Introduction
The U.S healthcare system is undergoing significant transformation, marked by a shift in care delivery and patient-doctor interactions Over the past two decades, the landscape has evolved from doctors making house calls to patients visiting medical offices for brief consultations, often within managed care groups Additionally, the traditional dynamics of doctor-patient relationships have changed; historically, predominantly white male physicians sometimes withheld medical information, believing it was in the patient's best interest This evolution reflects broader changes in healthcare practices and patient engagement.
In 1982, it was noted that the doctor-patient relationship often begins with an inherent power imbalance, where the doctor is viewed as the expert and the patient as someone in need of care This dynamic places the doctor in a position of greater authority and prestige, leading to an expectation that patients will passively adhere to the doctor's instructions, similar to a parent-child relationship (Parsons, 1951).
The landscape of healthcare delivery has evolved, with doctors and patients often engaging on more equal terms during brief office visits to discuss ailments and diagnoses Effective communication between healthcare providers and patients is crucial for fostering a productive relationship, as it significantly influences patient satisfaction, treatment compliance, trust, and engagement Insufficient communication can lead to decreased trust in physicians, lower satisfaction with care, and reduced adherence to treatment plans, ultimately affecting patient health outcomes.
Poor doctor-patient relationships negatively affect patients' health and lead to indirect costs, including psychosocial distress and unnecessary out-of-pocket expenses for treatments and informational materials (Thorne et al 2005) Additionally, ineffective communication contributes to physician burnout and emotional exhaustion (Roter and Hall 2006:159-61) Research indicates that emphasizing psychosocial interventions in healthcare can lower overall costs, including billing expenses (Simpson et al 2001; Thorne et al 2005).
A significant body of research highlights the crucial role of doctor-patient communication in determining health outcomes for both patients and physicians However, there is limited exploration of the mechanisms that shape this communication This study investigates the influence of cultural health capital (CHC) and status characteristics theory (SCT) on doctor-patient interactions CHC offers insights into how cultural factors affect communication within medical settings, while SCT addresses variations in communication styles based on individual status Analyzing audio recordings from 121 patient visits, we seek to determine whether patients' cultural health capital or their status characteristics more significantly affect their medical encounters The findings aim to enhance the understanding of doctor-patient communication dynamics, ultimately contributing to efforts to reduce health disparities.
Healthcare delivery predominantly relies on direct interactions between patients and doctors, where medical issues are addressed and treatment plans are formulated The nature of these discussions and their development significantly impact patient outcomes Therefore, it is crucial for the communication during these medical visits to be effective and constructive to ensure optimal healthcare delivery.
Doctor-Patient Encounter
Doctors in the United States have historically held a unique position of power, as outlined by Parsons (1951) and further developed by scholars like Paul Starr (1982) and Eliot Freidson (1970) Their research highlights the rise of the medical profession and the concept of professional dominance, illustrating how occupations attain and sustain societal status Studies consistently show that physicians rank at the top of occupational prestige, reinforcing their significant influence over patients and contributing to the imbalance of power in healthcare dynamics.
Power dynamics in healthcare, characterized by a passive patient and a dominant physician, have long been established in society (Starr 1982) This traditional model often leads to imbalanced communication during medical encounters (Charles et al 1999) However, these roles are evolving in response to the modern healthcare landscape, shifting towards more engaged patients and supportive physicians (Alexander et al 1999).
2012), which the traditional model of paternalism does not afford
Effective doctor-patient communication is crucial for building a strong doctor-patient relationship during medical visits (Roter and Hall, 2006) These interactions, which typically last around 17 minutes (Shaw et al., 2014), serve as the primary means of addressing health concerns through dialogue about the patient's medical situation The medical interview encompasses 14 key elements and fulfills three main functions (Goold and Lipkin).
A medical visit serves three primary functions: gathering patient information, fostering a productive relationship, and communicating health concerns and treatment options These functions are interconnected; for instance, a nervous patient may struggle to comprehend the physician's explanations, while a patient lacking trust may withhold critical medical details Consequently, the quality of the patient-physician relationship significantly influences the completeness and accuracy of the information exchanged.
The 14 elements of a medical visit significantly influence the quality of the doctor-patient relationship Ineffective utilization of these elements can lead to poor communication, resulting in misunderstandings and dissatisfaction For instance, when physicians fail to answer questions clearly or do not allocate sufficient time for patient inquiries, it can diminish trust and lead to misdiagnoses Consequently, enhancing communication is essential for fostering a positive doctor-patient relationship and ensuring better health outcomes.
Effective communication in healthcare fosters a sense of being heard, respected, and cared for among patients, allowing them to express their ailments and gain understanding (Goold and Lipkin 1999) Superior doctor-patient communication leads to more accurate diagnoses, effective medical interventions, improved quality of life, quicker recoveries, and higher patient satisfaction (Roter and Hall 2006:6), ultimately empowering patients to make informed decisions about their health (Matusitz and Spear 2014).
Doctor-Patient Characteristics and Communication
Communication styles between physicians and patients can be influenced by various characteristics, including race, gender, and health literacy A qualitative study indicated that patients from different cultural backgrounds often felt uncomfortable sharing personal information during discordant encounters, fearing that their doctors might not understand their concerns The study suggested that structured medical interviews limited opportunities for patients to address cultural barriers (Gao et al 2009) Furthermore, research by Peck and Denney (2012) revealed that non-white patients tended to experience physician-dominant interactions when consulting white doctors, contrasting with the more balanced encounters seen between white patients and their white physicians This trend of physician dominance was similarly observed in interactions between female patients and male doctors.
A recent study by Dubbin, Chang, and Shim (2013) revealed that physicians tend to provide more information to patients they perceive as having higher health literacy skills Through 23 in-depth interviews, the research indicates that physicians prioritize efficiency and prefer to engage with patients who demonstrate a better understanding of their medications and medical history One physician noted that his initial impression of a patient significantly influenced their interaction, as he felt it would be unproductive to spend time with patients who appeared uninformed about their medical conditions The findings suggest that patients with health literacy skills are more adept at processing information and communicating effectively with their healthcare providers, highlighting the importance of effective communication during medical visits.
The dynamics between physicians and patients significantly influence medical visits and are crucial in establishing a strong doctor-patient relationship A positive interaction fosters patient satisfaction, leading to higher retention rates, reduced likelihood of switching doctors or health plans, and fewer malpractice claims.
The doctor-patient relationship has evolved significantly over the past two decades, moving beyond the traditional paternalistic model (Falkum and Fứrde 2001) While this paternalistic approach still exists, contemporary medical encounters now feature diverse roles for both doctors and patients Roter and Hall (2006) categorize these interactions into four typologies: paternalistic, mutuality, consumerist, and default, which reflect the varying levels of control and influence exercised by each party.
The paternalistic model of doctor-patient relationships is characterized by high physician control and low patient involvement, where the physician takes an authoritative role in directing the visit and determining the patient's needs (Parsons 1961; Roter and Hall 2006) In this model, doctors typically utilize closed-ended questions, leading to a passive patient role and limiting open communication This dynamic can result in potential manipulation of medical authority and patients feeling unable to fully discuss their health concerns (Roter and Hall 2006:29).
Paternalism is historically characterized as the interference with an individual's freedom of action, justified solely by considerations related to their welfare, happiness, needs, interests, or values (Weiss 1985:184).
Medical paternalism involves physicians interfering with a patient's autonomy under the guise of acting in their best interest, as highlighted by historical practices where doctors withheld critical information about medical conditions or procedures For instance, surgeons would often delay informing patients about serious operations to prevent them from opting out of surgery, believing that ignorance would lead to better compliance with medical directives This approach, prevalent in the 1970s, particularly affected women and marginalized healthcare practitioners, jeopardizing patient safety and well-being Although contemporary medical paternalism has evolved, it can still lead to adverse outcomes for patients, emphasizing the need for transparency and respect for patient autonomy in healthcare.
The mutuality model of the doctor-patient relationship is often viewed as the ideal approach, characterized by high levels of control from both physicians and patients This relationship-centered model emphasizes collaboration during medical visits, allowing both parties to contribute their strengths and resources Patients are encouraged to openly discuss their concerns, while physicians assist in clarifying these issues This open dialogue paves the way for negotiating treatment decisions collaboratively Research indicates that patients who actively engage in their medical encounters experience higher satisfaction, fewer physical limitations, and better adherence to treatment plans Ultimately, this model fosters a meaningful exchange where patients feel heard and physicians' insights are valued.
The consumerist model of the doctor-patient relationship is characterized by high patient control and low physician control, positioning patients as the primary decision-makers during medical visits (Roter and Hall 2006:26) In this framework, physicians act as technical consultants, catering to patients' requests and facilitating a “marketplace transaction” for noncurative services like annual check-ups (Roter and Hall 2006:27) Research indicates that younger and more educated patients are more inclined to adopt this consumerist approach in their healthcare interactions (Roter and Hall 2006:32) Together with the mutuality model, the consumerist relationship type emphasizes patient-centered medical encounters, which is the central focus of this study.
Theoretical Framework
This study is guided by two theoretical frameworks: cultural health capital (CHC) and status characteristics theory (SCT) We investigate the patient and physician characteristics that significantly influence medical encounters and compare the impact of these theories on the outcomes of such interactions SCT highlights how beliefs about individuals' characteristics contribute to observable inequalities in social interactions, while CHC explores how the capabilities, cultural skills, and communication styles of both patients and physicians affect their relationship Although SCT has been widely recognized for explaining communication inequalities, our research is among the first to empirically assess the role of CHC in understanding doctor-patient interactions.
Cultural Health Capital (CHC), rooted in Bourdieu's concept of cultural capital, applies the accumulation of tangible and intangible resources—such as language, dress, and education—to the healthcare context, influencing individuals' advantages in society Bourdieu viewed cultural capital as a mechanism of social stratification, where cultural attributes significantly affect life chances This concept highlights that the value of cultural skills varies across different social settings and relative to others' social positions, leading to disparities in power and prestige due to the arbitrary valuation of certain skills or artifacts.
Cultural capital plays a crucial role in personal and medical interactions, enabling individuals to adapt effectively to new social environments (Grenfell, 2012) In medical settings, specific types of cultural capital, such as healthcare experience, education level, communication skills, and literacy, significantly influence patient outcomes (Grineski, 2009) A lack of cultural capital can lead to misunderstandings about treatment options and poor decision-making (Grineski, 2009) Cultural health capital (CHC) encompasses the skills necessary for patients to comprehend medical information and communicate effectively with healthcare providers (Madden, 2015) These skills are essential for processing medical information and making informed health decisions (Eberle, 2013) CHC acts as a “toolkit” for patients, enhancing their relationships with physicians and improving engagement during medical encounters (Shim, 2010; Dubbin et al., 2013) Without adequate cultural health skills, patients may struggle with communication and engagement, impacting their overall medical experience (Katz et al., 2007; Shim, 2010) Therefore, it is vital for patients to demonstrate these skills during medical visits to foster effective dialogue and understanding with their doctors.
SCT, or Status Characteristics Theory, is a key element of the expectation-states theoretical framework, which posits that expectations significantly influence interactions among individuals with varying characteristics (Berger et al 1977) This theory, initially developed to explain behaviors in contexts where individuals hold differing performance expectations and status attributes—such as age, gender, or race—highlights the role of these expectations in social dynamics (Burke 2006:271) While expectations can emerge during interactions between strangers, they are often shaped by pre-existing beliefs regarding individuals' status characteristics (Berger et al 1980:481) Status characteristics are categorized into two types: specific and diffuse.
Specific status characteristics, such as a patient's communication skills with a doctor, highlight proficiency and respected abilities, while diffuse status characteristics encompass broader expectations of competence linked to factors like race or gender Research indicates that individuals with higher-status characteristics face greater expectations, whereas those with lower-status characteristics encounter diminished expectations.
Status characteristics significantly influence an individual's participation and impact in social interactions (Berger et al 1972) According to Berger et al (1980), non-whites and females tend to interact differently with their own groups compared to whites and males (p 481) This dynamic also applies to individuals sharing similar status characteristics, leading to an equal exchange in interactions (p 488) The Status Characteristics Theory (SCT) posits that suggestions from higher-status individuals are perceived more positively than those from lower-status individuals (Burke 2006) This principle is particularly relevant in the doctor-patient relationship, where patients often trust their doctors' expertise and judgments, assuming they know what is best for their health.
In the context of physician-patient interactions, both parties come with expectations that influence their behavior during medical encounters The inherent status differences, where physicians hold a higher status and patients a lower one, dictate the dynamics of their relationship For instance, in paternalistic situations, physicians expect patients to adopt a submissive role, which can lead to lower expectations of patients' involvement, particularly for those who differ in status characteristics, such as race or gender Research indicates that race-concordant encounters, where physician and patient share the same racial background, tend to be longer and more effective, resulting in better patient outcomes, including increased discussion of health issues and preventative care Conversely, when significant status differences are present, the interaction often becomes physician-centered, potentially hindering patient engagement and satisfaction.
Research Question & Hypotheses
The aim of the current study is to gain a deeper understanding of the factors that influence doctor-patient communication, and consequently, their relationship
This study investigates the differences in status characteristics, such as race and gender, between patients and physicians, and how these differences influence doctor-patient communication during medical encounters Social Cognitive Theory (SCT) suggests that individuals interact based on their status characteristics, which come with varying expectations In contrast, the newer theory of Cultural Health Capital (CHC) specifically addresses the medical context and can elucidate communication imbalances between doctors and patients, as proposed by Shim (2010) To explore these dynamics, we will test a research question and associated hypotheses.
Do patients’ level of cultural health capital influence the type of encounter that he or she experiences more or less than his or her status characteristic?
Cultural health capital (CHC) theory is posited to have a greater impact on medical encounter outcomes than status characteristic theory (SCT) This hypothesis arises from the understanding that the doctor-patient relationship often starts with a status imbalance, where the doctor typically possesses a higher status than the patient Consequently, we also propose that status characteristic differences will have a more significant influence on the outcomes of medical encounters compared to cultural health capital.
Data and Methods
In a study conducted over an 11-month period from 2007 to 2008, data was collected from 121 patients and 17 physicians at a large family medical practice The participating physicians represented the entire clinic, while other healthcare providers, such as physician assistants and nurse practitioners, were not included Patients were randomly selected from daily appointment schedules and approached in the waiting area To qualify for the study, participants had to be at least 18 years old, proficient in English, and scheduled for an appointment with their primary care physician.
During the data collection period, approximately 3,500 patient appointments were logged in the clinic’s database, but only a small fraction of patients were approached for participation Once a patient consented, recruitment ceased to allow for data collection, which included previsit interviews and audio recordings of medical encounters A total of 271 patients were approached, with 121 (45 percent) consenting to participate and successfully completing all three phases of data collection—previsit questionnaire, audio-taped medical encounter, and postvisit questionnaire—without any missing data The remaining 150 patients either declined or did not provide consent, with 35 specifically refusing to participate.
Out of the total patient sample, 13 percent were ineligible for participation, while 3 percent did not meet the criteria, and 19 percent failed to complete all three phases of data collection The demographics of the remaining patients were consistent with those in the current analysis Factors contributing to incomplete data collection included patients being redirected to other clinic areas for scans or labs, equipment malfunctions, and patients leaving the clinic while interviewers were occupied with other enrollments.
A comparative analysis was conducted between patients who completed all phases of data collection (n = 121) and those who did not or had missing data (n = 51) Peck (2011) examined the groups based on status characteristics and social demographic variables, revealing no significant differences except in patient race The findings indicated that a higher proportion of white patients were included in the analyses, with 66 percent compared to 34 percent of patients from other racial backgrounds.
After obtaining consent, patients completed both pre-visit and post-visit questionnaires, consisting of 34 closed-ended questions and 60 mixed-format questions, respectively Trained interviewers facilitated the patient questionnaire, which gathered demographic information and the purpose of the visit Immediately following their doctor visit, patients filled out a post-visit questionnaire that evaluated the visit's processes, tests, and medications, as well as their overall satisfaction with the visit and the physician Additionally, patients were encouraged to assess and describe their interaction with their doctor.
The medical visit was audio recorded, and trained coders analyzed the recordings using the Roter Interaction Analysis System (RIAS) to evaluate doctor-patient encounters RIAS is recognized as the most widely used coding scheme for assessing interactions in medical settings, as evidenced by various studies (Roter and Larson 2002; Heritage and Maynard 2006; Innes et al 2006; Inui et al 1982; Johnson Thornton et al.).
The Roter Interaction Analysis System (RIAS), developed from Robert Bales' work on small group interactions, evaluates problem-solving and decision-making patterns in medical encounters It integrates social exchange theories that highlight the influence of social dynamics and the reciprocal nature of doctor-patient interactions The RIAS coding scheme captures all statements made during medical visits, categorizing them into 34 distinct and comprehensive categories, which are further condensed into four general categories for analysis.
The RIAS coding manual defines communication units as "utterances," which are the smallest distinct speech segments eligible for classification These units can vary in length, with a single sentence treated as a whole unit if it conveys one thought or references a single item of interest Compound sentences are typically divided at conjunctions If a thought is interrupted for more than a second, each segment is coded as separate utterances If the first part of an interrupted thought can be categorized, the second part is assigned to the same category; however, if the first part lacks discernible content, it is considered a transition Fragments without any content or meaning that cannot be categorized are also coded as transitions.
RIAS categories reflect both socio-emotional and task-focused elements of medical interactions Task-focused elements for physicians involve technical skills essential for addressing medical issues, such as selecting diagnostic tests and performing procedures like blood draws and vaccinations While these activities are crucial, their effectiveness is enhanced through meaningful dialogue between doctor and patient, which helps gather medical histories and fosters an informative exchange Additionally, physicians engage in educating and counseling patients, while the socio-emotional aspect of the visit focuses on building rapport through dialogue, ultimately enriching the patient experience (Roter 1999).
RIAS distinguishes itself from other doctor-patient communication assessment tools, such as Bale’s Process Analysis, by utilizing a unique coding approach tailored for two-person exchanges specific to medical visits This method categorizes the dialogue between patients and doctors, with certain categories being more relevant to one party than the other Additionally, the categories are customized to reflect the specific content and context of the medical conversation Notably, RIAS codes verbal elements directly from audio recordings rather than relying on transcriptions, enabling coders to capture the tone and meaning of the interaction This approach highlights the emotional context of the medical visit, which is conveyed through tonal qualities beyond the spoken words (Roter, 1999).
This study investigates the dynamics of the doctor-patient relationship during medical visits, focusing on whether encounters are patient-centered A cluster analysis was employed to categorize interactions based on six communication variables: biomedical information exchange, psychosocial interactions, the ratio of closed to open-ended questions, overall communication length, and the functions of medical interviews such as data gathering and relationship building The analysis revealed two distinct types of encounters: patient-centered and physician-centered, with the variable coded as binary, where a value of 1 indicates a patient-centered encounter.
The study examines independent variables based on cultural health capital (CHC) and status characteristics theory CHC is represented by patient health skills, as outlined by Shim (2010), with a focus on health literacy Health literacy is defined as a patient's capacity to engage in medical conversations, which includes asking pertinent health questions and comprehending physicians' explanations (Katz et al.).
Health literacy is assessed through the Rapid Estimate of Adult Literacy in Medicine (REALM), which includes 66 medical terms This tool evaluates a patient's ability to read and pronounce these terms accurately, with scores ranging from 0 upwards (Davis et al 1993) Effective measurement of health literacy is crucial for improving patient understanding and communication in healthcare settings (Shim 2010).
We defined health literacy using a binary variable based on REALM scores, categorizing them into high and low by the median REALM is a validated tool for assessing health literacy in medical contexts, demonstrating greater accuracy than relying solely on a patient's educational background, as education alone does not reliably reflect an individual's medical comprehension.
This study explores the differences in status characteristics, specifically focusing on gender and race, between patients and physicians The gender variable is coded with females as the reference group, while males are assigned a value of 1, resulting in scores of zero for same-gender pairs, positive one for male physicians with female patients, and negative one for female physicians with male patients Similarly, the race variable distinguishes between white and non-white individuals, with non-white as the reference category and whites coded as 1 The status characteristic scores reflect the same race with a zero score, a positive score for white physicians treating non-white patients, and a negative score for non-white physicians treating white patients These status difference scores are calculated by subtracting the patient’s score from the physician’s, indicating whether the physician has a higher, lower, or equal status compared to the patient.
Analyses
The analysis involved patients clustered within doctors, leading to correlated errors and an underestimation of total variance, which can result in Type 1 errors (Hox 2010:5) To assess the impact of physician clusters on outcome variation, we calculated the intraclass correlation coefficient, revealing that between-doctor differences account for approximately 25% of the total variance in patient encounters, while 75% is attributed to within-doctor differences Given the significant contribution of between-doctor differences, we applied the Huber-White sandwich correction to obtain adjusted standard error estimates for the nonindependent observations (Huber 1967; White 1980) Since the dependent variable is binary (patient-centered versus not patient-centered), we utilized binary logistic regression for our analysis.
This article presents unadjusted bivariate analyses highlighting the relationship between various status characteristics and patient-centered encounters, alongside the bivariate relationship between REALM and these encounters Additionally, we provide adjusted multivariate analyses predicting patient-centered encounters based on differences in status characteristics and REALM.
Results
Characteristics of the Study Sample
During an eleven-month study period from 2007 to 2008, 121 patients met the inclusion criteria, with a sample comprising slightly more females (53%) than males (47%) The demographic breakdown reveals that 34% of the patients are non-white, while 66% are white Health literacy, as measured by the REALM score, is nearly evenly divided between high (53%) and low (47%) categories A significant majority, 74%, of participants have less than a college degree, and only 26% are college-educated or higher Most patients earn $50,000 or less annually, likely influenced by their median age of 60 years, with 56% being 56 years or older This older age profile may be attributed to the study's physicians, two of whom are board-certified in geriatrics, all affiliated with family medical practice.
The demographic characteristics of the physicians are summarized in Table 2, revealing that 59% are male and 41% are female A significant majority, 82%, identify as white, while three physicians are non-white Most physicians have between five to ten years of medical experience, accounting for 52%, with 28% having less than five years and 20% exceeding ten years Additionally, the age distribution shows a near-even split, with 53% of physicians aged 40 years and below, and 47% aged 41 years and older.
Table 3 reveals that 79 percent of doctor-patient encounters are patient-centered, while 21 percent are not Additionally, a significant portion of these encounters, 64 percent, involve doctors and patients of the same race, and 51 percent involve the same gender This aligns with previous research indicating a preference among both doctors and patients for concordant encounters based on race or gender (Cooper et al 2003; Laveist and Nuru-Jeter 2002).
Encounters where the patient had a higher status for race or gender were the least common in our data (11 and 17 percent, respectively).
This study employs both Social Cognitive Theory (SCT) and Cattell-Horn-Carroll (CHC) theory to determine which framework more accurately predicts the nature of patient encounters Table 4 illustrates a series of adjusted multivariate analyses examining the impact of status characteristics, such as race and gender, on patient-centered encounters, presented as odds ratios from binary logistic regressions Model 1 focuses on bivariate analyses of these status differences, while Model 2 incorporates patient-level covariates Model 3 adds a control for the physician's years in practice, and the final Model 4 integrates all patient and physician-level variables for a comprehensive analysis.
The results across all models show a consistent trend, indicating that differences in race status significantly correlate with reduced odds of patient-centered encounters Specifically, Model 1 reveals that as the racial disparity between doctor and patient increases—such as a white doctor treating a non-white patient—the odds of a patient-centered encounter decrease by 18% Similarly, the analysis suggests that greater gender status differences also lead to a 28% reduction in the likelihood of patient-centered encounters, although these findings did not reach statistical significance Overall, higher physician status is linked to an increase in physician-centered encounters, highlighting the impact of race and gender disparities in healthcare interactions.
In a study analyzing patient-centered encounters while controlling for gender, race, income, education, and age, findings revealed that increasing racial status differences led to a significant decrease of 11 in the odds of such encounters (p ≤ 0.05) Gender status differences remained unchanged and did not reach significance Additionally, the inclusion of the number of years a doctor has practiced in Model 3 did not enhance predictions of patient-centered encounters Model 4, which incorporated all variables, mirrored Model 2, indicating that as racial status differences rise, there is a marginal decrease in odds of patient-centered encounters (p < 0.10) Furthermore, increasing gender status differences resulted in a 43 decrease in the odds of these encounters, although this finding did not achieve significance.
The analysis of cultural health capital (CHC) in patient encounters reveals significant findings presented in Table 5, which includes logistic regression models showcasing the odds ratios for predicted patient-centered encounters Model 1, which features the REALM variable without control variables, indicates an odds ratio of 0.52, approaching significance (p