-

The Influence of Doctor-Patient Communication on Health Outcomes 133

” Since quantitative research strategies may not be able to evaluate the whole dimension of human
relationship and communication, we chose to include qualitative studies in the review as well.

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terventions. We eliminated three of the original 27 items that were not applicable to
the type of studies included in our review.

The modified quality checklist finally consisted of 24 items that could be scored
with “Yes” (1), “No” (0), or “Unable to Determine” (0). The items were added up to
a total score ranging from 0–25 with higher values representing better study quality.
Because the subscales consisted of different numbers of items, mean values were
calculated to enable a comparison between the quality subscales. Five different qual-
ity criteria were assessed: quality of reporting (10 items), external validity (3 items),
internal validity–bias (6 items), internal validity–confounding (selection bias; 5
items), and power (1 item). Quality evaluation was independently conducted by two
reviewers, disagreement was resolved by reaching consensus. Interrater reliability was
assessed using Cohen’s kappa analysis on all items of the checklist. Values 0.6 were
defined as substantial, and values 0.8 as almost perfect (Landis & Koch 1977).

The checklist’s total score as well as its subscales were compared with study designs
using a one-way analysis of variance (ANOVA). Bonferroni Correction was used to
control the alpha error in multiple testing. The level of significance was taken as p < 0.05.

3. Results

The database search resulted in a total number of 1448 studies of which 269 were select-
ed as potentially relevant on the basis of their titles. After reviewing the abstracts of these
studies, a total of 31 articles were then assessed by a full-text review and among these,
14 articles fulfilled the inclusion criteria. The manual search of the reference lists of these
studies and previous reviews resulted in further 26 eligible studies. Finally, following the
full text evaluation, 40 articles with a total number of 27,499 patients were included in
the systematic review. The selection process is illustrated in figure 1.

Since design, sample sizes and content of the included studies were very hetero-
geneous, a calculation of a meaningful meta-analysis was not feasible. Studies were
therefore roughly divided in three groups based on the study design and consequent-
ly described based on the study content.

Qualitative studies comprised an average of 22 participants (range = 7–42), con-
trolled studies 1,194 participants (range = 3–8,140), and randomized controlled tri-
als included a mean number of 406 participants (range = 40–1,192). Interventions
in the included studies investigated a broad range of influential factors on health
outcomes and several studies contained more than one factor: the most frequent
topics were how to provide or gather information (n = 22), and to examine the
impact of relationship building (n = 19). About a fifth of the studies (n = 10) inves-
tigated the broad role of communication, including communication with patients or
relatives, and patients’ communication preferences. Four further studies examined
the role of treatment-related emotions.

About half of the studies were conducted longitudinally, with a mean duration of
eight months ranging from 0.5 to 36 months. The most frequently investigated clin-
ical disorders were cancer (n = 10), asthma (n = 8), and diabetes (n = 7).

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Regarding the quality assessment very good inter-rater reliability was found (Co-
hens Kappa = 0.9). The three study types differed significantly regarding the overall
study quality (F(2, 36) = 56.6, p < 0.001): RCTs showed the best overall quality with a mean score of 20.0 (SD = 2.4; range: 17–25), controlled studies had an average score of 14.4 (SD = 3.6; range = 8–21), and qualitative studies had the lowest quality with a mean of 7.1 (SD = 1.1; range = 6–9). For controlled studies the more prob- lematic areas were external validity and internal validity (confounding). For qualita- tive studies all areas appeared to be problematic. For details in the studies’ quality see table 1.

3.1. Relationship building

Several specific interventions to foster the doctor-patient relationship were investi-
gated. Participatory decision making (PCM) led to a better quality of the doctor–pa-

Figure 1: Selection process flow chart

The Influence of Doctor-Patient Communication on Health Outcomes 135

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tient relationship as perceived by the patient (Bieber et al. 2008). Furthermore, pa-
tients rated the physicians’ empathy higher after a specific empathy training, and phy-
sicians showed better abilities to decode the facial expression of emotions (Riess et
al. 2012).

The doctor-patient relationship was not only found to be the highest predictor of
patients’ satisfaction, but also to influence the subjective symptom burden (Little et
al. 2001). A better doctor-patient relationship was further associated with an im-
proved interpersonal exchange and with patient activation (Alexander et al. 2010),
positively influenced adherence (van Ganse et al. 2003), and led to a decrease in
patients’ uncertainty (Kuzari et al. 2013). A warm and empathic atmosphere during
treatments might even increase the placebo response (Kelley et al. 2009).

Regarding the direct influences of the doctor-patient relationship on the health
status contradicting evidence was presented: While Cooper et al. (2011) reported
more positive communication, and Zandbelt et al. (2007) observed improved doc-
tor-patient relationships to be associated with higher patient activation, both studies
found no direct influence on the health status. In contrast Auerbach et al. (2002)
realized a better doctor-patient relationship to be associated with improved disease-
related behavior and a better health status, and Wodskou et al. (2014) reported that
the physicians’ empathy correlated with a better health status of their patients. Fur-
thermore, Parchman et al. (2010) showed that participatory decision making led to
improved patient activation and consequently to better medication adherence and
an enhanced health status. In conclusion, three of five studies reported positive re-
sults (60%) and two studies negative results (40%) concerning the improvement of
health.

3.2. Information provision

Patients described uncertainty about their treatment and disease as a main issue (Ku-
zari et al. 2013). Informational needs were reduced by assessing the patients’ infor-
mation preferences, and fulfilled informational needs resulted in higher patient sat-
isfaction (Thoonen et al. 2002). Better provision of information and patient educa-

Table 1: Overview of Study Quality

RCT Controlled Qualitative p

Total Score (0–25) 20.9 14.3 7.2 < 0.001

Reporting (0–10) 8.3 6.5 4.2 < 0.001

External Validity (0–3) 3.0 1.8 0.8 < 0.001

Internal Validity: Bias (0–6) 4.8 3.7 2.2 < 0.001

Internal Validity: Confounding (0–5) 4.0 1.5 0.0 < 0.001

Power (0–1) 0.9 0.8 0.0 < 0.001

Note. Bonferroni correction was used to adjust p-value in post-hoc analysis.

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tion had a significant impact on the patients’ health status (Bhattacharyya et al. 2010;
Cabana et al. 2006; Casas et al. 2006; Clark et al. 2000; Smith et al. 2008; Sperl-Hillen
et al. 2011; Yilmaz & Akkaya 2002), on compliance (Bhattacharyya et al. 2010; Kostev
et al. 2014; van Ganse et al. 2003), and on quality of life (Aiarzaguena et al. 2007;
Dibbelt et al. 2010; Koff et al. 2009; Mackenzie et al. 2013; Martinez-Moragon et al.
2014). Moreover, better patient education did not result in more time spent with the
patients than usual care in the long run (Clark et al. 2000).

Yet, patients’ in-depth knowledge was sometimes seen as inappropriate, especially
by non-specialized doctors who did not feel comfortable with patients showing a
high level of expertise. These patients were therefore sometimes mistakenly consid-
ered as non-compliant by non-specialist doctors (Snow et al. 2013). Also, providing
more information was not always regarded as being a better approach. Skinner et al.
(2008) for example reported that the more the patients’ knowledge of their illness
increased the less the educators talked. Dibbelt et al. (2010) described that although
physicians showed good capabilities to establish emotional relationships during their
study they still lacked the ability to effectively inform and motivate their patients.

Especially in the field of cancer (Kimberlin et al. 2004; Kuzari et al. 2013; Macken-
zie et al. 2013; Wright et al. 2008) but also for other diseases (Wodskou et al. 2014),
high quality information and education were important for the patients themselves
as well as for their families and caregivers. This was appropriate not only for giving
support and for understanding the patients’ situation, but also for dealing with the
fatal consequences of the disease: Wright et al. (2008) for example described how
end-of-life discussions with advanced cancer patients and their families were able to
have a positive impact on the long-term bereavement adjustment after death.

3.3. Communication

Several studies showed that enhanced physicians’ communication skills can lead to
improved quality of life (Aiarzaguena et al. 2007). Physicians with better communi-
cation skills were more likely to inquire the patients’ concerns, encourage physical
activity and setting goals (Cabana et al. 2006), and were able to offer better emotional
support, which resulted in lower depression scores reported by the patients (Fujimori
et al. 2014). Cals et al. (2009) also found that better communication skills resulted
in less unnecessary prescription of antibiotics.

It was found that open communication was rated as the most important factor in
the patient-physician relationship by the patients (Schmidt et al. 2012) and that poor-
er communication might lead to an underestimation of the disease severity because
patients did not report important lifestyle issues (Moffat et al. 2006). Furthermore,
patient centered communication correlated with better emotional health and fewer
diagnostic tests and referrals (Stewart et al. 2000).

3.4. Enabling treatment-related emotions

Engaging patients in emotional work may not only facilitate coping with severe dis-
eases such as cancer and acceptance thereof, but also enable patients and physicians

The Influence of Doctor-Patient Communication on Health Outcomes 137

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to plan the best supportive care (Back et al. 2014). Specific training was found to
have a positive influence: if physicians were trained to detect psychological distress,
the patients’ anxiety decreased significantly (Girgis et al. 2009).

3.5. Enabling treatment-related behavior

Especially interventions targeting relationship and information provision are intend-
ed to improve the patients’ self-management. The willingness to take an active part
in his/her disease management is a major factor influencing adherence (van Ganse
et al. 2003). The physician’s empathy, good interpersonal exchange, and greater fair-
ness in the treatment process have led to higher levels of patient activation (Alexander
et al. 2012; Hojat et al. 2011), while improved patient activation itself has been asso-
ciated with higher medication adherence (Parchman et al. 2010). Several studies have
shown that appropriate patient education can help patients gain control over com-
plex diseases (Casas et al. 2006; Clark et al. 2000; Smith et al. 2008; Snow et al. 2013;
Sperl-Hillen et al. 2011), to feel more independent from medical advice (Snow et al.
2013), and leads to improved quality of life (Koff et al. 2009).

3.6. Economical evaluations

Two studies also included an economical evaluation: Zhang et al. (2009) reported
that end-of-life discussions with advanced cancer patients led to significantly lower
healthcare costs (950 $) in the last week of life and were associated with a higher
quality of dying. Koff et al. (2009) also found reduced healthcare costs if COPD pa-
tients were offered proactive integrated care compared to usual care, but the effect
was not statistically significant.

4. Discussion

The aim of this study was to investigate the influence of the doctor-patient relation-
ship on objective and subjective health outcomes. In their review Di Blasi et al. (2001)
showed that a modification of patient–practitioner relationships can have positive
effects on the patients’ health status. We followed this approach and conducted a
systematic review of peer-reviewed studies published between 2000 and 2015. The
aim of the study was to investigate high quality studies and to differentiate various
domains of doctor-patient relationship and communication.

4.1. Strengths and limitations

Of the initial 1,500 studies 39 studies fulfilled all inclusion criteria. The results of our
analysis showed convincing effects regarding the influence of the doctor-patient re-
lationship and communication on different objective and subjective parameters of
the patients’ health.

Regarding the rating of the studies’ qualities we had a very high inter-rater accor-
dance. While we found a good study quality across all RCTs and even controlled

The Influence of Doctor-Patient Communication on Health Outcomes 145

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studies, the quality of the included qualitative studies was comparably low. This may
be caused by the quality checklist we used in our study, which was not developed for
qualitative studies. Nevertheless, the included qualitative studies provided important
insights into influential factors for the physician-patient relationship. Not all aspects
of interpersonal relationships can be fully depicted by quantitative measures, which
is why we suggest not to neglect the findings of qualitative studies.

As mentioned, because of the high heterogeneity of intervention types and out-
come variables among the studies a statistical power meta-analysis (e.g., effect-size)
of the extracted data was not possible. An example of the different way of operation-
alization is how the concept of ’patient-doctor relationship’ was assessed in different
studies: while Kimberlin et al. (2004) used focus group interviews to identify aspects
of the doctor-patient relationship, other studies such as Little et al. (2001) or Alex-
ander et al. (2012) used self-administered questionnaires, which sometimes have
been previously validated and sometimes were pragmatically constructed for said
trial. We therefore follow the argument of Di Blasi et al. (2001): the results of a meta-
analysis would have been like comparing apples with oranges. As previously pointed
out by Salmon and Young (2005) and Young et al. (2011), the abundance of ap-
proaches and the lack of unifying theories hamper the comparability and general-
ization of studies in this field. Nevertheless, our systematic review showed a large
variety of studies investigating all kinds of different factors affecting the physician-
patient relationship and its influence on the patients’ health status. Although this did
not allow calculating overall effect sizes, the included studies were able to address
several fundamental topics which are of highest relevance in medicine. As most stud-
ies were longitudinal and covered enough patients to give the results good external
validity, the results may be generalized for other patients and other fields of medicine.

4.2. Different aspects of doctor-patient relationship and communication

Improved provision of information and adequate patient education did not only di-
rectly improve the patients’ health status, but also positively influenced compliance
and quality of life.

Contrary to a commonly expressed opinion, trained physicians did not need more
time in the interaction with their patients to accomplish improved information and
education results. Some studies even showed that the less time educators spent with
talking the better illness knowledge of the patients was observed. In the light of the
numerous positive influences of improved information provision and education on
the patients’ health status, there is sharing evidence how important specific and ap-
propriate communication training is, and not only for aspiring physicians. Dibbelt
et al. (2010) showed that although physicians might have good capabilities to estab-
lish emotional relationships, they often lacked the ability to effectively inform and
motivate patients.

When asked about their preferences, patients clearly rated open communication
as the most important aspect in their patient-physician relationship. Of course open
communication only works in a reliable relationship built on trust. Consequently,

146 D. Riedl, G. Schüßler

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means of relationship building are prerequisites for enabling satisfying education and
information provision. Insufficient relationship building may even have a deterio-
rating effect on health outcomes: Moffat et al. (2006) pointed out how insufficient
communication could even lead to underestimation of the severity of a disease and
therefore maltreatment, because patients did not feel secure enough to report im-
portant lifestyle issues.

Regardless of the unequivocal positive aspects of good patient education, Snow et
al. (2013) pointed out a very important problem in modern medicine: not all phy-
sicians are happy about well-informed patients. Their in-depth knowledge is some-
times even understood as inappropriate and doctors and nurses may get uncomfort-
able with a high level of patients’ expertise. Sometimes these patients are even con-
sidered as non-compliant by non-specialist doctors, because they tend to challenge
treatment decisions more often than less informed patients.

Several studies pointed out that adequate information and education were not
only important for the patients themselves, but also largely helped their families and
caregivers. This is not only true for giving support and for understanding the pa-
tients’ situation, but also for dealing with the fatal consequences of the disease:
Wright et al. (2008) described how end-of-life discussions with advanced cancer pa-
tients and their families had a positive impact on the long-term bereavement adjust-
ment after the patients’ death.

Concluding, our review presents further evidence for the importance of the doc-
tor-patient relationship and communication on different aspects of objective and
subjective health outcomes. Methodological high quality studies warrant further in-
vestigations of the different domains of the doctor-patient relationship.3

Conflict of Interest Disclosure

The authors report no conflict of interests.

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The Influence of Doctor-Patient Communication on Health Outcomes 147

# Acknowledgment: We want to thank Dr. Sylvia Kammerhofer for her active support during our
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Corresponding Author: Univ.-Prof. Dr. Gerhard Schüßler, University Hospital of
Medical Psychology, Medical University of Innsbruck
E-Mail: gerhard.schuessler @tirol-kliniken.at

150 D. Riedl, G. Schüßler

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Chinese Journal of Clinical Psychology Vol.23 No.5 2015

近年来，医患关系日趋恶化和复杂化，医疗纠纷

逐年增多，“医闹”事件频出，暴力伤医事件时有发

生。这些矛盾现象产生的原因是多方面的，其中医

患沟通问题可能是重要原因之一[1]。医学之父希波

克拉底曾说过，医者有“三大法宝”，分别是语言、药

物、手术刀，语言是三者中最重要的，它不仅能改善

医患关系、化解医患矛盾，对某些疾病还有治疗作

用。世界医学教育联合会《福冈宣言》指出：“所有医

生必须学会交流和处理人际关系的技能，缺少共鸣

（共情）应该看作与技术不够一样，是无能力的表

现。”国际医学教育专门委员会公布了《全球医学教

育最低基本要求》，其中“沟通技能”是 7 项最低基本
要求之一[2]。因此，在医学教育中，不仅要传授医学

知识和技术，还要培养医患关系意识和医患沟通技

能[3，4]。

医患沟通是医务人员与患者间就医疗活动相关

问题进行的信息交流和情感交流，既有一般人际沟

通的共同特征，也有其特殊性，与一般交往能力、羞

怯和社交自尊存在内在联系[5]。羞怯指个体在人际

情境（尤其与陌生人交往）中表现出不自在、压抑、行

为笨拙或回避等倾向。研究显示大学生普遍存在羞

怯倾向，且不同程度地影响其人际交往和未来职业

发展，对医学生而言，羞怯会影响其医患沟通行为[6，

7]。社交自尊是个体对自己社交能力和交往状况的

评价和情绪体验，Baumeister 等发现，社交自尊水平
与个体沟通行为效果存在显著相关，高自尊个体更

容易受他人欢迎，更愿意与陌生人沟通[8]，王倩倩等

研究表明社交自尊与羞怯心理显著相关[9]。本研究

对医学实习生的医患沟通行为、社交自尊和羞怯进

行调查，并考查三者间的内在关系，为医学生医患沟

通教育提供科学依据和实践指导。

1 对象与方法

1.1 对象
本研究采取整群抽样的方法，选取某医学院校

医学实习生医患沟通行为与羞怯、社交自尊的关系

国实 1，程灶火 2，刘新民 1，胡鸿 1

（1.皖南医学院人文与管理学院，芜湖 241002；2.无锡市精神卫生中心，无锡 214151）

【摘要】 目的：调查医学实习生医患沟通行为及与羞怯和社交自尊的关系。方法：按整群抽样方法，采用

沟通行为

问卷、羞怯量表和德克萨斯社会行为问卷对临床实习生进行问卷调查，获得有效问卷 607 份。结果：医学实习生沟
通行为得分与羞怯得分呈负相关（-0.189）、与社交自尊呈正相关（0.259）。社交自尊直接影响医患沟通行为（β=
0.217），羞怯通过社交自尊（β=-0.445）间接影响医患沟通行为，可解释的总变异为 7.4%。结论：社交自尊不仅直接
影响实习生的医患沟通行为，且在羞怯与医患沟通行为间起部分中介作用。

【关键词】 医学实习生；医患沟通行为；社交自尊；

羞怯

中图分类号：R395.6 DOI: 10.16128/j.cnki.1005-3611.2015.05.012

Relationship of Doctor-patient Communication with
Shyness and Social Self-esteem in Medical Interns

GUO Shi1, CHENG Zao-huo2, LIU Xin-min1, HU Hong1
1Humanities and Management School of Wannan Medical College, Wuhu 241002, China;

2Wuxi Mental Health Center, Wuxi 214151, China
【Abstract】 Objective: To investigate doctor-patient communication of medical interns and it’s relation with shyness
and social self-esteem. Methods: A total of 607 medical interns who practice more than six months were recruited by clus⁃
ter sampling. They were assessed with Questionnaire of Medical Student’s Communication Behavior of Doctor-Patient, Shy⁃
ness Scale，and Texas Social Behavior Inventory. Results: The communication score was negatively correlated with shyness
scores(-0.189), and positively with social self-esteem(0.259). Social self-esteem directly affected doctor-patient communi⁃
cation(β =0.217), and shyness indirectly affected doctor- patient communication through social self- esteem(β =- 0.445),
which explained 7.4% of total variation. Conclusion: Social self-esteem directly affects the doctor-patient communication,
and play a mediating role between shyness and doctor-patient communication.
【Key words】 Medical interns; Communication behaviors; Social self-esteem; Shyness

【基金项目】 安徽省优秀青年人才基金项目（2011SQRL106）；皖南
医学院校级教学研究项目（2012jyxm39）
通讯作者：程灶火 zaohuocheng@sina.com

··812

中国临床心理学杂志 2015年 第23卷 第5期

临床实习经验超过半年的在读临床专业医学生为研

究对象。共发放问卷 650 份，回收有效、完整问卷共
607 份，有效率为 93.4%。其中男生 340 人，女生 267
人；生源地来自农村 381 人，城镇 226 人；年龄 21-28
岁，平均23.68±0.9岁。
1.2 方法
1.2.1 医学生医患沟通行为量表[10] 医学生医患沟

通行为量表由邓云龙、程全等编制，主要评估医学生

的医患沟通意识和能力，共 48 个条目，分别评估信
息获取、信息告知、非语言交流、沟通意识、病情外关

注、过程掌握和支持关注 7 个领域，采用 Likert 5 点
计分，分数越高，沟通意识和沟通能力越强。

1.2.2 羞怯量表（Shyness Scale）[11] 由Cheek和Buss
编制，既评价社交焦虑，又评价行为抑制，共 13 个条
目，内容涉及个体在社交场合中的情绪体验和行为

表现，采用Likert 5点计分，分数越高，羞怯程度越高。
1.2.3 德克萨斯社会行为问卷[11] 由 Helmreich 和

Stapp 编制，1974 年修改成 A 和 B 两个平行本，用于
评价个体的自我价值感或社交能力，原量表为 32 个
条目，A 和 B 版本均为 16 个条目，采用 Likert 5 点计
分，分值越高，社交自尊越高。

1.3 统计方法
采用 SPSS13.0 统计软件对数据进行录入和分

析。采用描述性分析和 t 检验考查医学实习生的医
患沟通能力、性别差异和城乡差异，用相关分析和回

归分析考查沟通行为与羞怯和社交自尊的关联性和

作用路径。

2 结 果

2.1 医学实习生沟通技能及性别差异和城乡差异
男女生比较结果显示沟通总分和各维度分的性

别差异均无统计学意义（P>0.05）；城镇学生和

农村

学生比较结果显示沟通总分和各维度分的城乡差异

也无统计学意义（P>0.05）。结果见表1。

信息获取

非语言交流

信息告知

沟通意识

病情外关注

过程掌握

支持关注

沟通总分

总体

3.60±0.73
3.35±0.75
3.28±0.82
3.55±0.75
3.23±0.81
3.24±0.78
3.36±0.80

163.4±33.4

男生

3.56±0.78
3.38±0.78
3.34±0.81
3.51±0.79
3.26±0.84
3.28±0.80
3.36±0.82

163.7±35.3

女生

3.65±0.65
3.32±0.72
3.21±0.83
3.59±0.69
3.20±0.78
3.19±0.75
3.35±0.77

163.1±30.8

t值
-1.564
0.931
1.945

-1.275
0.830
1.417
0.142
0.230

农村

3.61±0.70
3.36±0.73
3.30±0.81
3.57±0.73
3.28±0.80
3.28±0.74
3.39±0.77

164.4±32.3

城镇

3.58±0.77
3.35±0.79
3.23±0.85
3.51±0.78
3.15±0.82
3.16±0.83
3.31±0.83

161.7±35.1

t值
0.633
0.070
1.015
0.824
1.942
1.880
1.292
0.971

表1 医学实习生沟通行为得分及性别和城乡差异比较

2.2 医患沟通行为与羞怯、社交自尊的相关分析
实习生羞怯与沟通总分（r=-0.189）和各维度分

（r=-0.123~-0.194）呈负相关（P<0.001），社交自尊与 沟通总分（r= 0.259）和各维度分（r=0.204~0.257）呈 正相关（P<0.001）。结果见表2。

表2 沟通行为得分与羞怯和社交自尊的相关分析

注：*P<0.05，**P<0.01，下同。

2.3 社交自尊在羞怯与沟通行为间的中介效应
采用回归分析考查羞怯和社交自尊、沟通行为

预测作用和作用路径，结果显示：羞怯对沟通行为具

有预测作用（β=-0.189），羞怯对社交自尊具有较强
的预测作用（β=-0.445），考虑两个变量对沟通行为
的联合影响时，羞怯（β=-0.093）的直接作用明显减
弱，而社交自尊（β=0.217）具有显著的预测作用，可
解释的总变异仅为7.4%。结果见表3。

表3 社交自尊在医学实习生羞怯与沟通行为间的中介效应

3 讨 论

本次研究医学生临床实习都在半年以上，即将

毕业从事临床工作，他们通过实习认识到医患关系

和医患沟通的重要性，具有主动沟通的意识，同时能

把学到的医学知识用于临床实践，能够通过沟通获

信息获取

非言语交流

信息告知
沟通意识
病情外关注
过程掌握
支持关注
沟通总分
羞怯

-0.186**
-0.178**
-0.123**
-0.174**
-0.159**
-0.194**
-0.192**
-0.189**

社交自尊

0.249**
0.240**
0.223**
0.257**
0.214**
0.204**
0.221**
0.259**

第一步

第二步

第三步

被

预测变量

沟通行为
社交自尊
沟通行为
预测变量
羞怯
羞怯
羞怯
社交自尊

β
-0.189
-0.445
-0.093
0.217

t值
-4.741**

-12.208**
-2.119*
4.973**

R2

0.036
0.198
0.074

F
22.480**

149.037**
24.046**

··813

Chinese Journal of Clinical Psychology Vol.23 No.5 2015

取患者的基本病情及就诊原因等信息，接诊时比较

有信心，已经具备相应的初步接诊能力。但本研究

也发现他们在病情外关注、过程掌握等方面自认为

做得不够好，不能与患者进行有效沟通。这可能与

目前医患关系紧张、医疗纠纷和医闹事件频发有关，

也与医学院校在课程设置上对医患沟通重视不够、

未能系统地教授医患沟通技巧有关[12]，加之现在的

医学生多数为独生子女和实践经验不足，不能设身

处地理解患者、面对复杂局面缺乏掌控能力。

医患沟通是一项特殊人际交往技能，它不是与

生俱来的, 需将一般人际交往技能、心理学知识和医
学知识融为一体，后天学习和实践可以不断提高该

技能。有研究表明科学设置《医患沟通》教学可提高

医学生的医患沟通能力[13]。除医学知识和心理知识

外，个体一般社交技能、社交自尊和羞怯等也会影响

医患沟通效果。本研究发现医学实习生医患沟通行

为与羞怯呈负相关，提示羞怯水平高的医学生与患

者或家属沟通交流时可能会产生焦虑、沟通行为受

到抑制。其次发现医学生医患沟通行为与社交自尊

呈正相关，提示低社交自尊个体对自己沟通能力和

行为缺乏自信，回避医患沟通，或者在医患沟通中避

重就轻，不能达到有效沟通。另外，本研究发现社交

自尊直接影响医患沟通行为，并在羞怯与医患沟通

行为之间起部分中介作用。

在医学教育中，不仅要重视医学知识教育，还要

加强医学心理学知识教育和医患沟通技能培训。针

对高水平羞怯、低社交自尊的医学生进行团体心理

辅导，提高医学生自我认知的能力，自信地、设身处

地理解患者、服务患者[14]。改变传统培养模式，加强

医患沟通技能培训，如增加医学生与患者接触的时

间，在医疗实践中培养与患者沟通的能力[15]；以问题

为基础的医患沟通教学可以在医患沟通能力的培养

方面起到积极作用[16]。

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(收稿日期:2015-03-08)

··814

Quality of doctor–patient communication through
the eyes of the patient: variation according
to the patient’s educational level

Karolien Aelbrecht • Michela Rimondini • Jozien Bensing •

Francesca Moretti • Sara Willems • Mariangela Mazzi •

Ian Fletcher • Myriam Deveugele

Received: 3 February 2014 / Accepted: 12 November 2014 / Published online: 27 November 2014
! Springer Science+Business Media Dordrecht 2014

Abstract Good doctor–patient communication may lead to better compliance, higher
patient satisfaction, and finally, better health. Although the social variance in how phy-
sicians and patients communicate is clearly demonstrated, little is known about what
patients with different educational attainments actually prefer in doctor–patient commu-
nication. In this study we describe patients’ perspective in doctor–patient communication
according to their educational level, and to what extent these perspectives lean towards the
expert opinion on doctor–patient communication. In a multi-center study (Belgium, The
Netherlands, UK and Italy), focus group discussions were organised using videotaped
medical consultations. A mixed methods approach was used to analyse the data. Firstly, a
difference in perspective in communication style was found between the lower educated
participants versus the middle and higher educated participants. Secondly, lower educated
participants referred positively most to aspects related to the affective/emotional area of
the medical consultation, followed by the task-oriented/problem-focused area. Middle and
higher educated participants positively referred most to the task-oriented/problem-focused
area. The competency of the physician was an important category of communication for all
participants, independent of social background. The results indicate that the preferences of
lower educated participants lean more towards the expert opinion in doctor–patient

K. Aelbrecht (&) ! S. Willems ! M. Deveugele
Faculty of Medicine and Health Sciences, Department of Family Medicine and Primary Health Care,
Ghent University Hospital – 6K3, De Pintelaan 185, 9000 Ghent, Belgium
e-mail: karolien.aelbrecht@ugent.be

M. Rimondini ! F. Moretti ! M. Mazzi
Department of Public Health and Community Medicine, University of Verona, Verona, Italy

J. Bensing
Netherlands Institute for Health Services Research, NIVEL, Utrecht, The Netherlands

J. Bensing
Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands

I. Fletcher
Health Sciences Research, Lancaster University, Lancaster, UK

123

Adv in Health Sci Educ (2015) 20:873–884
DOI 10.1007/s10459-014-9569-6

communication than the middle and higher educated participants. Patients’ educational
level seems to influence their perspective on communication style and should be taken into
account by physicians. Further quantitative research is needed to confirm these results.

Keywords Communication ! Doctor–patient communication ! Educational level !
Patients’ perspective ! Quality

Introduction

Equity in health care is a major issue in the health policy debate. The central principle of
the concept is equal access, treatment, and treatment outcomes for people in equal need
(Whitehead et al. 2001). It refers to the fact that personal variables (e.g. age) and social
variables (e.g. income) should not dictate that people with similar needs for health care
enter through different doors (public vs. private providers), are treated differently in terms
of the type or intensity of services provided, are more or less involved in treatment
decisions, or receive more or less information (Aday et al. 1999). Yet, research shows that
doctor–patient communication tends to differ according to the educational background of
the patient. Patients with a lower educational background are significantly less involved in
treatment decisions, are approached in a more directive way during the consultation, and
are less frequently asked to take responsibility for care than patients with a higher edu-
cation (Verlinde et al. 2012).

This social variance in doctor–patient communication seems to indicate that there is
inequity in communication in health care. For example, doctors might be less informative
with less educated and lower income patients, because they assume that these patients are
not particularly interested in learning about their health or do not understand this infor-
mation (Williams et al. 2010; Cerin and Leslie 2008; Baron-Epel et al. 2007; Starfield
2006; Street 1991; Waitzkin 1985). Yet, even though physicians often ground their
behaviour on these perceptions, it is not clear to what extent these perceptions are in
accordance with patients’ needs and preferences.

Studies exploring the patient side of communication merely focus on describing
patients’ actual behaviour. They report that patients from lower social classes are less
likely to ask questions and exhibit their opinions. They also react with less affect and take
less initiative to increase their participation in the decision making process (Verlinde et al.
2012; Longtin et al. 2010; Smith et al. 2009; Bernheim et al. 2008). However, not all
studies confirm these findings; a study conducted by Street did not find a relation between
the frequency of the patients asking questions and his/her educational background (Street
1991). Furthermore, no studies have reported on social differences in patients’ expectations
regarding doctor–patient communication.

More and more, medical students are receiving communication skills training throughout
their medical studies. The content of the training courses, however, is usually derived from
psychological theories and determined by professional experts (e.g. doctors, psychologists,
and nurses) (von Fragstein et al. 2008; Kinderman and Humphris 1995), and patients are
seldom involved in the development of these courses or in the development of clinical
guidelines (Boivin et al. 2010). Moreover, several studies show a low correlation between
patients’ and professionals’ quality assessments, underlining the need for a more direct
approach to tapping patients’ views about the quality of doctor–patient communication

874 K. Aelbrecht et al.

123

(Mazor et al. 2005; Greco et al. 2002; Rothman and Cusimano 2000). Therefore, a multi-
center study was set up in Belgium, the Netherlands, UK, and Italy.

The objective of this study is twofold. First, to analyse whether there is a difference in
the kind of topics participants address when talking about doctors’ communication style
according to their educational level, and to describe these differences, if any. Second, to
examine which participants lean most towards an expert opinion on doctor–patient
communication.

Methods

Background

Data were derived from the GULiVER project, an international, multi-center study in
Belgium (Ghent University), the Netherlands (Utrecht University), United Kingdom
(University of Liverpool), and Italy (University of Verona).

A study design using focus group discussions (FGDs) was adopted. In all four countries
the same procedures were followed according to a detailed protocol, pretested with three
pilot panels. The detailed protocol of the GULiVER study is described in a related paper
(Moretti et al. 2012).

Ethical approval to use the recordings in this study was given by the University of
Liverpool.

Recruitment of participants

To recruit the participants, the research teams applied stratified sampling according to age
(18–30; 31–49; C50) and gender (separate male and female panels). Inclusion criteria were
(a) age over 18 years; (b) at least one GP-visit over the last 12 months; (c) speaking one of
the country’s official languages; and (d) not being involved in a medical lawsuit or formal
complaint with a care provider during the last 2 years. The participants were approached in
a context not related to any medical consultation (e.g. in shopping malls, railway stations,
and market places).

Measurement instruments and data collection procedure

To collect the data, thirty-five data collection sessions were organised: nine in Italy, the
Netherlands, and United Kingdom, and eight in Belgium. In each session 6–9 participants
were included. During these sessions (all lasting around 6 h) different data collection
methods were used. The resulting heterogeneity in the data was intended to generate a
comprehensive view of the participants’ perspectives.

Firstly, the participants filled out a questionnaire on socio-demographic characteristics
including age, gender, and educational level. The latter was based on the highest educa-
tional attainment of the participant and was categorised in three categories: low (no
education or primary school), middle (secondary school), and high (higher education)
educational level.

Then, video-recorded medical consultations were presented. Two sets of four stand-
ardised recordings were used: one set on vaginal discharge after unprotected sex and one
set on severe menstrual pain. Both scenarios referred to clinical problems that can be

Quality of doctor–patient communication through the eyes of the patient 87

5

123

associated with high levels of emotional distress. These recordings were made as part of
the summative fourth year OSCE’s (Objective Structured Clinical Examination; i.e.
medical consultation with a simulated patient) at the Liverpool Medical School to assess
the competency of the medical students’ communication skills in a primary health care
setting. Four video recordings were selected per scenario: one with high ratings from both
examiner (E) and simulated patient (SP), one with a high rate from the examiner and a low
rate from the simulated patient, one with a low rate from the examiner and a high rate from
the simulated patient, and one with a low rate from both the examiner and the simulated
patient. The recordings were dubbed (Italy) or subtitled (Belgium and the Netherlands).
After watching the recordings, each participant was asked to rank them from 1 to 4: ‘‘1’’
being the recording of the consultation done by their most preferred doctor to ‘‘4’’ being
the recording of the consultation performed by their least preferred doctor.

Next, the participants participated in a focus group discussion. Participants were invited
to share their views on the doctors’ performance, and the underlying reasons for their
choices were explored. Because they were not directly involved in the consultations, the
participants could freely judge and comment on the student doctors’ communicative
performance, while still representing a patient perspective. After an hour, the discussion—
if it had not already ended—was summarised and closed.

All focus group discussions were moderated by a native speaker trained in the method
of focus group discussions. The discussions were audiotaped and fully transcribed ver-
batim, including information on the identity of the participant speaking. In order to make
the transcripts accessible to researchers in all four countries, they were translated into
English. Because of privacy issues all references to names (e.g. the participants’ name,
names of children, and doctors) were replaced by anonymous numbers.

Data coding

The four research teams coded one or two transcripts independently. To do so, the prin-
ciples of the framework approach, in which the pre-defined questions and objectives are
used as boundaries for the coding, were applied (Mazzi et al. 2013; Moretti et al. 2011).
Subsequently, codes were compared and differences in coding were discussed in order to
develop a common understanding of all codes. This classification system was then used to
code the transcripts of all the remaining focus group discussions.

The applied coding scheme was divided into six areas of communication of which three
will be discussed in this article—i.e. process-oriented area (i.e. all the comments about the
way a doctor is handling the process of the conversation), task-oriented/problem-focused
area (i.e. all the comments about the overall attitude of the doctor regarding the instru-
mental tasks during the conversation) and affective/emotional area (i.e. all the comments
about the overall attitude of the doctor regarding the affective/emotional components)—,
12 main categories, and 41 subcategories (Moretti et al. 2011). For more detailed infor-
mation about the scheme see Table 1 of Appendix.

Statistical analyses

A total of 7,067 quotes were coded, but 1,598 quotes were excluded from the analyses
because these were not related to the topic of the study (i.e. small talk, e.g. someone asking
for more coffee). The codes were inserted in the statistical software program SPSS (version
20.0.0, IBM) and linked with the information of the participant who was talking.

876 K. Aelbrecht et al.

123

First, the number of utterances according one’s educational level was calculated and
tested using one-way ANOVA. Further, to answer the first research question, a Chi squared
test of independence with adjusted residual analysis was used (Agresti 2002). For the
second research question, the videotaped consultations with a high expert assessment (i.e.
high E-high SP and high E-low SP) were merged and a generalised estimating equation
approach was used to provide a practical method with good statistical properties to model
data that exhibit association, but cannot be modelled as multivariate normal (Johnston and
Stokes 1999).

Results

Participant characteristics

A total of 259 lay people participated in the GULiVER study. UK data were excluded for
this article because reliable information on the educational level of the participants was
missing. As a result, for this paper, the data of 178 participants were analysed: 59 par-
ticipants in the Netherlands, 71 in Italy, and 48 in Belgium.

The sample included 79 male and 99 female participants, all between 18 and 71 years
old. There were 31 participants with a lower educational level, 73 participants with a
middle, and 74 participants with a higher educational level included (see Table 2 of
Appendix).

Discussed topics by educational level

Lower educated participants talked significantly less during the focus group discussions
than middle and higher educated participants: a mean of 15 quotes per lower educated
participant, a mean of 17 quotes per middle educated and a mean of 20 quotes per higher
educated participants. Consequently, lower educated participants were talking for 14 % of
the duration of the discussion, middle educated participants for 40 % of the duration, and
higher educated participants for 46 % of the duration. This was found statistically sig-
nificant as determined by one-way ANOVA (F(2, 3165) = 12.233, p = 0.000).

When asking participants about their perspective in doctor–patient communication
(‘‘Why do you prefer this doctor?’’), lower educated participants mostly referred to the
affective/emotional area of communication (41.1 % of the quotes expressed by this group;
187/454 quotes), followed by the task-oriented/problem-focused area of communication
(40.9 %; 186/454). Only 17.8 % of the quotes (81/454) referred to the process-oriented
area of communication. For the middle and the higher educated participants, the task-
oriented area was most frequently referred to (middle: 40.9 %; 515/1,259; high: 41.8 %;
609/1,455). The affective/emotional area came second (middle: 35.1 %; 443/1,259; high:
30.9 %; 450/1,455), and this group referred to the process-oriented area the least (middle:
23.9 %; 301/1,259; high: 27.2 %; 396/1,455). This was found statistically significant for
the task-oriented/problem-focused area and the affective/emotional area as determined by
Pearson’s Chi square test, respectively v2(6) = 14.9786, p = 0.020 and v2(14) = 84.8600,
p = 0.000.

When looking within the areas, we found an effect of the patient’s educational level in
four categories. Within the process-oriented area, the category ‘‘structuring’’ was statisti-
cally significant, with v2 (6) = 39.9304, p = 0.000, while in the task-oriented/problem-

Quality of doctor–patient communication through the eyes of the patient 87

7

123

focused area, the categories ‘‘attitude of the doctor’’ and ‘‘collecting information’’ were
statistically significant, with v2 (10) = 19.9900, p = 0.029 and v2 (6) = 14.7640,
p = 0.022, respectively. Finally, within the affective/emotional area, the category ‘‘attitude
of the doctor’’ was statistically significant, with v2 (14) = 84.8600, p = 0.000. Higher
educated participants referred significantly more to these four categories.

When looking within these four significant categories, we found differences between the
subcategories. Within the category ‘‘structuring’’, lower educated participants refer more to
‘‘time issues’’ than middle and higher educated participants, while middle educated par-
ticipants refer more to ‘‘opening or closing of the interview’’. Within the category ‘‘attitude
of the doctor’’ in the task-oriented/problem-focused area, lower educated participants refer
more to the subcategories ‘‘business-like/to the point’’, ‘‘other/general’’, and ‘‘competency
(of the doctor)’’ than middle and higher educated participants. The subcategory ‘‘self-
confident’’ is often referred to by the middle educated participants. Within the category
‘‘collecting information’’, lower educated participants refer more to the subcategories
‘‘medical’’ and ‘‘bio-psychosocial’’ than middle and higher educated participants. Within
the category ‘‘attitude of the doctor’’ in the affective/emotional area, lower educated
participants refer more to the subcategories ‘‘inviting attitude (of the doctor)’’, ‘‘showing
interest in the patient/commitment’’, ‘‘facilitating’’ and ‘‘listening’’ than middle and higher
educated participants. Both lower and middle educated participants refer significantly more
to ‘‘pleasant attitude (of the doctor)’’ than higher educated participants. The subcategories
‘‘empathic (attitude of the doctor)’’ and ‘‘reassurance/trust (in the doctor)’’ were often
referred to by the middle educated participants.

The expert opinion versus layman’s opinion on good doctor–patient communication

Participants with a lower educational level preferred the doctors who received a high score
by the experts (i.e. examiner/expert), significantly more than the middle and higher edu-
cated participants. The odds of choosing the expert opinion on good doctor–patient
communication is 1.443 times higher for participants with a lower educational level than
for participants with a secondary diploma (95 % CI 1.030–2.021).

No significant effect was found for the higher educated participants, meaning they do
not have a specific preference.

Discussion

This study shows that lower educated participants expressed their perspectives during the
focus group discussions significantly less than middle and higher educated participants.
Moreover, participants’ perspective on doctor–patient communication differ according to
the participant’s educational level. Lower educated participants emphasised the emotional
and task-oriented/problem-focused area more, while for the middle and higher educated
people the emotional area came second, after the task-oriented/problem-focused area. For
all participants, the process-oriented area was least referred to. The differences in partic-
ipants’ education were found statistically significant. Furthermore, we saw that participants
with a lower educational level preferred the expert opinion on doctor–patient communi-
cation significantly more than the middle and higher educated participants.

First, we found that lower educated participants talked less during the focus group
discussions. Willems et al. (2004) described how these patients often find themselves in a
vicious circle, where their more passive behaviour in a consultation elicits a less-involved

878 K. Aelbrecht et al.

123

behaviour from the doctor. This is not a new result. Lower participation from lower
educated people was also found in other studies (Galea and Tracy 2007; Moorman et al.
1999). It means that the voices of lower educated people are less heard in focus group
studies. However, focus groups discussions are meant to be used to encourage participants
to explore specific issues and attitudes. As stated by Kitzinger in 1994: ‘‘Tapping into such
interpersonal communication is also important because this can highlight (sub)cultural
values or group norms. It also makes them useful in studies examining why different
sections of the population make differential use of health services.’’ Our finding that
participants with low educational levels are less talkative in focus group discussions means
that in studies which are seeking for differential opinions and experiences, special effort is
needed to give these people a voice, either by organising homogeneous groups of people
with the same educational levels, or by targeted invitations by the moderator in hetero-
geneous focus groups.

Lower educated participants seem to attach the most importance to the subcategories
‘‘inviting attitude (of the doctor)’’, ‘‘pleasant attitude (of the doctor)’’, ‘‘showing interest in
the patient/commitment’’, ‘‘facilitating’’, ‘‘listening’’, ‘‘(being) business-like/to the point’’,
‘‘competency (of the doctor)’’, ‘‘collecting medical and bio-psychosocial information (by
the doctor)’’, and ‘‘time issues’’. Participants with a lower educational level also lean more
towards the expert opinion on doctor–patient communication than the middle and higher
educated participants. This is in accordance with the general educational guidelines of
what is generally considered as good doctor–patient communication: doctors need to be
competent, have to know their job, while adopting a patient-centered style (Roter and Hall
2006). At the same time, this result contrasts with what physicians tend to do, namely using
a more dominant communication style when dealing with patients from lower educational
backgrounds (Verlinde et al. 2012; Smith et al. 2009; Kelly-Irving et al. 2009). This means
that doctors often adapt their communication style based only on ingrained prejudices, and
therefore, in the opposite direction.

Moreover, while the lower educated participants described the affective/emotional area
and the invitation of the doctor to participate in the consultation as most important, the
middle and higher educated participants indicated the task-oriented/problem-focused area
as most important. Looking in particular to the middle educated participants, we saw that
they attach the most importance to the subcategories ‘‘opening or closing of the interview’’,
‘‘self-confident (attitude of the doctor)’’, ‘‘pleasant attitude (of the doctor)’’, ‘‘empathic
(attitude of the doctor)’’ and ‘‘reassurance/trust (in the doctor)’’. A possible explanation
could be that the field of affective communication is perhaps the field where lower edu-
cated people feel competent enough to make comments, and feel less secure when more
medical issues arise. Also, people with a higher educational background are perhaps more
aware of the ways in which doctors give direction to a consultation and have more to say
about this.

It appears that the specific needs of the lower, middle, and higher educated participants in
a medical consultation occur on different levels. While lower educated participants explicitly
ask to be invited to take part in a consultation, other elements of a consultation, in particular
about the attitude of the doctor towards the patient, seem to be more important for middle
educated participants. It is possible that the middle educated are asked to take part in the
consultation, and as a result attach more importance to other elements that are perhaps
missing for them in a consultation. None of the subcategories stood out for the higher
educated participants, probably because their expectations were met (Fiscella et al. 2002).

Looking at the concept of shared decision making, McKinstry (2000) found that a lower
educational level was associated with a lower preference for the shared approach. However,

Quality of doctor–patient communication through the eyes of the patient 879

123

it was not found to be an independent predictor and, moreover, specific minorities within
each group had opposite views than the rest. And yet, this is what we often see in practice,
where some physicians assume that they know the patient’s preference, and act on this
without first explicitly testing this assumption. Moreover, both patient and physician have to
be willing to share the process. And as described by Charles et al. (1997), ‘‘It takes at least
two to tango’’ for shared decision making to occur in a medical consultation.

This study has important strengths and limitations. The GULiVER study is one of the few
to research the perspectives of lay people regarding doctor–patient communication. The
importance of this type of research was strengthened by Frenk et al. (2010): ‘‘Health is about
people; thus the core driving purpose of professional education must be to enhance the
performance of health systems for meeting the needs of patients and populations in an
equitable and efficient manner.’’ Furthermore, it is done on a large scale, in four different
countries, applying a strict and well thought out method to ensure the validity of the results as
much as possible. Because of the explicit use of group interaction, focus group discussion is a
widely used technique to explore people’s experiences and perspectives (Kitzinger 1994).

The use of the OSCE’s to record the recordings can be criticised since recordings from
this setting do not necessarily resemble the natural variance observed in everyday medical
practices. However, for the aim of this study, namely to compare lay people’s opinions, we
needed to show all participants the same set of (standardised) recordings, and this could
easily be achieved by using the OSCE stations (Moretti et al. 2012). Also, the use of only
gynaecological scenarios might have been a bias in this study. These specific scenarios
containing levels of emotional distress were used in order to be able to assess the medical
students’ communication skills. Furthermore, in selecting the participants, we stratified on
age and gender, but not on education. While aiming for homogeneity is usually recom-
mended for each group, bringing together a diverse group can maximise exploration of
different perspectives within a group setting (Kitzinger 1994). Taking this advantage and
the research aim into account, we mixed the focus groups in terms of educational back-
ground of the participants. Nevertheless, the results concerning lower educated participants
being less expressive can call this decision into question. Finally, another important lim-
itation for this study is the limited number of included participants; this was due to the
exclusion of the British data.

Conclusion

Patients’ educational level seems to influence their perspective on communication style.
Patients from different educational backgrounds have different needs in consultations, in
particular with regard to doctor–patient communication. However, instead of behaving like
most patients want, doctors must be aware of these specific differences in needs, and take
them into account during consultations. Further quantitative research is needed to confirm
these results.

Acknowledgments We would like to thank all the participants for their significant contribution to the
study. Also, we would like to thank the other members of the GULiVER study, as well as the moderators of
the focus groups for their committed participation in the study.

Appendix

See Tables 1 and 2.

880 K. Aelbrecht et al.

123

T
a
b
le

1
N
u
m
b
er

o
f
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m
es

p
ar
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in
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p
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m
m
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(a
cc
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al

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)

A
re
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C
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(n
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Quality of doctor–patient communication through the eyes of the patient 881

123

T
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882 K. Aelbrecht et al.

123

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884 K. Aelbrecht et al.

123

RESEARCH ARTICLE Open Access

Instrumental and socioemotional communications
in doctor-patient interactions in urban and rural
clinics
Kristen Desjarlais-deKlerk* and Jean E Wallace

Abstract

Background: Location of practice, such as working in a rural or urban clinic, may influence how physicians
communicate with their patients. This exploratory pilot study examines the communication styles used during
doctor-patient interactions in urban and rural family practice settings in Western Canada.

Methods: We analyzed observation and interview data from four physicians practicing in these different locations.
Using a grounded theory approach, communications were categorized as either instrumental or socioemotional.
Instrumental communication refers to “cure-oriented interactions” and tends to be more task-oriented focusing on
the patient’s health concerns and reason for the appointment. In contrast, socioemotional communication refers to
more “care-oriented interactions” that may make the patient feel comfortable, relieve patient anxiety and build a
trusting relationship.

Results: The physicians in small, rural towns appear to know their patients and their families on a more personal
level and outside of their office, and engage in more socioemotional communications compared to those
practicing in suburban clinics in a large urban centre. Knowing patients outside the clinic seems to change the
nature of the doctor-patient interaction, and, in turn, the doctor-patient relationship itself. Interactions between
urban doctors and their patients had a mixture of instrumental and socioemotional communications, while
interactions between rural doctors and their patients tended to be highly interpersonal, often involving
considerable socioemotional communication and relationship-building.

Conclusions: Despite the different ways that doctors and patients communicate with each other in the two
settings, rural and urban doctors spend approximately the same amount of time with their patients. Thus, greater
use of socioemotional communication by rural doctors, which may ease patient anxiety and increase patient trust,
did not appear to add extra time to the patient visit. Research suggests that socioemotional communication may
ultimately lead to better patient outcomes, which implies that health differences between rural and urban settings
could be linked to differences in doctor-patient communication styles.

Keywords: Physicians, Family practice, Rural clinics, Urban clinics, Patient-physician communication,
Patient-physician interaction

* Correspondence: kdesjarl@ucalgary.ca
Department of Sociology, University of Calgary, 2500 University Drive NW,
Calgary, AB T2N 1N4, Canada

© 2013 Desjarlais-deKlerk and Wallace; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms
of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

Desjarlais-deKlerk and Wallace BMC Health Services Research 2013, 13:261
http://www.biomedcentral.com/1472-6963/13/261

Background
Examining doctor-patient interactions is important for
understanding the relationships between doctors and their
patients and how this affects patient health outcomes [1-7].
However, little if any attention has been given to the ways
in which doctor-patient relationships may vary across
different practices and different locales. While the basic
script may remain the same [7-12], the nature and type of
communications and interactions between doctor and
patient may differ across practice locations, such as urban
and rural settings. If doctors and patients interact differently
in urban and rural settings, then patient care and ultimately
patient health outcomes could differ as a result.
Research has shown that communication, as an inter-

actional process involving both doctors and patients, is
key to understanding the quality of care patients receive
[1,2,5-7,13]. Communicating and exchanging information
are key to diagnosis and treatment [3,14-17]. It is also
essential in building a trusting relationship between doctor
and patient that encourages better information-giving
from patients and better information-getting from
doctors, both of which are particularly important when
doctors have limited amounts of time with their patients
[15,16,18,19]. Furthermore, communication and trust
may influence patient satisfaction with care, patient
compliance, how patients cope with their health concerns,
and potentially patient health outcomes [3,6,14,20].
This paper explores whether doctor-patient communica-

tions differ across rural and urban family clinics. Based on
observation and interview data with two family physicians
from each setting, we illustrate subtle but important
differences in doctor-patient interactions in rural and
urban clinics.

Methods
This is an exploratory pilot study using interview and
observation data from four physicians working in either
rural or urban family clinics. These four participants were
part of a larger study on physician wellness that included
direct observations and interviews with 42 physicians work-
ing in a single health region in Western Canada. The health
region includes a major urban centre of approximately one
million residents and its surrounding areas. The four
physicians were purposefully selected to represent typical
“information-rich cases” [21], which allows us to study the
communication patterns of rural and urban doctors and
their patients in greater depth and detail. The two rural
physicians were selected for this analysis because they were
the only rural family doctors in the larger sample, while the
two urban physicians were selected because they were the
most information-rich relevant cases. Prior to this research
project, none of the physicians had any relationship with
the second author, who is a female professor of sociology,
and who carried out the interviews and observations.

First, the physicians were interviewed at their place of
work. The interviews consisted of mostly open-ended
questions where physicians were asked to describe their
work and non-work experiences, sources of satisfaction
and stress, coping strategies, and provide demographic
and practice information. The interviews ranged in
length from approximately 20 to 40 minutes, averaging
about half an hour in duration. The interviews were
face-to-face and digitally recorded. At the end of the
interview, a time was scheduled for a half-day of direct
observations, or job shadows, with each physician. While
the purpose of the observations was to observe physicians
during their typical workday, this paper focuses on the
communication styles utilized by physicians during these
observations. Their daily activities and patient interactions
are often so familiar and taken for granted that it makes it
difficult for them to identify, describe or explain them in an
interview or questionnaire. The researcher, as an outsider
to the medical profession, entered the settings with no
preconceived notions of what to observe, but rather with
the intent to explore and describe the experiences of
practicing medicine. The observer was a non-participant
during the doctor-patient encounters. Observation notes
were recorded into an electronic tablet that were then
edited and transcribed immediately following the job
shadow. Observations lasted from approximately 3½ to five
hours in duration. The field notes and other information
were not presented to the participants for comments.
Written informed consent was given before interviews

and observations were completed and all study participants
knew their participation was voluntary and they could
withdraw at any time. In order to protect the anonymity of
the participants, pseudonyms have been used. The two
urban doctors have been re-named as Dr. Jim Barrett and
Dr. Mary Cummings, and the two rural doctors have been
re-named as Dr. Alan Jones and Dr. Colleen Walker. Ethics
approval for this study was obtained from the Conjoint
Health Research Ethics Board of the University of Calgary’s
Faculty of Medicine.

Participants and clinics
The two urban doctors, Dr. Jim Barrett and Dr. Mary
Cummings (pseudonyms), have practiced medicine for
about twenty years. They worked in family clinics located
in “strip” malls in middle/upper class neighbourhoods that
primarily consisted of single family homes. In addition to
the clinics, these neighbourhood malls also contained other
small businesses, such as a convenience store and gas
station, dry cleaner, restaurant, and hair salon. Patients
attending these clinics had appointments scheduled in
advance and usually had seen the physician previously.
Many of the patients lived in the surrounding community
where the clinic was located. The observed appointments
involved such activities as refilling prescriptions, baby

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checks, reviewing test results (e.g., ultrasound, bloodwork),
follow-ups for pre-existing conditions (e.g., rash, wart,
blood pressure, blot clots, fibromyalgia), referrals, and
physical exams. The average length of patient visits
was approximately 11 minutes, although they varied
significantly ranging from 4 to 20 minutes.
Both rural physicians, Dr. Alan Jones and Dr. Colleen

Walker (pseudonyms), have practiced medicine for
eighteen and twenty-two years respectively, and were
both working in group family practices. The rural family
clinics were located in two small towns – one with a
population of less than 2,000 and the other less than
10,000. The primary industries in these communities are
agriculture and natural resources. Patients booked their
appointments in advance and often included several
family members (e.g., spouses, parents or children). The
rural physicians seemed to see their patients quite regu-
larly and if a non-urgent health concern was raised on
the way out, the doctor often said they could talk about
it next time. The health concerns presented to these
rural physicians included referrals, prescription refills,
reviewing test results (e.g., MRIs, blood work, biopsies),
taking biopsies and conducting physical exams. The
visits averaged approximately 12 to 13 minutes in dur-
ation, although some were as short as 3 minutes and
others as long as 30 minutes.

Data analysis
Utilizing a grounded theory approach [22], and a line
by-line-coding strategy exercised by one coder, the first
author, a doctoral candidate with graduate training in
grounded theory, several themes emerged from the ob-
servation data until saturation was reached and nothing
new emerged. The themes indicated different types of
interactions displayed between doctors and patients.
These themes were also detected in the interview data.
After the themes were identified, bearing in mind that
“all is data”, the authors searched the literature for more
information on doctor-patient communication styles,
which further informed the conceptual labels developed
and used in this paper (Glaser, 2001 [23]: 145).

Results
Analysis of the observation and interview data yielded two
different patterns of interactions between doctors and
patients that were consistent with ones previously identified
in the literature. Specifically, these included instrumental
communication and socioemotional communication [3,5].
Instrumental communication refers to “cure-oriented
interactions” [2] where the doctor and patient discuss
the health concerns or reason for the appointment
and share information that is directly related to the
patient’s physical health [3]. It involves information giving
and question asking by both patient and physician with the

primary goal of treating the patient’s illness and health con-
cerns [5,6]. The content of instrumental communication
often includes the physician asking about symptoms,
recording information in the patient’s chart, explaining tests
or illnesses, and prescribing and explaining medications.
Socioemotional communication refers to “care-oriented
interactions” [2] that have the primary goals of making the
patient feel comfortable, relieving patient anxiety and
building a trusting relationship [3,5]. It may involve
positive talk where the physician expresses friendliness, em-
pathy, sympathy, concern, reassurance and partnership
building. The specific elements of socioemotional commu-
nication may include greeting the patient in a friendly way,
addressing the patient by name, engaging in small talk,
being friendly, and listening attentively. Three specific types
of interactions were central to the socioemotional commu-
nications observed in this study: the use of informal
pleasantries, the use of humour and active relationship
building. Informal pleasantries often occurred at the begin-
ning of the interaction and refers to casual communication
that the doctor and patient engage in without any advanced
knowledge of each other, such as discussing the weather or
a recent sporting event. Humour during the interaction was
also observed and involves sarcasm, teasing and joking
from either the doctor or the patient. Laughing and making
jokes has been identified as a necessary ingredient of good
inter-personal relationships between doctors and patients
[3]. Relationship-building refers to communication involv-
ing any personal talk about the patient’s and/or physician’s
life outside the medical office and their roles in it. Table 1
provides examples of instrumental and socioemotional
communication observed in the four cases examined
in this study.

Urban doctors
The urban doctors, Dr. Jim Barrett and Dr. Mary
Cummings, displayed socioemotional communication
with some of their patients, but at least half of the
appointments were purely instrumental in nature. An
appointment was considered “strictly instrumental”
when both the physician and patient only discussed
the medical reason for the visit without engaging in
other more personal, non-medical communications.
That is, these appointments involved discussion of the
patients’ ailments and potential treatment without any
socioemotional communications such as informal pleasant-
ries, humour, or relationship-building. For example, 12 of
the 18 patient visits observed for Jim and 13 of the 19 visits
observed for Mary were strictly instrumental in that they
did not engage in any socioemotional communication.
In contrast, in other patient visits in the urban clinics,

informal pleasantries (e.g., discussion about the weather)
were exchanged during the course of the appointment
and the doctors referred to their patients by their first

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Table 1 Descriptive information on observations and examples of instrumental and socioemotional communication
Setting
(Physician)

# Patients and
visit duration

Examples of instrumental
communication

Examples of socioemotional communication

Urban (Mary) 19 patient visits
observed

● Patient asks about test results ● Greet each other by their first name

270 minutes
of observation

Average of 11
minutes per visit

● Patient asks for refills ● Patient asks about physician’s daughter and what grade she’s in now

(range 5 to
20 minutes)

● Patient asks when test results
will be back

● Patient teases physician about being tanned from recent vacation

● Physician asks about symptoms ● Physician asks about how patient’s sibling is coping

● Physician explains tests being
scheduled for patient

● Patient and physician talk about people they both know who are
retiring

● Physician explains prescriptions
and side effects

● Physician teases patient about smoking

● Physician reviews test results

Urban (John) 18 patient visits
observed

● Patient describes symptom

● Greet each other by first name

220 minutes of
observations

Average of 11 minutes
per visit

● Patient asks about health
coverage of tests, medications

● Patient jokes that he is there because his wife told him to come in

(range 4 to
19 minutes)

● Patient asks for refills ● Physician teases patient about being an “empty nester”

● Patient asks about their self
diagnosis (e.g., thyroid problem,
appendix, cancer)

● Physician asks about patients’ parent’s recent surgery, about son in
overseas, say “hi” to dad

● Physician explains medications
and side effects

● Physician ask how patient’s recent trip was traveling with babies

● Physician asks patient if s/he has
any questions about treatment or
prescriptions

● Physician explains tests being
scheduled for patient
● Physician reviews test results

Rural (Alan) 23 patient visits
observed

● Patient describes symptoms and
health concerns

● Greet each other by first name

275 minutes
of observations

Average of 12 minutes
per visit

● Patient asks about health
coverage of treatment

● They joke about aging, failing knees, bunnies do well eating salads,
giving up coffee, golf not being exercise

(range 3 to
19 minutes)

● Patient asks about prescriptions
and side effects

● Talk about summer vacations, exercise routine, daughter getting
married, grandson in hockey tournament, restoring cars, hockey game
last night, family conflicts and estrangements

● Physician reviews test results ● Physician teases patient about drinking too much at local weekend party

● Physician explains tests being
scheduled for patient

● Doctor refers to some patients as “My Dear”

● Physician explains health concerns ● Physician asks patient how he’s doing and pats patient’s knee

● Physician asks about symptoms ● Physician talks to teens about sex, tattoos, drinking and drugs

Rural (Colleen) 13 patient visits
observed

● Patient asks about tests and
referrals

● Greet each other by first name

297 minutes of
observations

Average of 13 minutes
per visit

● Patient describes tests and
referrals

● They joke about patient falling off examining table and a good looking
doctor to come help her up, about weight loss, quitting smoking,

(range 4 to
30 minutes)

● Physician asks about symptoms ● Talk about deer eating flowers, each others’ daughters, retirement
celebration for a physician in the clinic, parent who is recently
widowed, vacation, sister’s health, new haircut

● Physician explains test results

● Physician explains procedures

● Physician explains health concerns

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name. The urban doctors asked some medical history
questions of the patients and appeared to have general
knowledge of many of their patients’ day-to-day lives and
could speak to that on a more personal level rather than just
to their immediate health concerns. Socioemotional com-
munication and relationship-building, however, appeared to
depend on the specific patient involved. For example, Jim
left a solo downtown practice for a group suburban one,
and many of his patients followed him from his downtown
practice. One of the patients he saw during the course of
the observation had recently bumped into Jim at a nearby
restaurant. Many patient-interactions, however, were purely
instrumental where the majority of the appointment
was devoted to discussing the reason the appointment
was scheduled.
When asked about her primary duties, Mary did not

include descriptions of taking medical histories or
reviewing the charts as her primary work tasks. Rather,
she drew attention to the time she spends specifically
seeing patients and getting to know them. Jim responded
similarly to the same question: “Well most of my time is
patient care.” When probed for more information, he
explained further:

“I mean on a typical schedule day we tend to slot
patients in for 10 minute appointments but that’s for
individual issues, individual visits for doing oh
medicals and things, I usually allot a half an hour for
those to give us a bit more time.”

When asked what she enjoys most about her job, Mary
answered: “I enjoy getting to know my patients.” Mary
finds her patients to be the most satisfying part of her
job, yet her enjoyment does not end with merely spending
time with patients, it is about “getting to know” them. Jim,
the other urban doctor, stated: “You know, I like spending
time with patients, I like talking with patients but on an
economic basis you just can’t afford to do that.”
This comment suggests that while Jim enjoys spending

time with patients, talking to patients and getting to
know them on a personal level, he feels limited in how
much time he can afford each patient because economically
it is not viable. His comments are consistent with the
patterns that emerged during observations. While the
urban doctors spent time cultivating supportive ties with
their patients, these were somewhat restricted interactions
and they did not typify every appointment. Later in the
interview, Jim explained why he enjoyed spending time
with his patients:

“Um, getting to know them and after many years, not
just getting to know them in a professional sense, but
I mean I lived very close to where my office was for
the bulk of my career and many of my patients’ kids

actually went to school with my kids… so that’s part
of the reason I sometimes get behind is now we’re at
the point where talking about what’s [doctor’s kid’s
name] up to today and where is he going to school
and so and so is getting married and various kinds of
things… that to me is very satisfying.”

Jim expressed his desire to establish long-term
relationships with his patients. He wants to engage
with his patients in a community setting rather than
merely doing “medicine, medicine, medicine, medicine”
and simply moving from one patient to the next during
his work day.

Rural doctors
The observation data showed that both rural doctors
interacted with their patients on a very personal level,
and talked with their patients about their personal,
medical and social lives as well as those of their
family and friends. Very few of the patient visits with
the rural doctors were strictly instrumental. In fact,
only one of the 23 patient visits observed for Alan
and only two of the 13 visits observed for Colleen
were considered purely instrumental without any
socioemotional communication.
During most visits, both doctors and their patients

usually chatted about non-health related topics in terms
of personal matters and activities, and community events
that reflect how these socioemotional relationships were
cultivated between patient and physician in addition to
patients’ health-related concerns. These appointments
drew on both socioemotional and instrumental communi-
cations, thereby reflecting more blended communication
styles. For example, Alan talked to his patients about such
topics as their summer vacations, children’s marriages,
grandsons’ hockey games, hobbies, renovations, and
gardening. He also shared some very personal aspects of
his life with his patients during their appointments.
Colleen often checked on her patients’ emotional and
mental wellness to see how they are coping with any
personal difficulties they were experiencing, such as ailing
parents or difficult children. In many patient encounters,
Colleen and her patients’ faces visibly lit up when
they saw each other, like old friends seeing one
another, and they would almost pick up on an
ongoing conversation as if it had been interrupted
only a few minutes ago.
Alan, coaches a local youth sports team, which

provided an easy topic to discuss life apart from the
office and offered a way to introduce informal pleasantries.
Additionally, both rural doctors frequently called patients
by their first names, nicknames, or even pet names, such
as “My Dear”. In addition, some of the patients referred to
the doctors by their first names.

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When asked about their general duties and work tasks,
Alan answered quite plainly: “Seeing patients.” The
urban doctors elaborated on what seeing patients
entailed, but Alan saw no need to do so, nor did he
mention the amount of time he spends doing paperwork
or other office tasks. Like the urban doctors, he did not
mention needing to take past medical histories and the
like, probably because he was more familiar with his
patients and their day-to-day lives. In contrast to Alan,
Colleen, described the administrative responsibilities that
she is also responsible for in addition to her family practice,
and did not discuss patient care in much detail.
When asked about the most satisfying thing about his

work, Alan answered: “Well patient contact. There’s ah
yah, that’s why I’m in general practice or family medicine.”
Colleen responded similarly: “The patient interactions.”
Like the urban doctors, the rural doctors found spending
time with patients to be the most satisfying part of
practicing medicine. However, when asked what she found
most rewarding about her work, Colleen explained:

“Um, [p] the most rewarding? Um the patient
interaction… But it, and so it’s the relationship, um
fostering a patient to be able to do a lot of self care,
that type of thing, that’s good.”

Here, Colleen draws attention to how rewarding it is to
get to know her patients better and help them engage in
self care and self management practices.
Everyone in these communities knows everyone else and

patients keep the physician up-to-date on what is going on
in their lives and in the community. It appears that there
is an immense amount of trust and caring in these
relationships that exhibited considerable socioemotional
communication and relationship building, where patients
not only disclosed physical health matters but also raised
more personal concerns about their spouse, parents or
children.

Discussion
This paper explored whether doctor-patient interactions
differ across urban and rural clinics. The observation
and interview data suggest that differences exist in
doctor-patient interactions in different locales. Of the
four doctors that we studied, those who live and practice in
small rural towns appeared to know their patients and their
families on a more personal level and outside of their office,
and engaged in more socioemotional communications
compared to those who live and practice in suburban clinics
a large urban centre. Knowing patients outside the clinic
seems to change the nature of the doctor-patient inter-
action, and, in turn, the doctor-patient relationship itself.
Instrumental communication was the basis of more of

the doctor-patient interactions observed in the urban

settings, whereas rural doctors and patients exercised
more blended communications that drew on both
socioemotional and instrumental styles. Socioemotional
communication and relationship-building typified most
of the interactions observed in rural settings although these
interactions also contained instrumental components, and
were also seen in many of the urban doctor-patient interac-
tions. Informal pleasantries were more often used in urban
clinics, but rural doctors used them as well. Humour was
used in both settings, but was more prevalent in rural ones.
While communication styles differed across settings, it is
interesting to note that the average amount of time allotted
for purely instrumental visits was the same as that
devoted to blended visits involving both instrumental
and socioemotional communication. That is, even
though the urban doctors were more likely to engage
in strictly instrumental interactions with their patients, their
appointments that also included socioemotional communi-
cation averaged about the same length of time. This is im-
portant to consider particularly in light of Becker et al’s
(2010 [15]) and Wiegl et al’s (2009 [19]) findings that
patients feel they spend little time with doctors.
Building rapport with patients is necessary to make
the most of these minutes, and quickly developing a
trusting relationship can help physicians make the
most of that time.
Rural doctor-patient interactions observed in this

study involve discussion of many personal, family and
community topics unrelated to the health concern.
Informal pleasantries are exchanged, and much joking
and bantering occurs throughout the interaction. Both
patients and physicians refer to each other with terms of
familiarity and endearment. These relationships are
clearly long-term, trusting and personal. Each knows
intimate information about the other and their families as
“everybody knows everybody” in these small, rural com-
munities. These doctor-patient interactions are character-
ized by considerable socioemotional communication and
relationship-building.
The urban interactions involved informal pleasantries

as patients and physicians checked in with one another
at the beginning of the visit. This small talk was usually
not as personal nor intimate as that observed in the
rural clinics. The interactions were also supportive and
relationship building, however, in that the physician may
have asked about other family members during the visit
in regards to non-health related topics. Again, these
urban conversations, while personal and emotionally
supportive, were not to the same extent as those
observed in the rural clinics. The urban interactions
tended to be more instrumental and task oriented
than those in the rural clinics where most of the
conversation in the urban clinics was focused on the
patients’ health concerns.

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As indicated above, differences in doctor-patient interac-
tions may affect patients’ health and future health outcomes.
A growing body of literature suggests that socioemotional
communication with ones’ physician positively influences
individual health outcomes [3,5-7,14,17]. A socioemotional
relationship with one’s doctor may enhance patient health
through establishing a trusting relationship where anything
can be shared. However, it could also be detrimental
through an assumed understanding and knowledge of a
patient’s condition. Doctors who feel they know their
patients on a more personal basis, and who assume they are
more familiar with the patient’s medical background, may
not take as thorough a history at each visit compared to
doctors who rely more on instrumental communication
during patient visits. More research should examine the
relationships between different types of communication
involving physicians and patients and the health of patients
and quality of healthcare offered at different sites.
In addition, future research might consider rural

doctor-patient relationships and healthcare outcomes,
particularly as rural health could be adversely affected by
shortages of physicians and medical practices in these
areas. Potentially, rural residents with family doctors
could have very different health outcomes compared to
rural residents without family doctors, urbanites with family
doctors, and urbanites without family doctors. Research
that compares these groups could provide a better
understanding of the impact of doctor-patient relationship
on patient health and healthcare outcomes.
There are several limitations to this research. Because

of the exploratory nature of this pilot study, the sample
size is small, thus raising concerns about generalizability.
In other words, the themes found based on the data for
these four physicians may not be generalizable to the
greater population of urban and rural family doctors.
The transferability or usefulness of these results to
practice may be limited until a larger sample size of both
urban and rural family doctors are observed. Additionally,
while saturation was reached with the limited number of
observations in this study, a larger sample of physicians
may generate more themes than those discovered in this
project. Further, as in all observational research, the data
were restricted to that which the particular field
researcher drew attention to and noted in her observations.
In this case, the researcher was an “outsider” in the research
setting, that is, she did not have a background in practicing
medicine. While “insider” perspectives such as medical
professionals observing medical practice settings, can be
beneficial as insiders may better understand the nomencla-
ture and culture of what they are observing, “outsider” per-
spectives of those relatively unfamiliar with the phenomena
being studied may be better able to observe the taken for
granted [24]. It should also be recognized that small towns
located nearer to major citites, such as those included in

this study, are very different from small towns in more
remote locations [25]. Our dichotomy of rural–urban does
not capture the varying degree of rurality of communities,
particularly those in remote locations. Last, consultation
time may not fully reflect the entire domain of doctor-
patient interactions. Physicians and patients may also inter-
act outside of patient visits that occur beyond the clinics,
for example through phone calls, mail, or face-to-face
encounters in the community. As well, most of the
appointments observed in this study were extensions
of already established relationships between the doctors
and their patients, and represent only a single interaction
within an ongoing cycle of care [4]. Additionally, because
the authors did not access patient histories or ask the
physicians how often they saw each patient, it is
impossible to account for the development of physician-
patient interactions outside the observed encounters
during patients’ appointments in the clinics. Familiarity
outside of patient visits could also enhance the use of
socioemotional communication within these interactions.

Conclusions
The results of this study show that the doctor-patient
interactions observed in the urban settings were primarily
instrumental, or “cure-oriented interactions”, that were
oriented towards the health concerns or reason for the
appointment and information that was shared was directly
related to the patient’s physical health [3]. In contrast, the
results suggest that doctor-patient interactions in rural
settings involved significantly more socio-emotional com-
munication that was characterized by more “care-oriented
interactions” [2]. These socioemotional communications
may ease patient anxiety and increase patient-doctor trust,
but they did not appear to add extra time to the patient
visit. In these rural interactions, medicine happened in
between conversation that may alleviate anxiety and builds
a trusting relationship. An interesting and somewhat
unexpected finding of this study is that despite the different
ways in which doctors and patients communicated with
each other, for urban doctors, purely instrumental and
blended appointments averaged approximately the same
amount of time. Thus, it does not appear that building
trusting, personal relationships with patients while garner-
ing vital instrumental information resulted in lengthening
the time of patient appointments.
Research suggests that socioemotional communication

ultimately leads to better patient outcomes [3,5]. This
implies that health differences between rural and urban
settings could be linked to differences in doctor-patient
communication styles. And while some might argue that
socioemotional communication takes up too much time,
the results of this study suggest otherwise. While uncer-
tainties remain about the role of physician communication
style and patient outcomes [25,26], by better understanding

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the different types of doctor-patient communications and
how they vary across urban and rural settings, it may
provide an important piece to the complex puzzle of
explaining urban–rural variations in health care and
health outcomes.

Abbreviations
CA: Conversation analysis; AHS: Alberta health services; AHFMR: Alberta
Heritage Foundation for Medical Research.

Competing interests
The authors declare that they have no competing interests.

Authors’ contributions
JW was involved in the design and implementation of the study. JW
completed the observations and interviews of the physicians that
contributed to this study while KDD, supported by JW, completed the first
wave of analysis for this paper and completed the first draft of the
manuscript. Both authors contributed to the manuscript, and have read and
approved the final manuscript.

Acknowledgements
Support for this research was provided by a Research Grant from the Alberta
Heritage Foundation for Medical Research’s (AHFMR) Health Research Fund
and financial and in-kind support from Alberta Health Services (AHS) (former
Calgary Health Region). The opinions contained in this paper are those of
the authors and do not necessarily reflect the position or policy of AHFMR or
AHS. The authors wish to thank Jane Lemaire and Jyoti Gondek for their
helpful comments on an earlier draft of this paper.

Received: 16 March 2012 Accepted: 5 July 2013
Published: 8 July 2013

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doi:10.1186/1472-6963-13-261
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and rural clinics. BMC Health Services Research 2013 13:261.

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Use of Electronic Health Record
Documentation by Healthcare
Workers in an Acute Care
Hospital System
Daleen Aragon Penoyer, PhD, RN, director. Center for Nursing Research, Orlando
Health, Orlando, Florida; Kendall H. Cortelyou-Ward, PhD, assistant professor. Health
Management and Informatics, University of Central Horida, Orlando; Alice M. Noblin,
PhD, assistant professor. Health Management and Informatics, University of Central
Florida; Tim Bullard, MD, medical chief Business Development à Innovation, Orlando
Health; Steve Talbert, PhD, RN, assistant clinical professor. College of Nursing, University
of Central Florida; Jason Wilson, RN, healthcare consultant, CIC Advisory, Tampa,
Florida; Beatrice Schafhauser, RN, manager. Clinical Informatics, Orlando Health; and
Joshua G. Briscoe, MD, physician. Emergency Physicians of Central Florida, Orlando

E X E C U T I V E S U M M A R Y
Acute care clinicians spend significant time documenting patient care information in
electronic health records (EHRs). The documentation is required for many reasons,
the most important being to ensure continuity of care. This study examined what
information is used by clinicians, how this information is used for patient care, and
the amount of time clinicians perceive they review and document information in the
EHR. A survey administered at a large, multisite healthcare system was used to gathe

r

this information.

Findings show that diagnostic results and physician documents are viewed more
often than documentation by nurses and ancillary caregivers. Most clinicians use the
information in the EHR to understand the patient’s overall condition, make clini-
cal decisions, and communicate with other caregivers. The majority of respondents
reported they spend 1 to 2 hours per day reviewing information and 2 to 4 hours
documenting in the EHR. Bedside nurses spend 4 hours per day documenting, with
much of this time spent completing detailed forms seldom viewed by others. Various
now sheets and forms within the EHR are rarely viewed.

Organizations should provide ongoing education and awareness training for
hospital clinical staff on available forms and best practices for effective and efficient
documentation. New forms and input fields should be added sparingly and in col-
laboration with informatics staff and clinical team members to determine the most
useful information when developing documentation systems.

For more information about the concepts in this article, contact Dr. Penoyer at
daleen.penoyer@orlandohealth.com.

130

USE OF EHR DOCUMENTATION BY HEALTHCARE WORKERS IN A HOSPITAL SYSTEM

INTROOUCTION
Documentation in the medical chart
originally served to provide a record of
a patient’s care and to improve com-
munication among healthcare provid-
ers. As medical records have evolved
into true health records, documenta-
tion has come to serve many purposes,
such as evidence for medical legal cases,
required backup for reimbursement, and
information for developing measures
for quality and regulatory purposes. This
expansion requires clinicians to spend
increased time and effort documenting
the care provided, with the unintended
consequence that they potentially spend
less time providing direct patient care.

Study findings demonstrate that
nurses have mixed perceptions about
the electronic health record (EHR): It is
extensive but time consuming (Saarinen
& Aho, 2005; Scott, Rundall, Vogt, &
Hsu, 2005); it helps and hinders nursing
work (Kossman & Scheidenhelm, 2008;
Hakes & Whittington, 2008; Dennis,
Sweeney, Macdonald, & Morse, 1993);
and it has both positive and negative
effects on patient care (Koppel et al.,
2005; Han et al., 2005; Fraenkel, Cowie,
& Daley, 2003; Mekhjian et al., 2002).
In one study, 73% of nurses reported
spending at least 50% of their time
using the EHR, which leaves less time
for patient care (Kossman & Scheiden-
helm, 2008). Some nurses reported
that their critical thinking is reduced by
using the EHR, but most nurses believed
that its benefits outweigh its drawbacks
(Moody, Slocumb, Berg, & Jackson,
2004; Fraenkel et a l , 2003).

Most research to date has looked
specifically at the time and burden
associated with documenting in an

EHR. Few studies report clinician use
of information from the EHR. Qur aim
was to determine what information
from the EHR is viewed and how that
information is used by different types of
clinicians.

B A C K G R O U N D
To guide discussion of the concepts,
the structure-process-outcome (SPO)
framework of Donabedian (1988) is
used. According to Donabedian, struc-
ture refers to the settings in which care
occurs, including equipment and facili-
ties; process includes what is actually
done in healthcare activities; and out-
come is the impact of care on the health
status of a population. This framework
describes our approach to examining
how a variety of healthcare clinicians
use data and information documented
in the EHR at a multihospital system.
Figure 1 demonstrates the use of this
model for the study, and each SPO step
is explained further in the following
paragraphs.

Structure
The EHR represents the structure for
the documentation of healthcare in this
study. This documentation provides the
basis for patient care decisions. Clini-
cal practitioners regularly contribute a
great deal of information and data to
the record to complete a multitude of
tasks. For example, nurses record the
patient’s condition, care given, measure-
ments taken, and medication adminis-
tered through menu-driven checklists
of nursing diagnoses, human body
systems, and common patient problems.
Although viewed as a time-saver by
some nurses (Kossman & Scheidenhelm,

131

JOURNAL OF HEALTHCARE MANAGEMENT 59:2 MARGH/APRIL 2014

F i G U R E 1
Structure-Process-Dutcome Quaiity iVIeasurement iVIodei

EHR • Interactions ‘ Decisions

2008), the drop-down menu options
for nursing documentation may lack
the detail needed by physicians for
a complete picture of the patient’s
physical and psychosocial status (Kelley,
Brandon, & Docherty, 2011). Therefore,
nurses may need to provide additional
free tejrt to fully describe a patient’s
clinical picture.

Process
The process is clinicians’ interactions
with the EHR, including communica-
tion among practitioners, how docu-
mentation is completed, and time spent
in doing so. Hripcsak, Vawdrey, Ered,
and Bostwick (2011) report that 8

0%

of nurses’ notes go unread by physi-
cians. Increased verbal communication
between physicians and nurses often
accounts for this lack of reading (Hripc-
sak et al., 2011; Brown, Borowitz, &
Novicoff, 2004). Clinicians appreciate
the convenience of conversations and
the use of a bedside fiow sheet to obtain
necessary patient information. During
nurse shift changes, a combination of
verbal and written communication is
preferred and considered most efficient
for handoffs (Street et al., 2011).

In terms of time spent reviewing and
documenting in the EHR, Likourezos
et al. (2004) surveyed physicians and
nurses at a large, urban, teaching hos-
pital emergency room and discovered
that nurses believed they were able to
complete their work faster with the EHR
than physicians thought they could
complete their own work. Inpatient care
nurses have also perceived time sav-
ings with the EHR (Dennis et al., 1993;
Moody et al., 2004; Banner & Olney,
2009; Bosman et al., 2003; Fraenkel et
al., 2003).

Outcome
The outcome measures for this study
were related to how EHR information
was used by practitioners to make deci-
sions regarding patient care issues. These
frequently include reviewing the docu-
mentation of other clinicians, evaluating
the patient’s response to treatment, and
understanding the patient’s overall clini-
cal picture. For example, the availability
of previous history and physical docu-
mentation has been shown to lead to
better decision making regarding patient
readmissions (Ben-Assuli, Leshno, &
Shabtai, 2012). However, patient-level

132

USE OF EHR DOCUMENTATION BY HEALTHCARE WORKERS IN A HOSPITAL SYSTEM

outcomes were beyond the scope of this
project.

In this study, we sought to answer
the following questions related to the
use of the EHR in the clinical setting:

1. Which parts of the EHR do clinical
practitioners access to view
documented information?

2. How do clinical practitioners use
information from the EHR in their
practice?

3. What information from the EHR are
practitioners using when caring for
patients?

4. What is the perception of the
amount of time clinical practitioners
spend reviewing documentation in
the EHR?

5. What is the perception of the
amount of time clinical practitioners
spend documenting in the EHR?

METHODS
We administered a descriptive and
exploratory online survey to a conve-
nience sample of clinical practitioners
at a large, six-facility community hos-
pital system in the southeastern United
States. The study population included
clinical practitioners and caregivers who
accessed, used, or contributed infor-
mation to patients’ EHRs, including
physicians/providers, bedside nurses,
managers/educators, medical/nurse
assistants, advanced clinical nurses,
ancillary professionals, discharge plan-
ners/social workers, and ancillary diag-
nostic personnel. Excluded from this
study were team members who were not
clinical practitioners, did not interface
with the patient for a clinical purpose

or service, did not use or document data
in patients’ EHRs for patient care, and
worked in outpatient diagnostic areas.

At the study organization, the EHR
had been implemented incrementally
over the course of the prior decade,
starting with availability of diagnostic
results (2004), nursing documenta-
tion (2005-2007), and physician order
entry (2008). Gradual increases in
adoption and use of various compo-
nents were seen, which were integrated
and expanded to a number of areas
in the organization. At the time of the
study, the inpatient (IP) and emergency
department (ED) units were fully inte-
grated into the current EHR and thus
were the only areas of the organization
that participated in the study.

The survey instrument underwent a
series of rigorous assessments and itera-
tions by our multidisciplinary investiga-
tive team. To assess for face validity, the
instrument was distributed to key clini-
cal experts, leaders, and users of clinical
documentation across disciplines. Evalu-
ators were asked to assess for burden of
completion, relevancy of documentation
used in practice, clarity of the questions,
and feasibility of survey items. We used
the feedback and input from all reviews
to make final revisions to the survey.

We received approval from the study
organization’s nursing research coun-
cil and institutional review board. The
online survey was open for participation
from November 1, 2011, to December
20, 2011. We used SPSS version 19 (IBM,
2010) to analyze all data.

RESULTS
In total, 837 healthcare practitioners
accessed the online survey. Of those.

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JOURNAL OF HEALTHCARE MANAGEMENT 59:2 MARCH/APRIL 2014

9 did not consent to participate in the
study, leaving 828 surveys. Eighty sur-
veys were blank, leaving 748 possible
surveys for analysis. Nineteen surveys
were less than 80% completed and were
eliminated. We then eliminated those
surveys completed by individuals whose
role types were ineligible for inclusion,
leaving 700 total usable surveys.

To determine the number of poten-
tial subjects who would be eligible to
join the study, we applied several filters
to the approximately 14,000 team
members from the study organiza-
tion’s human resources database. We
used specific job codes for roles, hos-
pitals, and unit locations that would
meet inclusion. Applying those crite-
ria, the number of eligible IP and ED
team members was 6,664. Qur sample
represented approximately a 10.5%
response rate based on this assessment.
Of those, 591 subjects were from the IP
setting and 109 were ftom the ED. Data
on EHR usage by subjects from the ED
were analyzed separately from IP find-
ings because of the differences in pace,
priorities, and patient flow. Because
fewer types of providers are actively
involved in ED patient care, providers
were grouped as prescribers (MDs, nurse
practitioners, or physician assistants),
nurses, and ancillary staff in this sub-
analysis. Table 1 summarizes the total
sample in the study.

Sample Characteristics
The sample of 591 subjects from the
IP setting consisted primarily of
women (78.3%) and individuals who
had achieved a baccalaureate degree
or higher education (75.8%). The
average age of the participants was

41.49 years; the youngest respondent
was 19, and the oldest was 71. The
sample also reflected an average tenure
of 14.6 years in participants’ role and
8.59 years’ longevity with the organiza-
tion. The primary role represented in the
sample was bedside nurses (40%), fol-
lowed by ancillary clinical roles (19%).

Study Question Results

Which parts of the EHR do clinical
practitioners access to view
documented information?
An analysis of IP results was performed
in 50 specific areas of the EHR to
determine which areas are most often
reviewed during patient care. We found
that Diagnostic Results was the most
frequently accessed (89%) by all provid-
ers, with 96% of advanced clinical nurse
professionals accessing this screen often
or ftequently. Physicians Orders was also
heavily used to review information, with
86% of respondents often or frequently
accessing this portion of the record.
Two forms of provider core documents
heavily accessed were History and Physi-
cal by a Physician (84%) and Physician
Progress Notes (83%), while the Nurs-
ing Care documents and Patient Work
List were less frequently viewed by all
subjects; only 63% of respondents indi-
cated that they view this area regularly,
of whom 90% of bedside nurses and
7% of prescribers access this area of the
EHR for review. Table 2 summarizes the
parts of the EHR that subjects reportedly
review often in their role.

In contrast, many other areas of the
EHR were less frequently accessed for
review. Numerous nursing and ancillary
core documents were rarely reviewed.

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USE OF EHR DOCUMENTATION BY HEALTHCARE WORKERS IN A HOSPITAL SYSTEM

TABLE 1
EHR Study Participant Characteristics

Characteristic

Age in years
Years in role
Years at facility

Gender
Female
Male
No response

Education
No formal degree
Associate degree/diploma
Baccalaureate degree
Master’s degree
Doaorate

Role

Prescribers

Bedside nurses
Ancillary clinical roles
Managers/leaders
Nursing/medical assistants
Advanced clinical nurse
Discharge planner
Ancillary diagnosticians

(iV=700)

inpatient
(/; = 591)

Average (Range)

42.49 (19-71)
14.61 (0-45)
8.59 (0-38)

Percent
7 8 %

19%

2 %

2 %

2 2 %
4 1 %
16%

19%

14%
4 1 %
19%
14%

2 %

4 %
4 %
2 %

“All ancillary roles combined into one category for the ED.

Emergency Department
(/i=109)

Average (Range)

40.84 (24-60)
13.23 (1-47)
7.52 (0-26)

Percent
6 7 %

3 3 %
—

0%

2 6 %
2 4 %

16%
3 4 %

3 8 %
4 6 %
16%^

n/a
n/a
n/a
n/a
n/a

and many respondents indicated they
did not know what they were. Table 3
summarizes some key documentation
areas and the reported frequency of
access to those areas.

Various existing clinical summary
tabs within the EHR were also evalu-
ated for access. With input from clinical

practitioners in different disciplines,
team members from the informatics
department developed and incorpo-
rated integral components of the EHR
into these summaries to provide an
overall summary of important clinical
information in one snapshot view. We
found that the nursing general clinical

135

JOURNAL OF HEALTHCARE MANAGEMENT 59:2 MARGH/APRIL 2014

T A B L E 2
Parts of the EHR IVIost Frequently Viewed, by Roie (%) (/i = 591)

Advanced
Documentation Bedside Ciinlcal Anciiiary Discharge

Type Prescriher RN Manager Nurse Caregivers Planners Ail

Diagnostic
Results
Physician Orders
History and

Physical
Physician Progress

Notes
Patient Work List

9

7

81

96

94

7

97

94

85

84

90

88

83

74

73

72

96

88

100

100

33

76

84
85

85

54

81

81

92

92

46

89

86

84

83

63

summaries were often or frequently
reviewed 57% of the time by all groups,
and 60% by bedside nurses. The sum-
mary version developed for physicians
was accessed frequently by 23% of
prescribers; medication summaries
were reportedly viewed by 65% ofthat
group.

How do clinical practitioners use
information from the EHR in their
practice?
Respondents were asked how they use
the information they review in the
EHR. The results showed that prescrib-
ers (95%) and bedside registered nurses
(RNs) (86%) most commonly used the
information to make clinical decisions
for the patient, while diagnostic profes-
sionals rarely (15%) used information
for this purpose. The most common
reason to access the information was
to gain an understanding of the overall
condition of the patient (84%), and the
least common reason was for review and

sign-off purposes (19%). Table 4 lists
reasons for access by type of clinician.

What information from the EHR are
practitioners using when caring for
patients?
Respondents were provided a list of
common data elements in the EHR
and asked which elements were most
important to them when caring for a
patient. Results from subjects in the IP
group indicated that Vital Signs, Weight/
Height/BMI, and Diagnostic Tests (51%)
were perceived as most important by
all roles, closely followed by History
(50%). These results were consistent
among prescribers (58%), bedside RNs
(56%), advanced clinical nurse practi-
tioners (64%), and discharge planners
(92%), all of whom noted that these
data elements were important when
providing care to patients. The diagnos-
tic professionals indicated that none of
these data elements were important to
their provision of care. Low responses

136

USE OF EHR DOCUMENTATION BY HEALTHCARE WORKERS IN A HOSPITAL SYSTEM

TABLE 3
Parts of the EHR Least Frequently Viewed

Documentation Type

Plan of Care
Nursing Assessment
Patient Education
Restraint Use
Discharge Assessment
Patient Screenings

Braden Score
Vaccines
Falls Risk
Pain
Tuberculosis

Ancillary Caregiver Progress Notes
Pharmacy
Nutrition
Respiratory Therapy
Wound Manager
Rehabilitation/PT
Spiritual Care

by Clinical Practitioners (%) (/; = 591)

Percentage Reviewed
Often by All Groups

35

3 8
3 3
22
41

35
22
30
4 6
2 3

15
19
21
2 6
2 3
21

Percentage Reviewed
Often by Prescribers

7
4

5
1

25

2
11
1

13
5

12
18
10
25
20
8

for usefulness (20% or less overall) were
found for patient education; nutritional,
mobility, or respiratory status; ancillary
reports; language and culture; and peri-
operative events.

How much time do clinical practitioners
spend reviewing documentation?
Subjects were asked to estimate how
much time they spend reviewing
already documented information in
the EHR. Answers for selection were
provided in 0.5-hour increments;
thus, mean values were not calculated.
Results from the IP participants indicate

that 42% of the sample spend an hour
or less reviewing documentation,
while 15% spend 2.5 hours or more.
Discharge planners reported that they
dedicate the most time to record review,
with 37% indicating that they spend
between 3 and 4.5 hours a day review-
ing. More than half of the prescribers
and bedside RNs reported spending 1.5
hours or less per day reviewing docu-
mentation. Figure 2 demonstrates the
results from perceived number of hours
per day spent reviewing versus hours
perceived spent documenting for IP
clinicians.

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JOURNAL OF HEALTHCARE MANAGEMENT 59:2 MARCH/APRIL 2014

How much time do clinical practitioners
spend documenting?
The perceptions regarding the amount of
time spent documenting provide insight
into the workload for each role in the
organization. Answers for selection were
provided in 0.5-hour increments; thus,
mean values were not calculated. Wide
variation in the amount of time spent
authoring documentation was found
across both the IP and ED settings.
Bedside RNs reported the largest burden
of documenting, with 62% of respon-
dents indicating that they document
more than 3 hours per day. This group is
followed by prescribers, of whom 40%

indicated that they document more than
3 hours per day. Managers perceived
that they spend the least amount of time
documenting, with 59% reporting that
they document 1 hour or less per day.

To evaluate and better understand
the impact that type of unit and team
member work location can have on
the perceived differences in time spent
reviewing and documenting, we sub-
categorized respondents by work area.
We found no statistically significant
difference among the amount of time
spent reviewing or documenting in the
EHR between five subcategories: ancil-
lary, critical care, step-down, medical/

TABLE 4
Inpatient Clinician Use ot Information Accessed

Make clinical decisions for
patient

Evaluate response to
treatment

Review other disciplines’
documentation

Understand plan of care
Understand overall condition
Effectively communicate

and collaborate
Leam more about patient
Plan for discharge
Regulatory requirements
Review and sign off
Patient medication list
To give report
Order clarification

Prescribers

95

84
84

68
83
81

65

58
11

2 8
4 6
1Ö
20

From tiie EHR |

RN-Bedside

86

77

66

75
85
82

80

56
2 5

2 5
49
52
44

Ancillary

69

70

66

79
9 4

81
83

39

8

36
15
56

25

Discharge
Planners

50

50

62

81
89
96

62
92
37
12

46
4

39

Overall

80
70

67

72
84

80
72

51
21

19
39
2 8
34

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USE OF EHR DOCUMENTATION BY HEALTHCARE WORKERS IN A HOSPITAL SYSTEM

F I G U R E 2
Perceived Numher of Hours per Day Spent by IP Clinicians Reviewing Components in the EHR and
Documenting in the EHR

r

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

— Hours Reviewing ~~»— Hours Documenting

surgical, and perioperative/procedural
areas in the IP settings.

Additional Emergency Department
Results
In addition to the results reported here,
109 surveys were received from personnel
in the ED. These findings mimicked those
of the IP staff, but we found sufficient
differences in the way the EHR is used in
the ED to warrant their exclusion ftom
the primary data. However, some interest-
ing data were obtained ftom this analysis
(available upon request ftom the corre-
sponding author). Of particular interest
is the high usage of the clinical résumé by
ED prescribers (95%) and nurses (64%).

D I S C U S S I O N
In this research, clinical practitioners’
perceptions on which areas of the EHR
they access for review (structures), how

that information is used (processes),
and which components are useful for
delivering patient care (outcomes) were
explored. Most of the findings relate to
the structures accessed in the EHR and
the processes by which the information
is used. For purposes of this study, the
perception of usefulness of components
when delivering patient care was the
type of outcome we explored.

The structures within the EHR
include the discrete data elements for
documentation and specific areas within
the record, such as assessments and
diagnostic results. While these structures
were routinely used for documenta-
tion by many clinicians in all settings,
their use for review and for making
clinical decisions varied significantly.
Other structures within the EHR include
special views where summary reports are
generated. Surprisingly, these findings

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JOURNAL OF HEALTHCARE M A N A G E M E N T 5 9 : 2 M A R G H / A P R I L 2 0 1 4

showed that clinical summaries were
not used to their highest potential by
the various disciplines and roles.

Additional sections in the structure
of the EHR are tools for practitioners,
such as patient screening. Clinical
personnel rarely reviewed these struc-
tures, whereas managers accessed these
more frequently, possibly for auditing
purposes. This finding was expected,
as screening and subsequent actions
are ongoing and ever-changing. The
option “Do not know what this is” was
included in the survey to assess use of
components in the EHR. Most prescrib-
ers were not aware of many of the non-
physician sections of the record. This
finding may explain the low percentage
of access for many documents.

The processes used for documen-
tation include the methods for docu-
menting and accessing components of
the EHR as well as the perceived time
spent in reviewing and documenting
in the EHR. While reports from studies
demonstrate a wide variation in time
spent documenting, they do show that
19-27% of time is considered average in
the IP setting (Yee et al., 2012; Hendrich,
Chow, Skierczynski, & Lu, 2008). The
fact that most nurses in IP settings work
about 12 hours per day can account for
up to 4 hours of documentation per day.

Results from this study demon-
strate that nurses perceived they spent
about 3.5 hours per day documenting,
compared to 2 hours spent by their
prescriber colleagues. These perceptions
are consistent with literature findings.
In this research, 62% of bedside RNs
indicated that they document more
than 3 hours per day, which is about
25% of the workday. For IP providers.

40% of prescribers indicated that they
document more than 3 hours per day,
and in the ED, 61% reported spending
2.5 to 3.5 hours per day documenting
in the EHR. Although we do not have
perceptions or measurements of docu-
mentation time prior to implementa-
tion of the EHR, Scott et al. (2005) note
that clinicians perceive spending 30-75
minutes extra per day in documentation
with the EHR versus paper records.

Findings from this study add infor-
mation about the time clinicians spend
reviewing data already documented
in the EHR. These findings are signifi-
cant in that about 2 hours are spent by
nurses reviewing components in the
EHR and 1.5 hours are spent doing so
by prescribers. Hripcsak et al. (2011)
found that most clinicians actually view
EHR data for 7-56 minutes per day.
Although the current research looked
at perceptions, rather than actual time
logged into the EHR, 42% of the IP
sample perceived spending less than an
hour per day reviewing information,
and most prescribers and bedside nurses
reported spending 90 minutes or less
per day. These findings appear to be
similar to findings from previous studies
in which actual measurements on time
and motion were performed.

The outcome measured in this
research involves the useflilness of
information contained in the EHR. The
components of the record that were
used most often for care were diagnostic
findings and physiologic measures, such
as vital signs. This result was expected,
given the frequent nature of their use to
assess responses to clinical treatments.
Surprisingly, our data demonstrate less
frequent use of clinical summary areas

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USE OF EHR DOCUMENTATION BY HEALTHCARE WORKERS IN A HOSPITAL SYSTEM

specifically designed by and for clinical
workers to simplify review of clinically
relevant indicators. One possible expla-
nation is that many clinicians were not
familiar with these documents.

Hripcsak et al. (2011) found that
progress notes of residents and medical
students are read by clinicians. Previous
history and physical records are also
found to be helpful when patients are
readmitted. This research study found
that, for inpatient EHRs, Diagnostic
Results was the most frequently accessed
(89%) area by all providers. Physician
Orders was also frequently used, in
addition to the History and Physical and
Progress Notes areas.

According to Creen and Thomas
(2008), physicians look to nursing doc-
umentation for details about changes in
patients’ status. Nurses also use informa-
tion in summary reports to synthesize
patient data between shifts (Staggers,
Clark, Blaz, & Kapsandoy, 2011). One of
the limitations in electronic documenta-
tion is the lack of narrative description
about significant events, thus hinder-
ing a complete understanding of the
patient’s “story.” In this research, prac-
titioners such as prescribers and nurses
most commonly used the EHR informa-
tion to make clinical decisions for the
patient and to gain an understanding
of the overall condition of the patient.
These practitioners most often look to
Vital Signs, Weight/Height/BMI, and
Diagnostic Tests for this information.
The SPO “loop” is closed through the
use of the clinical information con-
tained in the EHR to guide patient care
decision making and communication.

An important finding from this
study was knowledge about which

elements in the EHR are viewed by
various clinicians in acute care and
how that information is used to guide
clinical care. To meet the needs of
clinical caregivers, it is key to determine
which EHR components are impor-
tant to those clinicians and ensure
ease of access in user-friendly formats.
Our finding on how little prescrib-
ers reviewed nursing and ancillary
documentation supports results from
previous studies. Many hours are spent
documenting information that no
one uses, potentially reducing time
for patient care. The finding that few
clinical practitioners review the plan of
care may partially explain the common
problems of communication and frag-
mentation in acute healthcare.

Another important finding in the
study was the limited awareness and use
of EHR components available for clini-
cians. The lack of clinical summaries use
may be explained by a lack of awareness
or limited useñilness of the tools to guide
clinical care. It is essential to engage
clinical practitioners with the designers
of these documents to meet clinicians’
needs as consumers. Creating views of
data that are concise, relevant, and mean-
ingftil for clinicians may augment their
ability to make clinical decisions.

Findings from the sample of practi-
tioners in the ED indicate that they use
information needed in real time to man-
age single episodes of care. Much infor-
mation in the ED is passed on in verbal
conversations and reviews of previous
care. Having access to clinical resumes
helps caregivers develop a story about
patients who enter the hospital and may
explain the frequent use of these résu-
més in the ED setting.

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JOURNAL OF HEALTHCARE MANAGEMENT 59:2 MARGH/APRIL 2014

Implications for Managers In
Healthcare
As regulatory requirements continually
evolve, hospitals are under pressure to
collect more data that are not pertinent
to direct patient care, such as present-
on-admission indicators and Core
Measures data sets. Clinicians may not
be aware of why they are asked to docu-
ment this additional information, but
they do recognize the burden of time
required to do so. Facilities should be
cognizant of this perception and avoid
redundancy in documentation require-
ments. Other implications for optimized
use of the EHR include streamlining
documentation for concise entry of
information and facilitating efficient
health information exchange during
care transitions.

Clinicians at all levels rely on vital
information to make clinical decisions.
Automatically populating informa-
tion into numerous forms may reduce
workload, but it requires information
to reside in multiple places in the EHR.
Thus, important information may go
unread when it resides on flow sheets or
forms unfamiliar to the users. Although
clinicians go through a mandatory
orientation upon hire, they may rely
significantly on coworkers to help them
use the EHR once they start working. If
the more experienced coworkers are not
familiar with forms or have developed
work-arounds, new hires may follow in
those footsteps.

We recommend that leaders and
EHR designers be mindful of adding
fields for documentation and to include
end users in discussions about changes
that will involve them. Opportunities
for shared documentation between

disciplines may further reduce redun-
dant documentation. Providing front-
line caregivers with information about
availability of clinical summary views
and soliciting input on information for
inclusion may expedite widespread use.
Finally, some areas of the EHR are made
up of multiple checkboxes and lists,
which may not tell the story of signifi-
cant events. Incorporating options for
narrative descriptions in a format con-
ducive to reading may augment clinician
communication and understanding for
patient care.

Study Limitations
The study had several limitations. It was
conducted in a single hospital system
and had a low response rate and small
sample size; thus, our results are not
generalizable across all practice settings.
Additionally, we only included team
members from the IP and ED settings,
and our findings may not be appli-
cable to other patient care areas. While
we did assess a variety of settings and
included subjects from many clinical
disciplines, there may have been varia-
tion in documentation review practices
beyond the study findings. The sample
size of provider types was too small
to conduct an analysis of difference
between particular specialty practices to
answer the research questions. Selection
bias in the study was possible toward
subjects who are comfortable complet-
ing online surveys, as they may have
been more willing to participate and
experience more comfort using an EHR
than nonparticipants. Another limita-
tion was recall bias and using measures
of self-report rather than actual mea-
sures of access.

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U S E OF E H R D O C U M E N T A T I O N BY HEALTHCARE W O R K E R S IN A H O S P I T A L SYSTEM

Future Research
Implications for future research may
include studies to further understand
patterns of information use from the
EHR and the effects of using selected
components on patient care decisions
and patient outcomes. A study using
direct observation of clinicians’ use of
EHR information may yield further
understanding of how and why they use
it. Studies using methodologies to cap-
ture actual access to and timing of EHR
components may serve as better mea-
sures of EHR use. Finally, further study
into the effects of streamlining EHR
components with clinician use would
add insight into strategies to improve
end users’ experience with the system.

C O N C L U S I O N
Critically evaluating an organization’s
EHR processes and redesigning its struc-
ture to streamline documentation are
important steps toward saving time and
maximizing efficient use of the system.
Findings ftom this study demonstrate
that clinical care workers from a vari-
ety of disciplines spend a significant
amount of time reviewing information
ftom the EHR; however, only a few areas
are ftequently reviewed. Many areas of
the EHR are rarely accessed for review
by numerous study participants. It is
possible that clinicians operate through
real-time use of information, where his-
torical documentation may seem irrele-
vant. The sections in the EHR ftequently
viewed may indicate the data deemed
important by clinicians for patient care.

Final Note on the Study
Subsequent to this study’s completion,
the organization’s informatics depart-
ment used these findings in part to

drive changes through forming a rede-
sign team to streamline the EHR and
address complexities and redundancies
in documentation. Changes in nursing
documentation reduced the number
of fiow sheets required and included a
new “condition narrative” field to allow
a more complete telling of the patient’s
story. In addition, clinical summaries
were created to contain meaningful data.

The redesign team also met with
the regulatory personnel to ascertain
the necessity of discrete elements of
documentation to meet government and
accreditation requirements. Those com-
ponents without clear rationale for use
were eliminated. Recently, these changes
were implemented and have resulted in
positive outcomes, consolidated flow
sheets, and approximately half the num-
ber of computer clicks needed compared
to before the redesign, with positive
feedback about the improved ease of use
of the EHR.

The heightened level of awareness
about what clinicians are asked to docu-
ment and increased scrutiny of addi-
tions to documentation have proved
beneficial, and areas within the EHR
identified to have low usage are now
assessed for usefulness and considered
for elimination.

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Poster Abstracts

38 www.thelancet.com

Doctor-outpatient communications in Chinese public
hospitals: a cross-sectional survey
Guanping Wang , Jinzhu Xie, Yinhuan Hu

Abstract
Background Communication can be seen as the important component in medical care. The improvement of doctor-
outpatient communication can improve not only the doctor-patient relationship, but also the quality of health care.
In this study, we aimed to estimate whether the doctor-outpatient communication experience is satisfactory in
Chinese public hospitals and how various factors aff ect this experience.

Methods In this cross-sectional study, we used a typical sampling survey. Six sample hospitals were chosen by typical
sampling method, and in each hospital, 100 outpatients were invited to participate in the survey when they ended
their visits. The respondents were a random sample of 300 outpatients from three tertiary hospitals and 300 outpatients
from three secondary hospitals in the Hubei Province, China. We used EpiData 3.1 to establish the database and
SPSS19.0 to perform the related statistical analysis. A fi ve-point Likert scale was used in the questionnaire, in which
5 meant best experience and 1 meant worst experience. The total communication experience score was the mean
of all item scores and we rated scores under 3 as “bad” communication experience. We used the one-way ANOVA
method and multiple linear regression to assess diff erence between doctor-patient communication experience and
the demographic variables and how it infl uenced the experience. Written ethical approval of the study was obtained
from the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (IORG
Number IORG0003571). Verbal informed consent was also obtained before the survey.

Findings 600 outpatients participated in the survey between July 5, 2015, and July 22, 2015, and 583 questionnaires were
valid. 11·22% of the 583 outpatients had bad doctor-patient communication experience. The mean score of doctor-
patient communication experience was 3·72 (SD 0·66). According to the result, the experience dimension of the clarity
of doctors’ explanation got the highest score (4·12 [0·71]), and the experience of the degree of outpatients’ participation
in decision-making got the lowest score (3·21 [1·07]). Besides, the age, self-perceived health status, and the type
of payment aff ected communication experience (the standard coeffi cient were: 0·195 for age, 0·219 for health status,
and 0·193 for type of payment, p<0·001 for each), and those socio-demographic factors were positively associated with doctor-patient communication experience. Moreover, the communication experience in the secondary hospitals (3·82 [0·61]) was better than in tertiary hospitals (3·61 [0·68]), p<0·001).

Interpretation The doctor-patient communication experience needs to be improved. Patients of younger age
(<65 years), patients with bad self-perceived health status, and patients who pay out-of-pocket totally have worse communication experience, probably because the patients of younger age and those with bad self-perceived health status have higher communication demands, and the patients who pay out-of-pocket totally have higher expectations for communication. The overload of doctors in tertiary hospitals could mean that they have not enough energy and time to communicate with patients, leading to poor communication experience for patients. Useful ways to improve the outpatients’ communication experience include taking measures to meet the needs of diff erent outpatients by concentrating more on their age, health status, and payment type, giving outpatients more opportunities to participate in medical decision-making, and strengthening the system of triage.

Funding This study was supported by the Fundamental Research Funds for the Central Universities (2015AC023).
The funders did not participate in study design, data collection, and analysis.

Contributors
YH conceived and designed the study. GW analysed and interpreted the data. JX contributed to data acquisition and provided statistical analysis
support. JX and GW drafted the Abstract. YH participated in the reviewing and editing of the Abstract. All authors have read and approved the fi nal
version of the Abstract and agreed to publication.

Declaration of interests
We declare no competing interests’

Published Online
October 30, 2016

School of

Medicine and Health
Management, Tongji Medical

College, Huazhong
University of Science and

Technology (G Wang);
School of Medicine and

Health Management,
Tongji Medical College,

Huazhong University of
Science and Technology

(J Xie); and School of
Medicine and Health
Management, Tongji

Medical College, Huazhong
University of Science and

Technology, Wuhan,
China (Y Hu PhD)

Correspondence to:
Dr Yinhuan Hu, School of

Medicine and Health
Management, Tongji Medical

College, Huazhong University of
Science and Technology, Wuhan

430030, China
hyh288@hotmail.com

Impact of Electronic Medical Record Use on the Patient–Doctor
Relationship and Communication: A Systematic Review
Maria Alcocer Alkureishi, MD, FAAP1, Wei Wei Lee, MD, MPH2, Maureen Lyons, MD2,
Valerie G. Press, MD, MPH3, Sara Imam, BA4, Akua Nkansah-Amankra, BA4, Deb Werner, BA, MLIS5,
and Vineet M. Arora, MD, MAPP2

1Department of Academic Pediatrics, University of Chicago, Chicago, IL, USA; 2Section of General Internal Medicine, University of Chicago,
Chicago, IL, USA; 3Section of Hospital Medicine, University of Chicago, Chicago, IL, USA; 4College of the University of Chicago, Chicago, IL, USA;
5John Crerar Library, University of Chicago, Chicago, IL, USA.

BACKGROUND: While Electronic Medical Record (EMR)
use has increased dramatically, the EMR’s impact on the
patient–doctor relationship remains unclear. This sys-
tematic literature review sought to understand the impact
of EMR use on patient–doctor relationships and
communication.
METHODS: Parallel searches in Ovid MEDLINE, PubMed,
Scopus, PsycINFO, Cochrane Library, reference review of
prior systematic reviews, meeting abstract reviews, and
expert reviews from August 2013 to March 2015 were
conducted. Medical Subject Heading terms related to
EMR use were combined with keyword terms identifying
face-to-face patient–doctor communication. English lan-
guage observational or interventional studies (1995–
2015) were included. Studies examining physician atti-
tudes only were excluded. Structured data extraction
compared study population, design, data collection meth-
od, and outcomes.
RESULTS: Fifty-three of 7445 studies reviewed met in-
clusion criteria. Included studies used behavioral analy-
sis (28) to objectively measure communication behaviors
using video or direct observation and pre-post or cross-
sectional surveys to examine patient perceptions (25).
Objective studies reported EMR communication behav-
iors that were both potentially negative (i.e., interrupted
speech, low rates of screen sharing) and positive (i.e.,
facilitating questions). Studies examining overall patient
perceptions of satisfaction, communication or the pa-
tient–doctor relationship (n=22) reported no change with
EMR use (16); a positive impact (5) or showed mixed
results (1). Study quality was not assessable. Small sam-
ple sizes limited generalizability. Publication bias may
limit findings.
DISCUSSION: Despite objective evidence that EMR use
may negatively impact patient–doctor communication,
studies examining patient perceptions found no change
in patient satisfaction or patient–doctor communication.
Therefore, our findings should encourage providers to
adopt the EMR as a communication tool. Future research

is needed to better understand how to enhance patient–
doctor- EMR communication. This research should cor-
relate observed physician behavior to patient satisfaction,
focus on physician communication skills training, and
explore inpatient experiences.

KEY WORDS: electronic medical records; EMR; patient–doctor
relationship; communication.
J Gen Intern Med 31(5):

548

–60
DOI: 10.1007/s11606-015-3582-1
© Society of General Internal Medicine 2016

INTRODUCTION

As physicians increasingly integrate the Electronic Medical
Record (EMR) into medical practice, it is important to under-
stand its impact on the patient–doctor communication dynam-
ic. Unfortunately, concerns have been raised over physicians
who pay more attention to the “iPatient” on the computer
screen than to the real patient during a clinical interaction.1

Leading primary care physician organizations issued the
Joint Principles of the Patient-Centered Medical Home
(PCMH) in February 2007, a model that affirms that patient
satisfaction with their doctor is an important marker in health
care,2 and that patient compliance,3 health outcomes,4–6 per-
ceptions of physician competence,7–9 and incidence of mal-
practice suits10 are all closely related to the doctor’s interper-
sonal skills and quality of the patient–doctor relationship.
While benefits of computerization in health care are well

described,11 important drawbacks exist. For instance, some stud-
ies show EMR use can prevent doctors from focusing on patients,
impede communication, and be detrimental to the patient–doctor
relationship.12–15 In order to provide patient-centered care in the
digital age, it is critical to understand how EMR use impacts the
quality of communication and the patient–doctor relationship.
Two prior systematic reviews have examined the impact of

EMR use on patient–doctor communication; however, both
had limitations impeding application to current clinical prac-
tice.16,17 First, due to limited search terminology, publication
sources and minimal inclusion of international or inpatient
studies, the scope of literature reviewed limits its inclusivity.

Electronic supplementary material The online version of this article
(doi:10.1007/s11606-015-3582-1) contains supplementary material,
which is available to authorized users.

Received June 23, 2015
Revised December 7, 2015
Accepted December 18, 2015
Published online January 19, 2016

548

Second, the studies lack results past 2012, which is prior to
increased meaningful use participation, and dates many of the
findings. To provide a more comprehensive representation of
the current literature, the aims of this systematic literature
review were to examine the impact of EMR use on the pa-
tient–doctor relationship and communication with a focus on
patient perspectives and to identify future directions for study.

METHODS

Data Sources and Searches
We conducted an electronic systematic search of the English
literature in Ovid MEDLINE from 1995 to 2015 by exploring
Medical Subject Heading (MeSH) terms and keywords related
to technology, communication, and relationship terminology
in consultation with a biomedical librarian (DW). Given the
heterogeneity and lack of standardized terms or MeSH head-
ings used to describe the various types of technologies used in
clinical care, additional terms were included (Appendix avail-
able online). Only studies or systematic reviews were includ-
ed; editorials and commentaries were excluded.
We conducted parallel searches in PubMed, Scopus, Psy-

cINFO and the Cochrane Library. In addition, we examined
references of prior review articles16–26 and had two indepen-
dent expert reviewers evaluate the results to ensure key articles
were included. To explore publication bias, we reviewed
meeting abstracts from two previous years of Society of Gen-
eral Internal Medicine, American Academy of Family Physi-
cians and International Conference on Communication in
Healthcare and European Association of Communication in
Healthcare conferences for studies that may not have been
published.
Inclusion criteria included studies related to EMR use, the

patient–doctor relationship, and face-to-face communication.
We included all study designs, all patient populations, and
international studies. We excluded studies that reported only
physician attitudes and perceptions, as well as articles that did
not pertain to face-to-face patient–doctor communication (i.e.,
patient portals and remote EMR access).

Study Selection
Following the initial search, duplicates were eliminated.
For the title and abstract review, each article was indepen-
dently reviewed for inclusion by three co-authors (ML, SI,
ANA). Articles were secondarily reviewed by two senior
authors (LAA, WWL). For any titles or abstracts that were
unclear, authors erred on the side of including for full
review.

Data Extraction and Quality Assessment
To ensure consistent article extraction, all reviewers partici-
pated in a training process. Ten articles were randomly select-
ed and reviewed by three title abstraction reviewers (LAA,

WWL, VGP) to ensure that training was successful and defi-
nitions were applied appropriately. All discrepancies were
resolved by consensus. Following training, all articles were
extracted onto a standard extraction form focused on identify-
ing the following for each study: physician type and character-
istics (position such as faculty or residents, age, sex, specialty),
patient type and demographics (age, sex, race/ethnicity), study
design (observational, RCT, single or pre-post survey), setting
(inpatient, outpatient, academic, nonacademic, practice type),
recruitment methods, study aims, primary and secondary out-
comes, identified barriers & facilitators to patient–doctor com-
munication in the setting of technology use, study strengths
and limitations. The validated Downs and Black (DB) check-
list27 was going to be used to assess study quality and bias;
however, since very few studies were interventional by design,
this was not feasible.
Funding for this review was made possible from a grant

from the Arnold P. Gold Foundation Research Institute Call
for Reviews of Research on Humanistic Healthcare. Funding
did not influence our study design, conduct or reporting.

Data Synthesis and Analysis
Authors systematically examined studies qualitatively by
comparing the study population, design and outcomes. Studies
were sub-divided according to method of data collection. A
structured data extraction table was created to facilitate collec-
tion of these key elements. Articles not meeting inclusion
criteria were excluded. Added to this were studies meeting
inclusion criteria identified from reference mining systematic
review articles, expert opinion, and review of conference
abstracts from unpublished studies.
Our review conforms to the Preferred Reporting Items

for Systematic Reviews and Meta-Analyses (PRISMA)
standards.28 Our systematic review did not meet guidelines
for submission to a systematic review protocol registry nor
did it facilitate a meta analysis due to the varied interven-
tions, methodology and outcomes, reported in our included
studies.

RESULTS

Among 7445 total articles identified, 53 were eligible for
review (Fig. 1, Tables 1, 2, and 3). Just over half (n=28)
objectively measured communication behaviors using video-
taped or direct observation of clinical encounters and 25
examined patient perceptions by survey or interview. Seven
studies examined both patient perceptions and observed
behaviors.30,31,43,44,48,49,55 Only two studies were interven-
tional in nature.61,70 Forty-seven of the 53 studies were pub-
lished after the year 2000, and 19 (35.8 %) were published
since 2011. Only nine studies reported on both pre- and post-
EMR implementation findings,2,12,49,56–61 of which only one
included both patient perceptions and objective behavioral
analysis.49

549Alkureishi et al.: EMR Impact on Patient–Doctor RelationshipJGIM

Study Setting
Thirty-one (58 %) studies were conducted in the US. Most
were conducted in an outpatient setting (n=51, 96 %), with
two (4 %) in the inpatient setting. Of outpatient studies, 39
(76 %) were in an adult primary care (i.e., family practice,
internal medicine) clinic; only seven (14 %) included pediatric
patients or their families. Eight studies (16 %) took place in a
specialty clinic. Approximately half (n=28) were at a single
clinic or institution, one-third (n=19) included multiple sites
(range: 2–78), and one examined 2988 unique hospitals.
Twenty of the studies (42 %) were conducted at academic or

academically-affiliated training sites; however, only six (26 %)
examined outcomes related to residents or their patients.

Behavioral Analysis Outcomes
Of 28 studies15,29–55 utilizing behavioral analysis to objective-
ly observe communication behaviors, 23 (82 %) analyzed
videotaped interactions and five (18 %) used direct observa-
tion.42,44,45,49,54 An average of 162 patients (range 10–1170)
and 15 providers (range 3–59) participated per study, and three
studies included resident observations.37,40,44

Characterizing EMR Communication Behaviors
Six studies quantified EMR use during a clinical encounter,
with an average of 32 % of visit time spent using the computer
(range 12–55 %).37,42,45,51–53 Although many studies reported
long periods of silence during the encounter, only one study
actually defined it as a percentage of the interaction (12 %,
mean duration 15.7 s).47 Studies reported changes in speech
style of both providers (i.e., abrupt topic shifts)29,30,42,48,51 and
patients (i.e., synchronizing speech with typing pauses).29,30,50

Eight studies described variation in the amount and manner in
which the EMR was used.15,36,39,41,46,48,51,54 Four studies
examined typing behaviors33,37,42,48 and six reported on
screen positioning, with only 8–10 % active screen sharing
during the visit.29,30,33,37,38,52 Interestingly, one study noted
patients had a more positive attitude towards the EMR when
they were shown the screen.30

Provider multitasking was another theme that emerged,
highlighting providers were unsuccessful at concentrating on
complex computer interactions while attending to the patient
simultaneously.29,33

There were also instances of communication behaviors that
researchers believed promoted communication. Four studies

Figure 1 PRISMA 2009 flow diagram.

550 Alkureishi et al.: EMR Impact on Patient–Doctor Relationship JGIM

Table 1 Behavioral Analysis Studies (n=28)

Author Setting Population

Design & outcome measure Key findings

Greatbatch29

1995
One inner-city general prac-
tice (Liverpool, UK)

– 4 doctors
– 200 patients
(100 pre- & 100
post-EMR)

Video pre- & post-EMR to examine
changes in interpersonal interactions

– Increased doctor computer
preoccupation (i.e., pausing mid-
sentence to attend to the computer)
– Patients synchronized speech with
typing pauses to avoid interrupting
computer activity

Als30

1996
Unknown number of urban &
rural general practice (GP)
offices (Aarhus, Denmark)

– 5 GPs
– 39 patients
observed, 12
interviewed

Video & patient interviews to identify
desktop use patterns, describe patient
perceptions of the computer

– Characterized speech of doctor
(pauses, short responses) and patients
(synchronized speech with pauses in
doctor’s work)
– 10 % of patients invited to look at
the screen; when done, increased
patient perception of understanding

Safran31

1998
One academic-affiliated out-
patient primary care unit
(Massachusetts, USA)

– 12 doctors
– Patient n
unknown

Video & direct observation, semi-
structured patient interviews to ex-
amine patient attitudes to effects of
EMR

– No relationship between time doctor
spent with computer and patient
satisfaction
– No patient report of computer
interfering with patient–provider
interactions

Makoul32

2001
One academic urban general
internal medicine faculty
practice (Illinois, USA)

– 3 doctors use
EMR, 3 doctors
use paper
– 204 patients

Video, provider questionnaire &
medical record review to assess
patient–doctor communication
patterns associated with outpatient
EMR use.

– EMR doctors more actively clarified
information and encouraged
questions
– Trends that EMR doctors are less
active outlining patient agenda and
exploring psychosocial aspects

Booth33

2002
Unknown number of General
Practice (GP) offices (New-
castle, UK)

– Doctor n
unknown
– Patient n
unknown

Video to identify communication
skills that enable maintenance of
rapport & computer use during
clinical encounter

– Doctors prefer typing when patient
is not watching
– Wide variation in doctors sharing
screen with patients
– Doctors appear unsuccessful
multitasking complex computer
interactions with attention to patient

Booth34

2004
Two GP offices
(Northumberland &Yorkshire,
UK)

– 10 doctors
– 10 patients

Video to define skills that enable
effective computer use in the clinical
encounter

– More successful communication
skills included signposting computer
use, cues they are listening, facing
patient, cessation of typing when
patients speak

Arar35

2005
One Veterans’ Administration
(VA) internal medicine clinic
(Texas, USA)

– 6 doctors
– 50 patients

Video to assess EMR role in content
and process of patient–doctor
medication discussions

– EMR facilitated medication
communication
– EMR clarified and expanded
medication discussion

Frankel36

2005
One primary care clinic
(USA)

– 6 doctors
– 54 patients

Video pre- & post-EMR introduction
to identify communication impact
themes

– Introduction of exam-room com-
puters affected clinician–patient com-
munication in four domains; visit
organization, verbal & non-verbal
behavior, computer navigation &
mastery, spatial room organization.
– Baseline physician communication
behaviors amplified with EMR

Margalit37

2006
Three academic primary care
(adult and pediatric) clinics
(Haifa, Israel)

– 3 doctors – 2
faculty, 1 resident
– 30 patients

Video to describe the extent of
computer use & impact on a
researcher
– assigned patient-centered commu-
nication (PCC) score

– Doctor spent 35–42 % looking at
screen, 24 % of visits demonstrated
heavy keyboarding
– PCC score negatively correlated
with screen gaze and keyboarding

Ventres15

2006
Four primary care clinics
(Pacific Northwest, USA)

– 6 doctors
– 52 patients
interviewed, 29
observed

Video & patient interviews to identify
factors influencing doctor EMR with
patients

– Factors fall into four thematic
domains: EMR impact on spatial
interaction, perceptions of EMR,
provider proficiency with and patient
understanding of EMR use,
technological forces influencing
doctor EMR use

McGrath38

2007
One Veterans’ Administration
internal medicine clinic
(Southwest USA)

– 6 doctors
– 50 patients

Video to identify dimensions of non-
verbal physician behavior

– EMR positions facilitating
unobstructed patient–doctor visual
field most conducive to
communication
– Breakpoints from EMR use allowed
doctors to engage in eye contact, head
nodding and verbal utterances

Chan39

2008
Three academic adult GP
training practices in one large
health center (Belfast, Ireland)

– 10 doctors
– 100 patients

Video to determine computer use
differences in clinical encounters
with/without psychological compo-
nents

– Three styles of doctor EMR use; at
the end to summarize encounters,
continuous users, and minimal users
– Psychological encounters were
longer with half as much doctor EMR
use

(continued on next page)

551Alkureishi et al.: EMR Impact on Patient–Doctor RelationshipJGIM

Table 1. (continued)

Author Setting Population Design & outcome measure Key findings

Johnson40

2008
One academic urban hospital-
based pediatric resident clinic
(location unknown)

– 59 residents
– 149 caregivers
pre- & 94
post-ClicTate

Video pre- & post-ClicTate (elec-
tronic visit summary software) intro-
duction to detect changes in
questioning style and patient-
centeredness of communication

– Significantly greater open-ended
questions, more partnership strategies,
reinforcing statements and overall
more patient-centered interaction
post-ClicTate

Pearce41

2008
Unknown number of GP
clinics (Melbourne, Australia)

– 20 doctors
– 141 patients

Video to describe patient–doctor-
computer relationship during the
opening of visit.

– Doctor, patient or computer
encounters start differently, each
dictating visit flow
– Initial behavior of the patient
important in shaping nature of
interaction for the rest of the
encounter

Shachak42

2009
Five academic HMO primary
care clinics (Israel)

– 5 doctors
observed
– 69 patients

Direct observation to describe
doctors’ EMR use patterns,
influences on communication

– Average doctor screen gaze 25–55
% of visit
– One instance EMR used for patient
education
– Skills to minimize negative impact
of EMR: read aloud while typing, eye
contact, empathetic language,
disengage from computer for
important or sensitive issues

Noordman43

2010
Unknown number of GP
offices (Netherland, Denmark)

– 35 doctors
– 1170 patients

Video two points post-EMR & pa-
tient surveys to evaluate how doctors
use computer during clinical encoun-
ters over time, if computer use related
to aspects of communication

– Computer use negatively related to
some communication aspects (i.e.,
GP gaze/posture toward patient)
– No change in post-EMR relation-
ships between GP computer use and
communication

Shield44

2010
One academic adult family
medicine clinic (Rhode Island,
USA)

– 26 doctors (13
faculty, 13
residents)
– 170 patients

Direct observation, patient exit
interviews to examine EMR effects
on patient–doctor communication,
behaviors and patient perceptions

– Mix of positive, neutral & negative
patient responses
– Patient trust in the doctor and
security in the patient–doctor
relationship appeared to override
most patients’ concerns

Fiks45

2011
12 hospital owned, two urban
academic & ten10 suburban
non-academic pediatric practi-
ces (USA)

– 27 doctors
– 529 patients

Direct observation to characterize
EMR use patterns and patient–doctor
interaction

– EMR used 27 % of all stages of visit
except exam

Pearce46

2011
Unknown number of GP
offices (Australia)

– 20 doctors
– 141 patients

Video to explore patients’ approach
to the doctor’s computer use,
influence on patient–doctor
relationship

– Two patient themes: dealing
primarily with doctor, or dealing with
both computer and doctor

Gibbings-
Isaac47

2012

11 GP practices (London &
Southeast London, UK)

– 12 GPs
– 127 patients

Video to study silent time in the
clinical encounter when an EMR is
used

– Median 12.3 % silence during
encounter, mean duration 15.7 s
– 52.4 % of silent periods doctor
initiated & terminated

Montague48

2012
Five adult primary care clinics
(Wisconsin, USA)

– 10 doctors
– 100 patients

Video & post-visit patient survey to
understand qualities contributing to
patient satisfaction with regard to
doctor EMR use

– Three styles of doctor EMR use:
technology-centered, optimizing
(short typing sessions, stopped when
patients spoke), human-centered (less
typing)
– All doctors had high patient trust
and EMR use satisfaction ratings

Pandit49

2012
One academic adult glaucoma
subspecialty practice
(Maryland, USA)

– Unknown
number doctors
– 131 patients

Direct observation pre- & two points
post-EMR, and patient survey assess
the EMR impact on patient experi-
ence, doctor behavior

– Patient visit perceptions largely
unchanged
– No change in level of personal
contact in the patient–doctor
relationship or quality of visit

Booth50

2013

One state hospital & two
private practice outpatient
rheumatology clinics
(Adelaide, Australia)

– 3 doctors
– 15 patients

Video to examine communication
when computers used in clinical
encounter

– Patients tried to reorient doctor’s
attention from computer to
themselves, instances where
unsuccessful – Doctors use computer
to structure conversation
– Patients spoke during computer use
gaps & stop speaking when doctor
oriented to computer

Dowell51

2013
Eight adult GP practices
(Wellington, Australia)

– 28 doctors
– 28 patients

Video to explore how computer
influences clinical encounter
interactional flow

– Doctor focused on computer 12 %
of encounter time
– Varied doctor EMR use, most input
notes during visit
– Multitasking, interrupted
conversation flow

(continued on next page)

552 Alkureishi et al.: EMR Impact on Patient–Doctor Relationship JGIM

noted that EMR use appeared to facilitate clarification, ques-
tions and discussion, as well as more open-ended questions
and partnership strategies.32,34,35,40 Specific behaviors that
seemed to facilitate a more patient-centered interaction includ-
ed actively inviting patients to look at the screen and using it as
an educational tool (i.e., showing test results), signposting
computer use, maintaining eye contact, cessation of computer
use when patients spoke about sensitive or important topics,
continued verbal and nonverbal cues of listening, and reading
aloud while typing.30,34,38,42,54 Additionally, being able to
make computer use less obvious (i.e., typing softly, continuing
to speak while typing) resulted in fewer patient speech pattern
modifications.29

Five studies29,32,36,40,49 included both a pre- and a post-
EMR implementation observation group; however, only
two paired findings were to the same physician at both
points.29,36 Paired observations showed greater doctor pre-
occupation with computer use and alterations in doctor and
patient speech patterns, such as delaying speech until fin-
ished with the computer.29 Two studies demonstrated doc-
tors tended to adopt a more active role in clarifying infor-
mation and encouraging questions when the EMR was
used.32,40

Correlating EMR Communication Behaviors
with Patient Perceptions
While 11 studies29–31,34,37,38,43,44,48,49,55 attempted to
correlate objective observations of communication behaviors
with patient perceptions of care, only seven of these studies
elicited patient perspectives directly.30,31,43,44,48,49,55 The
remaining studies used researcher perceptions of the patient
perspective as a proxy. Studies noted mixed patient percep-
tions. An increase in provider screen gaze, keyboarding,
silence and closed body posturing negatively impacted

communication.43,55 However, certain behaviors enabled
more successful integration of the EMR into the visit, such
as screen sharing that did not obstruct the visual field between
doctor and patient.30 Three studies directly examined patient
perceptions of change in overall patient–doctor relationship
and quality of care or satisfaction overall, and found no
significant change as a result of EMR use.31,43,49 While two
studies noted high rates of satisfaction or trust of their doctor,
these studies did not report baseline data, thus making it
unclear if there was any change in satisfaction related to the
introduction of the EMR.48,55 Furthermore, two qualitative
studies showed a mix of positive, negative and neutral patient
responses without quantifying of the effect.30,44

Patient Perceptions: Pre- and Post-EMR Surveys
Eight studies used pre- and post-EMR patient surveys as their
only method of data collection, with a range of 100 to 18,897
patients responses.2,12,56–61 Five2,56–58,60 studies (63 %), two
of which had sample sizes over 10,000, found that most
patients reported no change in measures of overall patient
satisfaction, communication and the patient–doctor relation-
ship as a result of the introduction of technology into the face-
to-face clinical interaction.
Three12,59,61 studies (38 %) reported largely positive satis-

faction with communication and patient–doctor relationship as
a result of EMR use. One of these was unique because it was
one of only two inpatient studies and it directly enabled
patients to interact with the EMR.61 In this study, Furness
et al. examined the effect of allowing inpatient trauma patients
to view their radiographic images on a tablet with their con-
sultant. After the introduction of tablets, patients perceived
significantly more involvement in their care decisions and
being given the “right amount of information” about their
treatment as compared to before the introduction of tablets.61

Table 1. (continued)
Author Setting Population Design & outcome measure Key findings

Kumarap-
eli52

2013

11 inner city or country GP
offices (London, UK)

– 16 GPs
– 163 patients

Video to explore EMR use with
regard to room layout, computer use
proportion, doctor–patient–computer
interactions

– Room layout & doctor actions
determined patient ability to view and
interact with EMR
– Active screen sharing in 8 % of
encounters
– Eye contact 39 % & computer use
41 % of encounter

Montague53

2014
Five adult primary care clinics
in the Midwest (USA)

– 10 doctors
– 100 patients

Video pre- & post-EMR to examine
gaze patterns between patients and
doctors

– 30.7 % of visit is spent looking at
EMR vs 8.75 % paper
– Doctor-initiated gaze patterns are
important drivers of interaction be-
tween patient, doctor and technology

Saleem54

2014
Three primary care clinics
located in three VA Hospitals
(Southeast, Midwest,
Northeast, USA)

– 14 doctors
– Unknown
number of
patients

Direct observation, occasional
opportunistic patient interviews to
explore variations in, barriers to and
facilitators of the use of the EMR in
clinical encounters

– Considerable EMR use variation
– Instances of using EMR as
education tool (i.e., showing test
results on the screen)
– No EMR use during sensitive topics

Street55

2014
Four VA adult primary care
clinics (California, USA)

– 21 doctors
– 125 patients

Video, patient post-visit satisfaction
survey, researcher-determined PCC
score to examine EMR influence on
quality of communication and patient
involvement

– Overall high satisfaction rates,
unknown comparison to previous
– Less effective PCC with increased
doctor EMR gaze &encounter silence

553Alkureishi et al.: EMR Impact on Patient–Doctor RelationshipJGIM

Lastly, two studies reported that patients perceived their
quality of care as higher with EMRs.56,59

Patient Perceptions: Cross-Sectional Surveys
Seventeen studies used single cross-sectional patient surveys
as their only method of data collection, with a range of 65–518
patient participants per study. Nine of these examined patient
perceptions of physician distraction by the computer, with a
range of 3–40 % (mean 18 %) of patients expressing some
level of concern.63,64,66–69,72,76,78

Eleven studies examined global perceptions, with
eight62,67–71,73,77 studies (73 %) reporting no change in overall
patient satisfaction, communication or the patient–doctor rela-
tionship as a result of the introduction of EMR. One study
(9 %) demonstrated equally mixed positive, negative and
neutral patient satisfaction,76 and two studies (18 %) demon-
strated a majority of positive outcomes.72,75 Only one study
reported patient-perceived quality-of-care (QOC), with the
majority of patients reporting technology contributed to a
better QOC.67

Table 2 Patient Perceptions Studies: Pre- and Post-EMR Surveys (n=8)

Study
authors

Setting Population
sample

Design & outcome measure Key findings

Gadd2

2000

Six academic physical medicine and
rehabilitation (PM&R) outpatient
practices (Pennsylvania, USA)

– 17 doctors
pre-EMR
– 11 doctors
post-EMR
– 165 patients

Pre/Post to assess patient satisfaction – Little EMR impact on
satisfaction, most very satisfied
with care
– Patients denied loss of doctor
rapport
– Patients paused more when
doctor typed, requiring
reassurance before continuing to
speak

Garrison56

2002
One academic family medicine clinic
(Minnesota, USA)

– 200 patients
pre-EMR
– 304 patients
3 years
post-EMR

Pre/Post to assess patient views of
computer use and patient satisfaction

– No differences in overall
satisfaction
– 74.6 % thought positively
impacted quality of care (QOC)
– Most reported positive effect on
face-to-face doctor communica-
tion

Hsu12

2005
Adult primary care clinics (Internal
medicine & family practice) in 1
freestanding prepaid integrated
delivery system – Kaiser Permanente
(Oregon, USA)

– 8 doctors
– 313 patients

Pre/Post to assess patient satisfaction
and comprehension. Between 2nd and
3rd observation periods, providers
received training how to use
computers in visit

– 7 month increase in overall
patient satisfaction,
communication about medical
issues, comprehension of
decisions made
– No significant change in patient
satisfaction with communication
about psychosocial issues

Nagy57

2007
All ambulatory care clinics
(including pediatrics) in one large
Kaiser Permanente medical center
(California, USA)

– 184 doctors
– 4140 patients
pre-EMR
– 3980 patients
1–3 months
post-EMR
– 3177 patients
4–6 months
post-EMR

Pre/Post to assess patient satisfaction. – No significant differences in
patient–doctor communication or
patient satisfaction

Stewart58

2010
One academic psychiatric outpatient
clinic (New Mexico, USA)

– 161 patients
pre-EMR
– 141 patients
4 months
post-EMR

Pre/Post to assess patient satisfaction – No significant changes in any
psychiatric patient satisfaction
measures pre- versus post-EMR

Rosen59

2011
One academic pediatric
rheumatology practice
(Pennsylvania, USA)

– 99 families
pre-EMR
– 107 families
post-EMR

Pre/Post to assess family satisfaction – Greater satisfaction with EMR
compared to paper
– Higher rating of quality of care
post-EMR
– EMR increased understanding
of child’s health

Fairley60

2013
One large sexual health outpatient
service (Melbourne, Australia)

– 9752 pre-
EMR patients
– 9145
post-EMR
patients

Pre/Post to assess patient satisfaction – No difference in patient
satisfaction with care

Furness61

2013
One district general hospital adult
inpatient trauma unit (Bath, UK)

– 50 pre-tablet
patients
– 50 post-tablet
patients

Pre/Post to assess if enabling trauma
patients to view radiographic images
on a tablet during consultation
improved satisfaction, understanding,
overall experience

– Post-tablet patients significantly
improved involvement in care
decisions
– 97.8 % felt it helped understand
what consultant told them,
95.6 % felt positive effect on their
overall hospital experience

554 Alkureishi et al.: EMR Impact on Patient–Doctor Relationship JGIM

Table 3 Patient Perceptions Studies: Cross-Sectional Surveys (n=17)

Author Setting Population Design& outcome measure Key findings

Aydin62

1995
One Kaiser Permanente
ambulatory adult preventative
medicine clinic (California, USA)

– 233 EMR patients
– 195 non-EMR
patients

Post-visit survey to assess patient
satisfaction with & without
CompuHx, an EMR.

– No significant difference in
patient satisfaction
– Use of CompuHx did not
depersonalized the patient–doctor
relationship

Gonzalez-
Heydrich63

2000

One academic outpatient pediatric
psychiatry clinic (Massachusetts,
USA)

– 87 parents Post-visit survey to assess parental
acceptance of EMR

– 100 % noted doctors paid
attention to concerns
– 90 % reported computer use was
a “good thing”
– 3 % reported concerns (i.e.,
provider distraction)

Chan64

2003
Three academic adult training GP
offices (Belfast, Ireland)

– 10 doctors
– 102 patients

Post-visit survey to assess
attitudes to doctor computer use
during clinical encounters

– 1 % distracted by GP computer
use, 3 % felt computer distracted
GP
– 100 % happy with how GP used
computer and that it was useful in
the encounter (95 %)

Houston65

2003
One academic adult internal
medicine resident clinic (Alabama,
USA)

– 82 residents
– 93 patients

Post-visit survey to assess patient
perceptions of handheld PDA use

– 59 % liked idea of a doctor with a
PDA in the exam room

Weaver66

2003
One adult family practice (Ohio,
USA)

– 212 patients Post-visit survey to assess patient
perceptions of electronic
knowledge coupling (KC) tool
use during a clinical encounter

– 28 % felt computer interfered
with doctor ability to listen &
contributed to less personal
attention
– 21 % had concerns of doctor
over-reliance on technology
– Positive points include patient
education, increased empowerment
to understand condition

Callen67

2005
One outpatient general practice
(Sydney, Australia)

– 77 patients Post-visit survey to assess patient
perceptions of computer use
during clinical encounters

– 27 % felt doctor distracted by
computer, 25 % uncertain
– 66 % felt relationship unaffected
by computer
– 63 % felt it contributed to better
quality of care

Freeman68

2007
One outpatient specialty headache
practice (North Carolina, USA)

– 394 patients Post-visit survey to assess patient
satisfaction and perceptions

– 78 % denied EMR interfered
with relationship
– 40.8 % feel medical care is better
with computer
– 14.6 % felt eye contact was less

Rouf69

2007
One academic VA adult primary
care faculty & resident clinic (New
York, USA)

– 33 doctors
– 155 patients

Post-visit survey to assess patient
satisfaction, quality of care and
impact of the computer on
patient–doctor relationship.

– 8 % felt EMR interfered with
relationship
– Residents’ patients more likely to
agree the computer adversely
affected amount of time doctor
spoke to and looked at them

Almquist70

2009
One academic internal medicine
clinic (Minnesota, USA)

– 6 doctors
– 65 patients – 30 in
standard room, 35
in experimental
room

Patient & care partner post-visit
survey after randomization to ei-
ther standard room favoring doc-
tor EMR use or experimental
room designed to favor patient-
centered care to determine effect
of room redesign on the patient-
clinician interaction

– No difference between rooms in
patient satisfaction with encounter,
mutual respect, or communication
quality
– Experimental room patients
reported clinicians allowed them to
review the medical record on the
screen, shared information on the
screen, and reviewed information
on the internet with the patient
significantly more than standard
room

McCord71

2009
12 academic community adult
family medicine resident & faculty
clinics (Ohio, USA)

– 284 doctors
– 284 patients

Single post-visit survey to elicit
perceptions regarding doctor use
of a PDA in clinic visit

– 73 % note no change to provider
communication
– 83 % note no change in their
relationship
– Communication rated more
positively when doctor explains
why they are using the PDA

Lelievre72

2010
One academic adult family
medicine center (Ontario, Canada)

– 175 patients Post-visit survey to assess patient
satisfaction

– Only a doctor’s attitude toward
computer shown to have a positive
correlation on patient preference
for computer
– 61 % note no effect on doctor
distraction
– 57.1 % thought computer had
positive effect on their overall
satisfaction, 30.3 % saw no effect

(continued on next page)

555Alkureishi et al.: EMR Impact on Patient–Doctor RelationshipJGIM

The remaining six cross-sectional studies63–66,74,78 (35 %)
in this group also examined patient perceptions, but lacked
global measures such as overall satisfaction with communica-
tion or the patient–doctor relationship. It appears, however,
that they contained more positive (i.e., use of the computer
was a “good thing”)63 than negative (i.e., the computer inter-
fered with my doctor’s ability to hear my complaints)66 patient
comments.
One study used a “patient-centered” spatial arrangement of

the room and computer, and found no difference in patient
satisfaction or perceptions of communication quality with the
ergonomic change.70

Characterizing Positive Deviants
An important but limited number of studies (n=4) examined
increases in patient understanding of their condition as a result
of their provider using the EMR in the clinical interaction,
demonstrating increased perceptions of empowerment and
informed decision-making.12,59,61,66 Also, of the 22 total
articles examining impacts of the EMR on overall patient
perceptions of satisfaction, communication or the patient–

doctor relationship as a result of EMR use, five (23 %) found
positive changes and these are important to high-
light.12,59,61,72,75 Three of these (60 %) were conducted out-
side of the US in countries in which a Universal Health Care
system exists (UK, Canada, Germany).61,72,75 Two focused on
the use of a somewhat novel technology aide; one using a
tablet to view radiologic images61 and another using an EMR
decision aid,75 both of which resulted in increased satisfaction
with the encounter, counseling, and involvement in their care.
Of the two US studies, Hsu et al.’s Kaiser study was remark-
able in that it was the only study that provided physician
training on how to integrate computers into the visit.12,59

Although there was a decrease in patient satisfaction after
physician training, from 67 % 1 month post-EMR (pre-
training) to 63 % 7 months post-EMR (post-training), there
was increased overall patient satisfaction 7 months post-EMR
introduction compared to baseline.12 Due the observational
design of the study, it is unknown whether the changes in
satisfaction were related to the training; however, it is an
important finding.
Interestingly, a greater percentage of positive studies ema-

nated from the international community, with 43 % (n=3 of 7

Table 3. (continued)

Author Setting Population Design& outcome measure Key findings

Strayer73

2010
One academic adult family
medicine center (Virginia, USA)

– 96 patients Post-visit survey to assess patient
attitudes toward doctor tablet PCs
use

– 98 % felt could speak as easily
compared to prior
– 84 % denied less personal
interaction
– Those that thought the interaction
was less personal (15 %) tended to
be minority patients

Kahane74

2011
Five academic affiliated family
medicine clinics (Ontario, Canada)

– 75 doctors
– 153 patients

Post-visit survey to assess patient
confidence in their family doctor
and perceptions of quality of care
after seeing doctors look up
medical information during the
clinical encounter.

– 9 % of patients perceived
decreased confidence when
information source not known
– When source known, confidence
was lower when patients saw
providers use a PDA (27 %) or
internet search engine (39 %)

Hirsch75

2012
Unknown number of adult primary
care practices (North Rhine-
Westphalia & Hesse, Germany)

– 29 doctors
– 192 patients

Post-visit survey to assess patient
attitudes with use of Arriba-lib, an
electronic library of decision aids,
during their clinical encounter

– 97.4 % of patients satisfied with
counseling received, 64.7 %
wanted to be counseled with the
module again in the future

Al Jafar76

2013
78 primary adult health care
centers (Kuwait)

– 518 patients Post-visit survey to assess patient
satisfaction

– 36 % felt EMR increased trust in
doctors, 35 % disagreed
– 31 % felt EMR improved the
relationship, 34 % disagreed, 35 %
uncertain

Jarvis77

2013
2988 different hospitals eligible to
participate in the Centers for
Medicare and Medicaid Services
Hospital Value-Based Purchasing
Program (USA)

– Unknown number
of patients

Single Hospital Consumer
Assessment of Healthcare
Providers and System (HCAHPS)
patient survey in order to evaluate
association between advanced
EMR use on patient estimated
process and experience of care
scores

– Hospitals with advanced EMR
use showed a 4.2 point higher
process of care scores
– There was no significant
difference in estimated patient
experience of care scores by level
of advanced EMR use

Ratanawo-
ngsa78

2013

One academically-affiliated inter-
nal medicine clinic in a public
hospital (California, USA)

399 patients
– 31 % Latino
– 17 % Asian
– 17 % African
American
– 18 % White

Post-visit survey to examine
associations of patient race &
ethnicity, language and education
with perceptions of doctor
computer use

– 20 % felt providers listened less
carefully because of computer,
non-English speakers less likely to
endorse this
– Most felt the computer helped
their provider take better care of
them (74 %) with non-English
patients recognizing benefits more
often

556 Alkureishi et al.: EMR Impact on Patient–Doctor Relationship JGIM

total studies)61,72,75 noting overall positive changes in satis-
faction in communication or the patient–doctor relationship as
a result of technology use versus 13 % (n=2 of 15 total)12,59 of
US studies.

CONCLUSION

This systematic review of the impact of the EMR on the
doctor–patient relationship and communication found while
physicians exhibited potentially negative communication
behaviors with EMR use (i.e., interrupted patient and doctor
speech patterns, increased gaze shifts and episodes of multi-
tasking, and low rates of sharing the computer screen with
patients), the majority of studies examining patient percep-
tions reported no change in overall patient satisfaction, com-
munication, or the patient–doctor relationship. Furthermore,
some studies identified instances in which patients felt the
EMR facilitated the process of communication, clarification,
and discussion as well as some potentially patient-centered
communication behaviors. These Bbest practices^ may be
taught to providers in order to guide them towards more
successful and collaborative EMR use. Given that the majority
of studies were conducted in adult primary care clinics, these
findings are highly pertinent to adult providers since commu-
nication is key to the patient–doctor primary care relationship
and patient outcomes.3–10 Lack of change in overall patient
perceptions may be surprising to clinicians, given accounts of
negative provider attitudes to EMR implementation.2,65 How-
ever, knowing that patient perceptions did not suffer, providers
and administrators should not be deterred by fears of its
adoption and instead learn to actively use it in a more
patient-centered manner.
It is important to reflect on the five of 22 studies that reported

positive changes in overall patient satisfaction, communication
or the patient–doctor relationship as a result of EMR use. These
positive patient perceptions are perhaps reflective of a different
culture of EMR use in these settings, and an increased accep-
tance in other countries or highly integrated healthcare systems.
It is possible that improved patient and provider familiarity with
the EMR in these environments created a different culture of
practice that enabled EMR use in a more patient-centered
manner. Comparatively, US patients and physicians are perhaps
not as cognizant or experienced in achieving this, as evidenced
by the greater positive patient perceptions abroad. Given the
tremendous potential of EMR integration for patient education,
it is important to highlight best practices in order to maximize
EMR use as an educational tool.
It is also worth considering why patient and physician

perception discrepancies regarding EMR use exist. Patient
satisfaction or their perceived quality of care may be driven
by factors other than provider communication behaviors. For
example, the EMR may improve clinical efficiency by making
it easier for physicians to communicate with other providers,
and in turn patients may perceive physician technology use as

positive overall. Because the majority of studies were con-
ducted in adult primary care settings, strong patient–doctor
relationships may have contributed to patients being more
accepting of their doctors being unfamiliar with the EMR at
first and slowly becoming facile with the EMR. Additionally,
patients may not consciously notice behavior differences as
much as trained observers.
This review identifies the need for further study in a variety

of areas related to EMR use. Future work should correlate
observed physician behavior with direct patient perceptions
rather than a trained observer as proxy, in order to identify how
to best use the EMR during clinical interactions to engage
patients in their care. Objective studies should further explore
how to integrate EMR use to enhance patient engagement and
communication.
Also, few studies took place in primary care academic

settings, which is particularly interesting due to issues around
the hidden curriculum and potential negative role-modeling by
attendings, given the lack of training on patient-centered EMR
use. This highlights the need to study academic settings fur-
ther, and to develop and implement effective curricula for all
providers on how to use the EMR to enhance patient–doctor
communication.
In the future, greater attention should be given to studies

outside of adult outpatient primary care. Since high levels of
continuity may influence patient perceptions of EMR use,
studies should specifically focus on inpatient or specialty
settings to understand the impact of EMR use in low continu-
ity settings. Also, given the increasing rates of technology
adoption by younger Bmillennial^ trainees (i.e., fellows, resi-
dents, medical students), further studies should look at how
this group may differ from older providers in their EMR use.
Lastly, future research should utilize randomized study
designs where possible; for example, randomizing providers
to EMR training and directly eliciting patient experience re-
garding technology use and the impact on patient–doctor
communication.
Although this systematic review found several significant

findings, there are important limitations to note. For instance,
while nearly one-third of studies examined patient percep-
tions, the heterogeneity in the type of questions asked and
lack of global measures such as overall satisfaction limited the
ability to compare findings within this cohort. Also, analysis
of the included studies reveals potential areas where study bias
could exist. The majority of studies used direct observation
methods, which are a proxy for the patient’s experience and
are subject to inter-observer variability when multiple individ-
uals are observing and reporting on behaviors observed. Inter-
viewer bias could also have occurred when those observations
were followed by questioning from the study personnel. There
was also the potential for publication bias, and while we
sought to address this by reviewing abstracts from related
meetings, we were not able to review abstracts for all possible
related meetings and could only review studies published in
English. Another limitation is the paucity of studies

557Alkureishi et al.: EMR Impact on Patient–Doctor RelationshipJGIM

documenting both specific observed communication behav-
iors pre- and post-EMR in addition to eliciting direct patient
perceptions. With increasing rates of EMR adoption, it will be
harder to conduct such a pre-post EMR study. Also, for those
studies where the is no pre-EMR observation, it is quite
possible that these providers were at baseline poor communi-
cators, and thus the introduction of the EMR is not to account
for the negative behaviors observed, but rather they are reflec-
tive of the providers’ poor baseline communication ability.
Reliance on convenience samples of both physician and

patient subjects may have contributed to selection bias in both
groups, as only one study70 was randomized. Most studies
identified had small numbers of physician and patient partic-
ipants as well as study sites. As such, external validity of the
findings and the ability to generalize them to other groups or
populations is not known. In addition, because many of the
studies were observational in nature, causal inferences could
not be made and unmeasured confounders may exist. Lastly,
multiple variables contribute to the overall experience of the
patient–doctor relationship and communication, and it is quite
plausible that some other factor is contributing to the observa-
tions and effects seen.
In conclusion, it appears EMR use can improve patient

understanding of conditions and treatment plans, and increase
sharing and confirmation of medical information. Several
studies identify behaviors that appear to facilitate patient-
centered communication (i.e., screen sharing, signposting,
cessation of typing during sensitive discussions) and future
work should adapt these best practices into a curriculum to
teach providers how to integrate patient-centered EMR use
into their clinical workflow. Medical education targeting the
continuum of learners can address this gap in training and help
foster humanistic patient–doctor-EMR interactions in the dig-
ital age.

Acknowledgements:

This project was made possible by a grant from the Arnold P. Gold
Foundation.

Contributors: Our two expert reviewers were Darcy Reed MD, MPH,
Associate Professor of Medical Education and Associate Professor of
Medicine, Department of Internal Medicine, Mayo Clinic, and Rich
Frankel PhD, Professor of Medicine, Indiana University School of Med-
icine, Associate Director, VA HSR&D Center for Health Information and
Communication.

Corresponding Author: Maria Alcocer Alkureishi, MD, FAAP;
Department of Academic Pediatrics, University of Chicago, Chicago,
IL, USA (e-mail: malkureishi@peds.bsd.uchicago.edu).

Compliance with Ethical Standards:

Funders: Funding for this review was made possible from a grant from
the Arnold P. Gold Foundation Research Institute Call for Reviews of
Research on Humanistic Healthcare.

Prior Presentations: The results of our review were presented at the
Arnold P. Gold Foundation Research Institute Symposium on Reviews
of Research on Humanistic Healthcare, 2 May 2015

Conflict of Interest: The authors declare that they have no conflict of
interest, financial or otherwise, to disclose in relation to the content of
this paper. Funding was provided by the Gold Foundation. The Gold
Foundation had no role in the conduct of the review, management,
analysis or interpretation of the data, or in the preparation of the
manuscript.

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Hospital Management Based on the Relationship
between Doctors and Patients

Armenia ANDRONICEANU1

Abstract: Doctor-patient relationship is an interesting issue that should be studied more
by the researchers The patients have become healthcare consumers. Their expectations
have grown and they want from the doctors more than professional skills. Through this
work we discover the expectations of the patients from the doctors and how could be
improved the relations between the doctors and the patients of the medical clinics located
in Bucharest. The purposes of this paper were to identify patients’ expectations and to
discover the extent to which they are satisfied by health services offered by private health
clinics in Bucharest. In accomplishing the proposed goals, the research methods used
were: the questioner and the interview. In order to synthesize and analyze the data, we used
the SPSS. We concluded that more than 77% of the patients are satisfied with the health
services offered by private clinics selected. However, patients have other expectations that
we have discovered through this research. These are analyzed and can significantly
influence the relationship between doctors and patients and the quality of medical services
in private clinics from Bucharest.

Keywords: doctor, patient, relationship, communication, satisfaction.

JEL: I1; I19.

Introduction

Doctor-patient communication has become very important lately for

patients as well as for doctors. It is desirable that this part of the medical act should
be constantly improved because it brings great advantages in the final results and in
medicine in general. Over time, the doctor-patient relationship has experienced a
number of transformations due to phenomena such as: increasing the patient’s
active participation in the medical act, while reducing the passive acceptance of
therapeutic indications, increasing the responsibility of individuals towards health,
increasing the degree of information, the level of knowledge and exigencies of the
patients, the assumptions, the medical declension, the role of doctor like educator
regarding the lifestyle and the risk behaviors, and even the changes in the
organization of the medical system.

Various studies have shown that classical, symptomatic-oriented medicine
tends to be more and more replaced by patient-centered medicine where the doctor
pays more time to the patient’s (not only medical) problems. According to a recent
studies (Besciu, Androniceanu, 2017; Friedman et al., 2016; Jakubowska,2016;

1 Professor PhD, The Bucharest University of Economic Studies; Bucharest; Romania;

armenia.androniceanu@man.ase.ro

Androniceanu, A. (2017). Hospital management based on the relationship
between doctors and patients. Administratie si Management Public, (29), pp.41-53.

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Jaworzynska, 2016; Ślusarczyk, 2017), which analyzed possible discrepancies
between the role of the patient and the doctor’s role in the therapeutic relationship,
it was found that most patients want an active collaborative involvement in the
management of their own illness. However, there is a relatively modest (about
30%) concordance between the desired role and the perceived role. Health is a
complex, multidimensional reality, being medical, but also economic and social
issue. In an open or cooperative environment, people increasingly perceive the
importance and value of their role, listen to and understand faster what they are
communicating, feeling that they can express their ideas with sincerity, without
fear. In an open society, the doctor-patient relationship is changing constantly and
is strongly influenced by communication, through which the patient transmits to
the doctor ideas, attitudes, feelings, information used in diagnosis and treatment.
Good communication between the doctor and the patient does not only increase the
level of patient satisfaction, but it also influences a number of health indicators.
The development and modification of the Romanian medical system after 2015 has
also led to a change in the expectations of both patients and medical staff.

Based on the principles of current medical practice, the relationship
between the doctor and the patient bring something extra to the two parties
involved in the medical act, such as: the comfort and safety in the diagnostic and
therapeutic approaches, increased recognition of the value of the doctors work and
an increased prestige of their activity.

1. Literature review

Initially, in the specialized papers (Krot & Rudawaska, 2016; Machan,
2016) a great deal of emphasis was placed on the medical act itself: interventions,
hospitalization and the administrative side. Later on, the researchers started to
bring attention and studying non-medical factors such as: doctor-patient
relationship, organizational climate, benefits provided by clinics outside strict
health services (Łakomy-Zinowik & Horváthová, 2016; Krzikallova & Strikova,
2016).

Given the changes in recent decades, many authors have emphasized their
studies on the patient-doctor relationship and have shown that it is an important
factor to be considered in defining patient satisfaction with the services provided
by different clinics (Ngo VuM & Nguyen Huan, 2016; Nica et. al., 2016; Rosario
& Nakagawa, 2016). An example of this is the work published by a group of
researchers coordinated by Chaohui (Chaohui et al., 2016) which highlights the
fact that non- medical professionals have a defining role in the choices of patients
who tend to choose one doctor or another according to the relationship they
manage to establish with it (Balcerzak, 2016; Androniceanu, 2016). The study
showed that respondents place great emphasis on trust, recognition and emotional
support, dignity, reassurance, and information provision. (The study showed that
all respondents were treated with dignity after their last visit to general practitioner,
98% were listened to by the doctor in the health problem. A share of 80% of

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respondents considered that their medical staff empathized with their health
problem and offered them insurance that they would be overwhelmed, 49% of the
respondent said they had obtained information from the doctor only if they asked
for it, while 45% received information whether they requested or not. The
researchers demonstrate that patients place great emphasis on medical services but
equally on non-medical services, on the relationship they can establish with their
doctor, on their ability to provide information even if they are not required, on
treating with dignity and on offering the possibility to make the decision together
with the patient.

Other authors have approached a similar theme (Acosta, 2014; Börzel,
2016). They reviled the fact that non-medical factors such as culture and language
are determinants in establishing a good relationship between doctors and patients
and implicitly in increasing patient satisfaction with this relationship.

The purpose of the study prepared by Siegfried (2011) was to demonstrate
how the differences in race, language, ethnicity and quality of medical act
influence the physician-patient relationship. In conducting this study, the authors
analyzed specialty studies to assess existing evidence of racial and ethnic
disparities and how they influence communication and patient-patient relationships
(Mihăilă, 2016; Rosario, et al., 2016; Siekelova et al., 2017). The study of Siegfried
showed that race, ethnicity and language significantly influence the quality of the
doctor-patient relationship and medical act. Patients who come from different
ethnic and racial minorities and who do not speak English fluently are predisposed
to establishing a poor relationship with doctors, also do not receive enough
information, doctors are not empathic with them, and do not allow them to
intervene in making decisions about diagnosis and treatment.

Taking into account the results obtained, the authors believe that patients
should make more efforts to learn the English language better, the work force
attracted to clinics being more diversified, allowing the access of doctors of
different ethnicities and different races. Also the authors believe that doctors need
to place more and more emphasis on communicating with patients regardless of
ethnicity or culture and to develop on this path.

Researchers are increasingly focusing on improving patient-to-patient
communication to demonstrate that it has an important role to play in increasing
customer satisfaction and increasing the quality of medical services in general. In
support of this statement, we can take as an example the study published by
Machan in 2016 showing how the doctor should communicate with the patient
from the first visit to establish effective communication and meet his/her
expectations. Researcher’s results demonstrate that taking into account the needs of
patients, understanding their problems and their expectations from the consultation
is the foundation for creating effective and successful communication between
doctor and patient. They emphasize both verbal and non-verbal communication to
describe a successful relation and describe these exchanges of information as a
two-step process.

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In the 21st century, medicine evolved greatly, focusing on technology,
profit, but at the same time improving the relationship between patients and doctors
to increase consumer satisfaction and keep profits. This idea is found in several
studies. The authors believe that the health systems are changing being more
emphasized on profit, technology. Paradoxically, in the era of communication
based on internet use medical systems face a distortion of communication between
doctors and patients, with a continuous decline in customer satisfaction and a
growing number of complaints. Most patients’ complaints do not relate to health
skills, but to an ineffective communication. Most often, patients complain that
doctors do not listen to them. The patients want more information about their
problem and treatment outcomes, more information on the side effects of
treatment, and advice on what they can do for themselves (Balica, 2017; Laudan et
al., 2016; Lăzăroiu, 2016). Different studies analyzed by the researcher have shown
that doctors and patients have different spikes in what might be effective
communication between them. These opinions influence the quality of the
relationship between the doctor and the patient as well as the respect, the patient’s
education and the final results of the medical act. Learning communication skills in
times of change and uncertainty depends on an emotional opening to oneself and
others. Medical educators should use patients ‘perceptions of care and focus on the
areas of teaching that will help them to meet patients’ expectations.

Doctor-patient relationship involves diagnosis, orientation and
postoperative surveillance, and affective-psychological counseling: the body heals
more easily if the soul is quiet. This interaction leads to a particular attachment of
the patient to the doctor. The diagnosis determined by the doctor is a complex, bio-
psycho-social one, the relationship between the patient and the doctor can be
compared to the friend-friend relationship (Ohanyan, Androniceanu, 2017).

The doctor-patient relationship is an important issue that should be
brought into public attention in Romania mainly because in this era of changes,
technology and the Internet, in this age when patients became health services
consumers, their expectations increased and want more than professional skills,
want to be involved in decision-making. This theme has been studied a little in our
country, most of the studies being built from psychological perspectives and
generally presenting types of communications that can be carried out between the
doctor and the patient without consulting the opinions of patients and doctors on
this topic. Studies are also based on public health systems without taking into
account private systems (Kyzenko et al., 2017). Considering these limitations of
previous studies, I chose to investigate the issue of doctor-patient relationship
based on communication from the perspective of private health clinics in Bucharest
and to find out the degree of patient satisfaction in these clinics.

2. Main research results and analysis

The general objective of the research was to know the expectations of the

patients from the private health clinics in Bucharest regarding the doctor-patient

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relationship and the extent to which these expectations are met by the medical staff.
The main specific objectives were: to identify the patient satisfaction degree and
the main causes of dissatisfaction; to discover the main qualities of medical staff
that lead to maintaining good communication between doctors and patients; to find
out what causes patients influence negatively the communication between the
doctors and the patients of the private clinics in Bucharest. The main instrument
used for data collection was a questionnaire with 14 items completed by 121
respondents. This was completed by a structured interview about the doctor-patient
relationship in the private health clinics. We chose the interview as a research
method to clarify some aspects or interpret the research results correctly. Tables 1
and 2 show the structure of the sample.

Table 1. The structure of the sample based on gender

Gender Frequency Percent

Valid

Percent

Cumulative
Percent

Valid
Female 66 54.1 54.5 54.5
Male 55 45.1 45.5 100.0
Total 121 99.2 100.0

Missing System 1 .8

Total 122 100.0

(Source: Author)

Table 2. The structure of the sample based on age

Age range (years) Frequency Percent Valid Percent

Valid

18-28 29 23.8 4.0
29-39 43 35.2 35.5
40-50 38 31.1 31.4
50 11 9.0 9.1

Total

121

99.2 100.0

Missing System 1 .8
Total 122 100.0

(Source: Author)

As far as the environment of origin is concerned, most respondents live in
urban areas (82%). Thus, 44 of the female respondents come from the urban area,
unlike 22 from the rural area. As for male respondents, we can observe the same
distribution, 38 of them having the urban environment as opposed to 17 from the
rural environment. Regarding the level of education, most of the patients of the
private health clinics have completed a high school studies (97%). Following the

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analysis of the subjects’ preferences for the clinics in Bucharest, we found that the
majority of respondents (87 out of 121) prefer private health clinics. The main
argument of most subjects (97%) is the better quality of health services. Most
respondents say they accessed more than once a year at private health clinics (100
respondents), unlike those who called once (21 subjects). These results show that
more than half of respondents are satisfied with the services provided by private
health clinics. The study highlights the fact that 92 respondents who were patients
of private clinics were satisfied with the relationship they have with doctors in
private health clinics. Only 7 people expressed their dissatisfaction with how they
related to medical staff in private clinics. All respondents contacted and benefited
from health services provided by public clinics in Bucharest. Through this research
we found that 32% of the subjects (26%) were satisfied with the relationship with
the medical staff, and the remaining 68% declared dissatisfied with 56 patients.
Among the causes mentioned, we note: the high waiting time to enter a
consultation (38 dissatisfied – about 68%); unsatisfactory communication with
doctors and other medical staff (7 respondents -12.5%); medical bureaucracy
(almost 86%) and informal payments (11 respondents – 19.64%).

The research has shown that the patients are focused more on the
communication skills of the doctors then the consultation (64 persons). Another 40
patients are focused both on the professional and the communication skills (40
persons). The rest of the respondents (17) are focused on professional skills only.
These answers legitimize our research, demonstrating that the relationship between
doctors and patients of private clinics is an important topic to address and need to
be addressed. It is a research niche that does not have much information at this time
in our country and needs to be carefully explored. Answers to the question of
patients’ expectations show their focus on communication during the medical
consultation. According to the answers to this question, we note that patients
expect to be treated with respect (27 persons), the others would like to obtain from
the doctors all information on diagnosis or treatment (27 persons) and the rest of
them would like to be involved in a special discussion with the doctor during the
decision making about the diagnosis and the treatment. Another question referred
to the factors that determine these expectations. The results are shown in the figure
1. We note that the main factors that determine patients’ expectations regarding the
patient-doctor relationship in the private health clinics are: the high cost of services
(38.02%) followed by the clinic’s notoriety (31.4 %) and the fame of doctors
working in these clinics (23.9%).

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Figure 1. The main factors that determine the expectations of patients towards
the medical services offered by the private clinics in Bucharest

0 5 10 15 20 25 30 35 4

0

High cost of services

Applying the law and bureaucracy

Clinical notoriety

The fame of private clinic doctors

(Source: Author)
According to another question we note that the main factors that determine

patients’ expectations regarding the patient-doctor relationship in private health
clinics are: the high cost of services (with the highest weight of 38.02%), followed
by the clinic’s notoriety (31.4%) and the fame of physicians working in these
clinics (23.9%). Research has led to the discovery of the reasons for patient
dissatisfaction (Figure 2). 38% of them think they are dissatisfied, if the doctor
does not pay much attention and time; 28.9% are unsatisfied when the doctor does
not provide enough information with regard to diagnosis or treatment, 17, 3% are
dissatisfied when doctors use special medical terms without explaining their
meaning, and only 15% are dissatisfied if the doctor does not listen to them.

Figure 2. The main reasons of the patients dissatisfaction
in their relationships with the doctors

(Source: Author)

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The research has led to the main reasons why patients would give up the
services of private sanitary clinics, as can be seen in figure 3.

Figure 3. The main reasons why patients would give up
the services of private sanitary clinics

0

5

10

15

20

25

30

35

40

Limited
profesionalism

Lack of respect Insults Safety

(Source: Author)
According to the answers, we can see that the main causes that lead

patients to no longer consult with a doctor are different: (1) if the doctor treated the
patient without respect (35.54%); if the patient was offended by the doctor
(33.06%), these answers having a share of over 65% of the total respondents. These
results highlight the major loopholes between doctors and patients in private clinics
in Bucharest.

According to the results of this study, the most important skills of a doctor
to maintain a good relationship with patients are presented in the figure 4. As can
be seen, the key qualities of a doctor in maintaining a good relationship with
patients are: respect (for 25.62% of respondents), understanding and compassion
(for 24.79% of interviewed persons) and time spent on consulting a patient (almost
20%). Less then 20% from the respondents consider professionalism and
encouragement from doctors like being relevant. From these correlations we can
see that the most patients are satisfied with the relationship they have with the
doctors from private health clinics. The research demonstrates that the relationship
between doctors and patients are influenced by the doctors skills.

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Figure 4. Main skills of the doctors preferred by the patients

of the private health clinics

0
5
10
15
20
25
30

(Source: Author)
The results of the survey based on the questionnaire are complemented by

those obtained on a structured interview. The structured interview was applied to 7
patients of the private health clinics in Bucharest who were willing to answer a
total of 5 questions.

To the first group of questions were: “Do you often go to private health
clinics in Bucharest? Do you have a health insurance? “We were surprised to find
that 5 of the 7 interviewed people go to consultations at these clinics and have an
individual health insurance. They claim that they go to consultations for a variety
of gynecological, dermatological, cold, pain, and endocrinology (one of the chronic
illnesses for regular visits to the health care supervisor). One of the other people
was for the first time at one of the health clinics in Bucharest. She had no
subscription but said she was happy and would like to make a health insurances
soon. The last person had a health insurance but came about 2-3 times a year only
for routine checks and annual analyzes. Since most of the people we discussed
have health insurances and often come to private clinics, we can conclude that they
are happy with the services provided by doctors.

The second group of questions helps us in the validation of the general goal
and specific objectives, namely to know the patients’ expectations regarding the
doctor-patient relationship.

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Are you satisfied with the doctor-patient relationship at the private health
clinics in Bucharest? Why?

To this question everyone responded that they were happy for different
reasons among the following: “We are respected, we can come on programming
and when it is time for the doctor to take us from the waiting room,” “I always
received all the information from the doctor, I’m not afraid to ask if I do not
understand something or if I want to know something extra because the doctor
answers me calmly and politely every time, “” if I have a ugly, I can call a doctor
because he gave me the phone number “,” the doctor is patiently listening
whenever I have a problem, do not interrupt my analysis, and explain each analysis
in part, “” no matter how many patients he had before me, my doctor always
smiles, is calm and relaxed, “He/She gives me all the explanations I need.”

Based on these assertions, we note that patients’ expectations regarding
patient-to-patient relationship are not just based on professional skills, patients are
very interested in an effective communication, they need to be listened to, have
patience with them, of calm and relaxation, to transmit all the information and to
understand them, to be able to call a doctor and in case of emergency. Also from
the primal responses we can state that the patients are satisfied with the relationship
they have with the doctors in the private health clinics. Question 3 helps us get
more information for validating another specific research goal.

What do you think are the most important qualities of a doctor in relation
to the patient?

To this question, patients have listed some qualities that they consider
imperative for a good patient – doctor relationship, and also considered that they
should be on both sides: patience, empathy with the patient, punctuality, being able
to offer all patient information and understanding, calm and professionalism.

The group of questions number 4 helps us to discover that there is a reverse
relationship between the time given by the doctor during the consultation and the
patient’s dissatisfaction with the doctor-patient relationship. The patients are
contented that they have enough time to expose the problem to the doctor. Even so,
they consider that the consultation time is too short.

One of these people says it’s not the doctor’s fault, but within 10-15
minutes there is not enough time for consultation and for diagnosis and treatment.
Another dissatisfied person says that 15 minutes is not enough time to establish a
relationship with a doctor. One of the personae (the person who is in the clinic for
the first time) claims that the doctor was patient and polite but still did not have
enough time to look at all of the previous analyzes.

The last person says that he is unsatisfied mainly because of the reduced
time spent in the doctor`s cabinet. We see that people who feel that there is not
enough time for consultations also show a sense of insecurity and dissatisfaction of
their relationships with doctors. This confirms the second hypothesis of the
research, namely that if the consultation time is shorter, then the patients’
dissatisfaction is increasing.

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ADMINISTRAȚIE ȘI MANAGEMENT PUBLIC x 29/2017 51

What are the causes that would lead you to be dissatisfied with your
relationship with doctors of private health clinics in Bucharest? We have received
various answers concerning the main causes of the patient’s dissatisfaction such as:
advances, not respecting the patient, not listening to him, offending him, failing to
give him a correct diagnosis, violating confidentiality, screaming, not giving me
enough time, not empathic.

3. Conclusions

The research pointed out the fact that the patients expect the doctor to be

professional, calm, patient, treat them with respect, provide them with all the
information they need and would like to take part in making the decision. The most
important factors that determine these expectations that we identified are: the extra
and usually quite high costs of consulting in private health clinics and patients are
also influenced by the clinic’s notoriety when setting up these expectations and at
the same time are influenced by the fame of doctors working in these clinics.
Although patients were shown to be satisfied with the doctor-patient relationship at
a rate of 77%, there are causes that may increase their dissatisfaction with this
relationship. The causes we have identified in this study with the interview
questionnaire are: misdiagnosis by the doctor, insufficient time spent on a
consultation, information sent to patients in special medical terms that they do not
understand. As the primary reasons that would cause patients to drop out of
consultations with a doctor is lack of respect and poor communication. In order to
maintain a better relationship with patients, our study shows that the main qualities
that a doctor should have are: respect, compassion, empathy, professionalism,
punctuality, calmness and sufficient time during each patient’s consultation.

This research proved the fact that the relationships between the Romanian
patients of the private clinics and the doctors of them are important for both parts
and need a special attention and a deep analysis further.

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Basic Writing Tips to Share with Students

Dr. Nina Haydel

You cannot write the way you speak; a reader does not function as a listener. Writing has its own set of conditions. Writing gives you the opportunity to revise your ideas and the way you present them. You must always consider your audience: what does the reader already know and what does he or she need to know in order to make sense of what you have written? Decide your purpose and deliver what you promise. By revising, you can make significant changes as you move through the drafts; continue to add, delete, move ideas around, and re-arrange your points until you have supported your thesis and achieved your goal. Consider the following tips:

You need not always begin at the beginning. The reader will never know where you have begun, once you have completed your final draft. Start with the section that is easier for you to write. Then, put the puzzle together later.

Brainstorm and write your first draft in a stream-of consciousness flow of words. Concentrate on putting your ideas on paper. This draft is for your eyes only.

Keep the assignment, question, focus, or thesis very much in your mind. After you write each paragraph, re-read it and ask yourself, “So what?” in reference to the theme. If you are not making any contribution to the theme, strike that paragraph or imbed that idea somewhere else. Everything you write must have relevance.

Be specific, and include interesting, supportive details.

Avoid words like good, bad, thing. They have no specific, concrete meaning.

Review your work for redundancies. If you have already said something, do not say it again.

Watch out for repeated wording. Look for synonyms that make your writing live.

Save all your notes, drafts, and especially a copy of your final draft.

When you think you are finished, put the “final” draft away for several days and return to it with a fresh perspective.

You are not cheating when you have someone serve as a peer evaluator. Don’t allow your reader to do the revising for you. Just listen to the comments.

Look at the logic of what you have written and rethink your approach.

At some point, consider the work completed. A writer can revise forever, as there are always new ways of stating the same idea. Abandon the writing; it will never be finished.

Remember

, it is the writer’s fault when a reader cannot understand the writing.

Dr. Hayes Do Not Dos

1) Do not start subsequent sentences or paragraphs with the same word/term/phrase

2) Do not use the word thing or derivations thereof

3) Do not use “it” at the beginning of a sentence, and avoid use of “it” altogether

4) Do not use contractions, e.g. don’t

5) Never use etc.

6) Do not use more than one “and” in a sentence

7) Do not have a paragraph that is longer than a page

8) Do not have one sentence paragraphs, even two sentences paragraphs are suspect

9) Do not use first person

10) Do not think you will only write the paper once

Remember
, technical papers should be alive with information, not prose.

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