Blackwell Publishing, Ltd.
Swenson et al., Patient-centered Communication
Do Patients Really Prefer It?
Sara L. Swenson, MD, Stephanie Buell, BA, Patti Zettler, BA, Martha White, BS,
Delaney C. Ruston, MD, Bernard Lo, MD
centered or a biomedical communication style.
To investigate patient preferences for a patient-
academic medical center.
Urgent care and ambulatory medicine clinics in an
patients, excluding patients whose medical illnesses prevented
evaluation of the study intervention.
We recruited 250 English-speaking adult
scenarios of simulated patient-physician discussions of com-
plementary and alternative medicine (CAM). Each participant
watched two versions of the scenario (biomedical vs. patient-
centered communication style) and completed written and oral
questionnaires to assess outcome measurements.
Participants watched one of three videotaped
MEASUREMENTS AND MAIN RESULTS:
sures were 1) preferences for a patient-centered versus a
biomedical communication style; and 2) predictors of com-
munication style preference. Participants who preferred the
patient-centered style (69%; 95% confidence interval [CI], 63
to 75) tended to be younger (82% [51/62] for age < 30; 68%
[100/148] for ages 30–59; 55% [21/38] for age > 59;
more educated (76% [54/71] for postcollege education; 73%
[94/128] for some college; 49% [23/47] for high school only;
= .003), use CAM (75% [140/188] vs. 55% [33/60] for non-
= .006), and have a patient-centered physician (88%
[74/84] vs. 30% [16/54] for those with a biomedical physician;
< .0001). On multivariate analysis, factors independently
associated with preferring the patient-centered style included
younger age, use of herbal CAM, having a patient-centered
physician, and rating a “doctor’s interest in you as a person”
as “very important.”
Main outcome mea-
prefer a biomedical communication style, practicing physicians
and medical educators should strive for flexible approaches to
Given that a significant proportion of patients
tions; knowledge, attitudes, practice; comparative study;
J GEN INTERN MED 2004;19:1069–1079.
patient-centered care; physician-patient rela-
in which physicians ascertain and incorporate patients’
expectations, feelings, and illness beliefs.
have found associations between patient-centered commu-
nication and patient satisfaction,
medical outcomes, and decreased rates of malpractice
Furthermore, clinician failure to elicit and discuss
patient expectations in the medical visit predicts dissatis-
faction with the visit and persistence of symptoms.
However, evidence for the impact of patient-centered
communication on medical outcomes is mixed
conducted trials, interventions to enhance patient-centered
communication among physicians failed to improve patient
pirical evidence exists about what physician communica-
tion styles patients in the United States prefer and whether
these preferences vary according to patient characteristics.
Such information could enhance our understanding of how
communication style affects outcomes, help physicians
tailor their communication to individual patient prefer-
ences and, ultimately, improve patient satisfaction and
We conducted a randomized study of patient prefer-
ences for a patient-centered versus a biomedical physician
communication style in which the physician is directive
and focuses primarily on biomedical issues. We used
videotapes of simulated office visits in which a patient
broaches the use of complementary and alternative medi-
cine (CAM) with her physician. Our primary study objective
was to compare patient preferences for a patient-centered
versus a biomedical communication style as depicted on
the videotapes. Secondary objectives were to identify
patient-centered approach to the medical interview
; in well-
Moreover, little em-
Received from the Program in Medical Ethics (SLS, SB, PZ, MW,
DCR, BL) and Division of General Internal Medicine (SLS, BL),
University of California, San Francisco, Calif; and Department
of Medicine (DCR), University of Washington, Seattle, Wash.
Presented in part at the 25th annual meeting of the Society
of General Internal Medicine in Atlanta, Ga, May 2, 2002.
Address correspondence and requests for reprints to Dr.
Swenson: University of California, San Francisco, Box 0320, 400
Parnassus Avenue, San Francisco, CA 94143-0320 (e-mail:
Swenson et al., Patient-centered Communication
predictors of preferring a given communication style and
to determine whether physician communication style pre-
dicts patient disclosure of CAM use.
Study Participants and Recruitment
We recruited 250 patients attending urgent care (231)
or general internal medicine clinics (19) at an academic
medical center during September 2001 to May 2002.
Eligible patients were English-speaking adults age 18 or
older. Based on assessment by the clinic triage nurse, who
was not involved in the study, we excluded patients whose
medical conditions would preclude watching or evaluating
the videotapes (due to significant acute illness, dementia,
and unstable psychotic disorders).
To recruit a representative sample on each study day,
the study administrator (SB) approached the first eligible
patient for recruitment. If that patient declined to partici-
pate or if the study administrator found the patient ineli-
gible due to limited English proficiency or dementia, she
approached the next eligible patient. After preliminary data
analysis revealed a paucity of geriatric patients, we altered
recruitment to enrich our sample for elderly participants.
To recruit the latter 100 participants, the study adminis-
trator initially screened only patients age 65 and older for
eligibility. If no patients over 65 were waiting, she recruited
the next eligible patient of any age. To minimize selection
bias, the study administrator recruited participants during
different days of the week and times of day. All participants
gave informed consent. Participants who completed the
study were reimbursed with a $20 grocery gift card. The
institutional review board at the University of California,
San Francisco approved the study.
Study Instruments and Measurements
scenarios in which patients broach their use of CAM. We
chose CAM use because it occurs frequently
sensitive topic that often goes unaddressed in the clinical
Although several authors have documented
benefits of discussing CAM use with patients
ommended that physicians do so,
patients prefer physicians to discuss CAM.
To evaluate patient preferences across a spectrum of
risk-benefit situations, we developed three videotape
scenarios: (I) “Unnecessary Cost,” (II) “Uncertain Efficacy,”
and (III) “Potential Harm” (see Box). We chose these sce-
narios based on focus group discussions with physician
experts regarding situations involving patient CAM use
that occurred commonly in their clinical practice. The Un-
necessary Cost scenario depicted a patient taking an
expensive, “individually formulated” vitamin preparation
that offered no clear benefit over a regular multivitamin. In
Uncertain Efficacy, the patient was attempting to lower
The study videotapes depicted common
and is a
it is not known how
his blood pressure by using an herbal supplement with
uncertain risks and benefits. In both of these scenarios,
the patient brings in the dietary supplement and asks the
doctor for her opinion regarding its use. The Potential Harm
scenario showed a patient taking an ephedra-containing
weight loss supplement that increased her previously con-
trolled hypertension to dangerous levels. In this scenario,
the doctor detects the patient’s use of the supplement by
asking if she is doing anything new that might explain
her elevated blood pressure. We also varied scenarios with
respect to patient and physician gender-ethnicity con-
For each scenario, we developed 2 distinct versions for
a total of 6 tapes. One version depicted a more biomedically
focused communication style (A); the second, a “patient-
centered” style (B).
To create the scripts for the bio-
medical versions, we interviewed a convenience sample of
15 experienced primary care physicians, 5 of whom had a
special interest in CAM, regarding their typical responses
to patient questions about CAM. For the patient-centered
versions, a working group of experts in doctor-patient com-
munication helped to develop the scripts. Each “patient-
centered” version included those elements that have been
evaluated empirically or mentioned in the literature on
patient-centered communication: 1) developing an under-
standing of the patient as a person; 2) conveying empathy;
and 3) finding common ground regarding treatment and
goals of care.
Within each CAM use scenario, the videotapes differed
only with respect to the doctor’s communication style. Each
version was identical in terms of patient history and clinical
presentation. In both versions, the doctor offered the same
“bottom-line” recommendation about the CAM supplement
and presented similar information regarding its risks
or uncertainties. Each utilized the same professional
actors who employed similar body language, tone of voice,
and conversational pace. Mean videotape lengths were 2:43
minutes. For each pair, the “patient-centered” version was
longer (mean 16 seconds; range 2 to 28 seconds), and the
patient spoke for a greater percentage of the time (47% vs.
38% on average). We showed all three versions of the videos
to 10 attending and resident physicians in general internal
medicine, to assess the videos’ face validity. (Samples of the
study videotapes can be viewed at http://dgim.ucsf.edu/
Patient Older white
Volume 19, November 2004
to assess participants’ demographic and clinical charac-
teristics, CAM use, and satisfaction with their current
physician. Using validated questions from prior studies
of patient satisfaction (see Appendix A available online at
we also developed a 7-item scale to assess
participant opinions regarding their interactions with
physicians. This “Important Aspects of Doctoring” scale
had a Cronbach’s
We developed a 20-item questionnaire
ticipants’ preference for the patient-centered or biomedical
communication style as assessed by the following question:
“Thinking back to the videotapes you just watched, which
of the doctors did you prefer?” We assessed participants’
perceptions about their own physician’s communication
style by asking: “Which of the two doctors in the videotapes
had a style that was most like your own regular doctor’s
style?” To gain a more nuanced understanding of par-
ticipants’ preferences, we developed an 11-item Physician
Assessment Questionnaire (see Appendix B available online
at http://www.jgim.org). Likert scale items were adapted
from validated patient satisfaction scales to assess three
dimensions of care: global satisfaction, patient centeredness,
and other characteristics.
dimension included items on developing an understanding
of the patient as a person, conveying empathy, and finding
that we hypothesized would differ for
the biomedical and patient-centered versions of the video-
tape. Six additional items measured global satisfaction
and other physician characteristics that had no
reason to differ between tape versions. For the qualitative
interviews, we asked: 1) “Thinking back to the videotapes
you just watched, which doctor did you prefer and why?”
and 2) “What was the biggest difference between the two
doctors in the videotapes?”
Our primary outcome was par-
pilot tested early versions of the study instruments and
interview questions among 20 health care professionals,
healthy volunteers, and elderly patients for clarity, flow,
and ease of completion. Based on pilot data, we eliminated
and revised several questions and reworded most nega-
tively phrased questions to achieve satisfactory patient
Two investigators (SLS, SB)
Randomization and Study Procedures
Prior to the study day, one investigator (SLS) random-
ized consecutive participants to view a specific videotape
scenario (I, II, or III) with either the biomedical (A) or the
patient-centered (B) version first. Randomization was
carried out in blocks of 12 participants. The study adminis-
trator remained blinded to scenario and tape order until
after each subject had undergone recruitment and agreed
to participate, at which time participants viewed the pre-
assigned videotape scenario and tape order. After watching
the first videotape, participants completed the Physician
Assessment Questionnaire. Next, they watched the second
tape and completed an identical questionnaire for the
second doctor. They then answered questions regarding
which doctor they preferred and which doctor’s style best
resembled that of their own primary doctor. They also
completed the demographic questionnaire, including the
Important Aspects of Doctoring scale. Finally, participants
underwent qualitative interviews, which were audiotaped
and transcribed verbatim for analysis. The study admin-
istrator used standardized prompts to encourage partici-
pants to elaborate or clarify answers.
Sample Size Calculations.
ferences for a patient-centered versus a biomedical
communication style in the videotaped doctor-patient dis-
cussions (two-tailed comparison). We thought that an effect
size of 20% would be clinically meaningful (e.g., 40% of
patients preferring the biomedical and 60% preferring the
patient-centered doctor). To detect predictors of communi-
cation style preference, we set
power at 0.80 and estimated a 10% dropout rate to yield
a total sample size of 230.
Our primary outcome was pre-
at 0.05 (two-sided) and
Chicago, Ill) for all quantitative data analysis. Data were
double entered, cross-checked, and cleaned. Due to cluster-
ing of responses, we collapsed Likert scale data from the
Important Aspects of Doctoring scale into dichotomous
variables (irrelevant, not important, somewhat important
vs. important, extremely important). We rescaled responses
so that higher scores represented higher levels of import-
ance or agreement. We performed bivariate analysis to test
our primary outcome variable with the following indepen-
dent variables: participant gender, age, ethnicity, education,
income, presence of chronic illness or disability, prescription
medication use, number of daily medications, and self-
perceived health status and control over health. We also
investigated age (Scenario I) and ethnicity and gender
concordance (Scenarios I, II, III, and all scenarios). We used
analysis or Fisher’s exact tests (two-tailed),
where appropriate, and Wilcoxon signed-rank tests for
nonnormally distributed variables. For testing hypotheses
related to proportion differences, we performed a two-sided
difference of proportions test using a normal probability
distribution, adjusting for overlapping populations. Unless
otherwise stipulated, statistical significance was set
We utilized SPSS (versions 6 and 11; SPSS Inc.,
substantive variables originally posited to answer the
primary hypothesis and secondary variables significant at
the 0.05 level on bivariate analyses. We used a stepwise
block procedure to enter variables into the logistic regression
model, entering first variables that are beyond physicians’
For the multivariate model, we selected
Swenson et al., Patient-centered Communication
control and last, tape order. Variables included gender,
ethnicity, education, age, and presence of disability or
chronic illness (block 1); participant use of herbal medicine,
communication style of the participants’ own physician, and
two items on the Important Aspects of Doctoring scale
) (block 2); and tape order and gender concordance
(block 3). For participant use of CAM, we chose use of
herbal medicine because it yielded a better fitting model
than did overall CAM use. We used the Hosmer-Lemeshow
goodness-of-fit deciles of risk test for determining the
appropriateness of the logistic regression model because
many predictor variables were categorical and our sample
size was less than 400.
interest in the patient as
tive findings will be published separately; we briefly sum-
marize our methods here. We used the method of constant
comparisons to develop a preliminary coding scheme. Two
of the study investigators (SLS, PZ) independently coded
all responses. The research team (SLS, PZ, BL) then
analyzed and discussed coding discrepancies and revised
and refined the coding scheme. The final scheme consisted
of 34 coding items and 12 themes.
A detailed description of the qualita-
We approached a total of 418 patients for study
participation. Forty-eight were excluded due to cognitive
impairment or an inability to speak English, and 120
declined to participate, for a response rate of 68% (250/
370). Our sample was gender balanced, ethnically diverse,
and relatively young, healthy, and well educated (Table 1).
Our sample resembled the overall patient population in the
urgent care clinic with respect to gender and age (data
available from authors on request). As expected from an
urgent care population, slightly over half had a regular
physician. Among participants with regular physicians,
71% reported being “extremely” or “very” satisfied with
them. Sixty-one percent rated their own physician as having
a style similar to that of the patient-centered doctor in the
videotape. Three fourths of participants (189/249) reported
using CAM within the past year. The most commonly
used forms included dietary supplements (41%; 103/249),
massage (38%; 95/249), relaxation or meditation (38%;
93/248), and herbal therapies (36%; 89/250).
Preferred Physician Communication Style
Most participants preferred the videotape doctor who
exhibited a patient-centered communication style (69%;
95% confidence interval [CI], 63 to 75). This preference was
similar across the three videotape scenarios (I: 67% vs. 33%,
z = 0.02,
= .99; II: 74% vs. 26%, z = 0.04,
67% vs. 33%, z = 0.02,
= .98). We therefore grouped tapes
= .97; III:
from all scenarios into either biomedical or patient-centered
versions for subsequent analyses.
Bivariate Predictors of Preferred Communication
Demographic and Clinical Predictors.
participants favored the patient-centered style, certain
subgroups were less likely to prefer it (Table 2). Older
participants, participants with less formal education, and
nonusers of CAM were significantly less likely than their
counterparts to prefer the patient-centered doctor. Gender
discordance was also associated with a tendency to prefer
the biomedical doctor only for the female physician
(Scenario III). No other demographic or clinical predictors
were associated with communication preference, including
ethnicity and age concordance. Two Important Aspects of
Doctoring items were significant predictors of preferring
Table 1. Participant Characteristics
White or European American
Black or African American
Asian or Asian American
Median age, y (range)
High school graduate or less
Some college/college graduate
Yearly income, $
20,000 to 39,999
40,000 to 59,999
Health and health care characteristics
Chronic medical problem or disability
Daily prescription medicine
Mean number of prescription medicines
Self-rated health status excellent or very
Current regular MD
Own MD style*
Satisfaction with own MD
(extremely or very)*
Any CAM use
Use of supplements, herbs, or folk
Disclosure of CAM use to MD†
39 (18 to 85)
3.4 (1 to 25)
* In subset of participants with a regular MD (N = 139).
† In subset of participants with a regular MD who use supplements,
herbs, or folk remedies (N = 70).
CAM, complementary and alternative medicine.
Volume 19, November 2004
a patient-centered doctor:
the doctor is open-minded
the doctor’s interest in you as a
Previous Health Care Experiences.
likely to prefer the videotaped doctor whose style was the
same as their own physician’s (Table 2). Among partici-
pants who were “completely” satisfied with their physician,
this effect was more pronounced; 91% (32/35) of partici-
pants who were satisfied with their own biomedical phys-
ician preferred the biomedical doctor in the videotape and
92% (59/64) of those who were satisfied with their own
patient-centered physician preferred the patient-centered
Participants were more
second communication style they viewed. Among those
who viewed the patient-centered tape second, 80% (100/
125) preferred the patient-centered doctor, whereas only
59% (73/124) of those who viewed the biomedical tape
second preferred the patient-centered doctor (
= .001). This recency effect was seen with all three CAM
Participants were more likely to prefer the
Multivariate Predictors of Preferred
Multivariate analysis revealed four significant pre-
dictors of participant preference for the patient-centered
communication style when the effects of tape order were
controlled (Table 3). These were having a patient-centered
physician, rating “the doctor’s interest in you as a person”
as “more important,” and using herbal medicine in the past
year. In contrast, older participants were less likely to prefer
a patient-centered approach. The goodness-of-fit (HL-GOF)
test for the final multivariate model was 0.42.
Likert Scale Ratings of Physician Communication
Data from the Physician Assessment Questionnaire
showed that participants rated the patient-centered doc-
tors more positively, especially with respect to dimensions
of patient-centered communication (e.g., “suggesting a
good plan for helping the patient”; Table 4). Conversely, dif-
ferences between patient-centered and biomedical versions
Table 2. Bivariable Predictors of Preferred Physician Interviewing Style (N = 250)
Demographic Characteristic (N)
No. (%) Preferring
No. (%) Preferring
Interviewing StyleP Value CHI-2
Level of education
</= 12th grade (47)
</= College grad (128)
> College grad (71)
18 to 29 (62)
30 to 59 (148)
Female MD-female patient (49)
Female MD-male patient (36)
MD is open-minded
< Important (1 to 3) (11)
> Important (4 to 5) (238)
MD interest in patient as person
< Important (1 to 3) (39)
> Important (4 to 5) (210)
Use of CAM
Use of herbal medicine
Own MD style†
Biomedical MD (54)
Patient-centered MD (84)
Last video seen
Patient-centered MD (125)
Biomedical MD (124)
* Subset of participants (N = 85) who viewed Tape Pair I.
† Subset of participants (N = 138) who had a current regular physician.
CAM, complementary and alternative medicine.
Swenson et al., Patient-centered Communication
were smaller for those dimensions that were
to patient-centered techniques and were not statistically
significant for two of these (decisiveness and knowing the
risks and benefits of CAM).
What Participants Liked About Physician Communication
Participants who preferred the patient-centered
doctor cited being “interested in the patient as a person,”
devising a “good plan” for the patient, and “listening more
to the patient.” As one participant remarked, “the [patient-
centered] doctor treated the patient more as a person,
listening to what her goals were…and trying to work out a
plan that would work much more humane.” A second noted
that the patient-centered doctor “heard the same infor-
mation as the [biomedical] doctor, but seemed more open-
minded about why she was doing what she was doing,
and…was more sort of taking into consideration her
In contrast, those who preferred the biomedical doctor
found her “direct,” “straightforward,” or “decisive” style more
appealing. One participant preferred the biomedical doctor
“because she wanted action, like right now.... She gave it her
best shot right away.” Another remarked: “I think the doctor
should take more of a leadership role, and I think the [bio-
medical] doctor did.” Still another appreciated this doctor’s
willingness to take a stand; for example: “He wasn’t all ques-
tion, he was to the point. He answered the question like he
knew what he was talking about. I didn’t have any doubt.”
Seeing Both Sides.
videotape scenario discerned key features of the com-
munication styles yet evaluated those styles differently. For
example, a participant who preferred the biomedical doctor
noted that he “was dealing more with the facts and the
Participants who watched the same
Table 3. Multivariate Predictors of Preference for a Patient-centered Interviewing Style*
Independent VariableOdds Ratio
18 to 29
30 to 59
Interest in patient as person: more important vs. less important
Use of herbal medicine: yes vs. no
Own MD style (patient-centered vs. biomedical)
Last video seen (patient-centered vs. biomedical)
(0.09 to 0.63)
(0.06 to 0.64)
(1.70 to 11.0)
(2.17 to 14.4)
(6.80 to 37.3)
(2.27 to 11.6)
* Other covariates were gender, ethnicity, education, and presence of a disability or chronic illness (block 1); one item on the Important Physician
Characteristics scale (physician open-mindedness) (block 2); and gender concordance (block 3).
Table 4. Mean Likert Scale Responses to Biomedical Versus Patient-centered Videotapes*
Item No.Dimensions of Care Items
Mean (± ± ± ±SD)
Mean (± ± ± ±SD)
The doctor suggested a good plan for helping the patient.†
The doctor seemed open-minded.†
The doctor was interested in the patient as a person.†
The doctor gave the patient a chance to say what was on his or her mind.†
The doctor gave the patient his/her full attention.†
The doctor took the patient’s problems seriously.†
The doctor communicated in simple, clear language.
The doctor seemed to know about the risks and benefits of alternative medicine.‡
The doctor seemed decisive.‡
This is a doctor I would trust.†
I would recommend this doctor to my friends.†
* In the Physician Assessment Questionnaire, respondents were asked to rate their level of agreement or disagreement with the following
statements regarding the videotapes. Question 11 utilized a 5-point Likert scale ranging from (1) definitely yes to (5) definitely not. All remaining
questions utilized a 7-point Likert scale ranging from (1) very strongly agree to (7) very strongly disagree. Due to multiple comparisons, the
level of statistical significance was set at P < .001.
† P < .0001.
‡ P > .01.
Volume 19, November 2004
[patient-centered doctor] was dealing more with…trying to
make the patient feel listened to, sympathized with. The
facts are what are useful to me.” After viewing the same
tape pair, another participant had similar observations but
preferred the patient-centered doctor’s approach: “In terms
of attitude, the [patient-centered] one was better. But in
terms of getting information quickly, the [biomedical]
doctor was better.”
Relationship with Own Physician Style. Some participants
sought out their preferred communication style in their
physicians. For example, one noted, “I like to choose my
doctors on how personable they are and if it’s somebody
I’m comfortable with. And if I’m not, I just look for another
doctor.... [The patient-centered doctor] is more how my
doctor is here. And that is what I look for.” Others disliked
a videotaped doctor’s style that departed from their past
experiences. For example, one individual who preferred the
biomedical doctor noted that the patient-centered doctor
“didn’t use any words that were typical words that a doctor
would use…I felt [he] was being a phony.”
Over half of participants (55%; 137/250) reported using
CAM therapies with potential side effects or drug-drug
interactions (e.g., supplements, herbal medicine, and folk
remedies). Among participants with regular physicians who
had used such potentially harmful CAM, 50% (33/66) had
told their own physician about their use of it. Participants
who thought that their current physician had a biomedical
approach were equally likely to have disclosed their CAM
use (50%; 13/26) as those who thought their physician was
patient centered (50%; 20/40).
Medical educators,1 researchers,2 and consensus
panels3 recommend teaching and practicing patient-
centered communication. However, our study represents
the first randomized study of communication style prefer-
ences among U.S. patients. We found that 31% of subjects
preferred a more traditional, directive communication style.
Certain patients were more likely to prefer the patient-
centered style, including those who characterized their own
physician as patient centered, valued physician interest in
the patient as a person, and were younger than 65.
Comparison to Existing Literature: Communication
Preferences and Predictors
Other studies have also found that most participants
prefer a patient-centered style,47 that patients prefer the
perceived decision-making style of their own physician,22
and that older patients prefer a more directive style.16,19,22,48,49
Similar to our findings, Schmittdiel et al. observed an asso-
ciation between gender concordance and patient prefer-
ences for a female but not a male doctor.50 However, unlike
other studies, we did not find that male gender,19 lower
levels of education,16,19,48,49 lower socioeconomic class,19,22
or more severe levels of illness19,49 were associated with pre-
ferring the more “directive,” biomedical style.
Although patient communication preferences in our study
did not vary across different CAM scenarios, other studies have
found preference variation across clinical scenarios.51
McKinstry found that UK patients were more likely to prefer
a directive style when evaluating doctor-patient interactions
about a physical problem but preferred either style equally
for interactions involving depression or smoking cessa-
tion.22 A randomized trial of a “directive” or “sharing” physi-
cian style among British patients found higher satisfaction
rates with a “directive” style when visits involved physical
problems and equivalent rates when visits were longer or
involved counseling, or chronic or psychological illnesses.52
Our finding that almost a third of patients prefer a non-
patient-centered approach may help to explain the mixed
impact of patient-centered communication on satisfaction
and medical outcomes. Patient communication preferences
may act as a key intermediary between physician commu-
nication style and patient outcomes. Several studies
suggest that patient perceptions of patient centeredness
or patient-physician congruence of interviewing styles are
better predictors of trust, visit satisfaction,19 and medical
outcomes17 than is actual physician patient centeredness.
Given this diversity of patient communication prefer-
ences, it makes sense to try to match patient preferences
with the physician’s actual style. Such matching respects
patient autonomy and might enhance patient satisfaction
with and trust in their medical providers.16,53 However, 29%
of patients do not experience their preferred physician
communication style with respect to decision making, with
greater mismatch among patients of low socioeconomic status
(E. Murray, MD, et al., unpublished data, September 2004).
Better congruence might be attained in several ways.
First, as our qualitative data suggest, some degree of
patient-driven matching occurs when patients choose their
primary care physicians.53 However, patient-driven match-
ing has drawbacks. Frequently changing providers is inef-
ficient. Moreover, socioeconomically disadvantaged or less
empowered patients may not be able to seek out their phys-
icians of choice.50
Second, physicians might modify their communication
style to match patient preferences. Physicians often use a
more directive, or “paternalistic” style with older, less
educated, and sicker patients and a more patient-centered
style with younger, better educated, and more socioeco-
nomically advantaged patients.54–57 However, it is not clear
whether these variations are physician responses to indi-
vidual patient preferences or demographic characteristics.
Because physicians often inaccurately predict patient
expectations,58 even those who consciously modify their
Swenson et al., Patient-centered Communication
communication may fail to match individuals’ preferences.
Furthermore, physicians demonstrate only limited flexibil-
ity with respect to communication style, with over 50%
adopting a single communication style during the majority
of their clinical encounters.42
Third, health care organizations might match patients
and physicians on the basis of communication preferences.
One randomized trial gave intervention patients provider
demographic characteristics, training, and decision-making
orientation and had them choose their primary care provider.
Although intervention patients reported greater satisfac-
tion and were more likely to have retained their providers
at 1 year, the independent contribution of giving infor-
mation on decision-making orientation was nonsignificant.53
Any approach to matching patient-physician commu-
nication styles would require an accurate, efficient way of
identifying patient communication preferences. In our study,
even the strongest predictor of communication preference,
the participant’s own physician’s style, misclassified many
patients. Other studies also suggest that inferring patient
preferences from demographic or clinical features would
result in substantial misclassification.22,49,51 Alternatively,
physicians could elicit patient preferences by directly
asking patients. Some of our study questions appear pro-
mising for this purpose but require validation.
In addition to these practical challenges, there are
ethical concerns about matching patients to physicians on
the basis of preferred communication style. First, patient
preferences for a biomedical style may be uninformed. Older
and less educated patients are less likely to experience
patient-centered communication54–57 and thus may be
unfamiliar with it. Our qualitative findings suggest that
such patients may perceive it as foreign to the physician’s
role. Second, more patients might prefer a patient-centered
style if they were exposed to good exemplars of it. In several
studies, patients who initially expressed little interest in
participating in decision making were more satisfied when
they experienced more participation than they initially
desired and when they felt that their doctor facilitated
such participation.59,60 Finally, studies report that patient-
centered communication is associated with superior
adherence to medical recommendations, visit satisfaction,
symptom resolution, and emotional well-being.8,11,61,62 Thus,
encouraging patient-centered communication may promote
patients’ best interests. Hence, for patients who prefer a
biomedical physician, there may be a tension between
respecting their preferences and enhancing their best
interests. Physicians should generally respect informed
patient choices about their medical care. However, doctors
also have obligations to ascertain whether potentially
harmful patient choices are truly informed and to try to
help patients become better informed.63
Implications Regarding CAM Disclosure
Patient centeredness is believed to enhance open
communication and information disclosure.64–66 However,
we found that participants whose regular physician used
a patient-centered style were no more likely to disclose their
CAM use than those whose regular physician was not
patient centered. Empirical studies of “sensitive” topics,
such as HIV risk behaviors and alcohol use, have found
that direct, relatively close-ended questions actually enhance
accurate disclosure.67–69 Our findings provide some empiri-
cal support for asking patients routinely and directly about
their use of CAM.36–38
Our study had several important limitations. Patient
responses to simulated videotape scenarios may not reflect
their communication preferences during actual physician
visits. Although no studies have directly compared patient
preferences assessed by ratings of videotapes to those in
actual patient-physician interactions, several lines of
evidence support the validity of videotape methodology
for evaluating patient preferences. First, data from our
study and two others that used videotape methodology22,51
resemble preference differences observed in nonvideotape
studies.16,48,49 Also, one study found that patients who
received their preferred treatment after evaluating video-
tape presentations of treatment alternatives had superior
therapeutic outcomes to those who received their non-
preferred treatment,70 suggesting that videotape-based
choices may have predictive validity with respect to clinical
outcomes. Finally, our videotape design has several poten-
tial methodologic strengths. It avoids the positively skewed
satisfaction scores that occur when patients rate their
own physician4,71,72 and standardizes communication styles
and controls for other physician and visit characteristics.
The preference of most patients for the patient-centered
doctor may reflect responses to aspects of the videotaped
doctors other than communication style, such as tone or
mannerism. For example, because the patient-centered
versions were slightly longer than the biomedical ones,
patients may have perceived the latter as more time
efficient or the former as spending more time with
patients. We did minimize differences in videotape length
and standardized the patient-centered and biomedical
versions of each scenario with respect to the doctor’s
recommendation about CAM use. Alternatively, given our
sample’s high rates of CAM use, our finding that a majority
preferred the patient-centered doctor could have arisen if
participants perceived the biomedical doctor as being more
critical of CAM. However, in multivariable analysis, regard-
ing the videotaped doctor as open-minded was not a
predictor of the respondent’s preference for a videotaped
Finally, simultaneously varying several factors (patient
and doctor gender, ethnicity, age) in each CAM scenario
could have led to spurious findings regarding preferences
for a given communication style. The association of gender
concordance with communication style preference on
bivariate analysis supports this possibility, and our sample
Volume 19, November 2004
size and study design limited our power to detect other
similar interactions. However, gender concordance was not
a significant predictor on multivariate analysis of commu-
nication style, and neither age nor ethnicity concordance
were significantly associated with communication style on
bivariate analysis. In addition, a majority of participants
preferred the patient-centered doctor across all three CAM
scenarios with varying gender, ethnicity, and age pairings
of the videotaped actors. Moreover, both the qualitative
data and the Likert scale ratings of physician communi-
cation (Table 4) suggest that participants discerned and
made choices based on distinct elements of the doctor’s
communication style. The Likert scale ratings, which par-
ticipants completed immediately after viewing each video-
tape, also validate that participants responded at least in
part to patient-centered communication skills.
Participants in our study were more likely to prefer the
most recently viewed videotape. Other studies, including one
videotape study,73 have reported a similar recency effect.75,76
Because our participants were randomized to view different
tape orders (biomedical first vs. patient-centered first), our
study design controlled for this effect with respect to our
main outcome of preferred physician communication style.
Moreover, our finding that four other variables remained
significant predictors of communication preference after
controlling for tape order in the multivariate analysis
suggests that a recency effect could account only partially
for participants’ communication preferences.
Our findings may not generalize to other clinical
settings, patient populations, or clinical problems. First,
discussions regarding CAM use may not be typical of other
physician-patient interactions. However, CAM use may
involve value conflicts or issues of behavioral change and,
hence, may resemble other interactions that physicians
find challenging and for which they need skillful commu-
nication. Second, our relatively young, healthy urgent
care population from an academic medical center may not
be representative of many general internal medicine prac-
tices.76–78 However, given that young, healthy patients are
more likely to prefer a patient-centered approach, our
finding that a significant proportion of our sample pre-
ferred a biomedical approach would likely be borne out in
populations that include more older patients.
Finally, asking participants to choose between a patient-
centered and biomedical doctor precludes a more nuanced
understanding of which elements of each physician com-
munication style patients prefer and how this varies during
different portions of the clinical encounter or in specific
clinical contexts. For example, patients who ordinarily pre-
fer a patient-centered communication style might want a
more directive approach if they needed emergency surgical
care. Furthermore, patients may have different communi-
cation preferences for interactions with their primary
care providers than for those with physician subspecialists.
Ultimately, skillful communication may entail knowing how
to elicit and adapt to patient preferences over time and in
different clinical contexts.
In conclusion, our empirical findings challenge un-
examined assumptions regarding the desirability of patient-
centered communication and raise ethical and practical
questions for clinicians, educators, and medical researchers
about matching patients and physicians on the basis
of communication style. For patients who prefer a bio-
medical communication style, clinicians currently face a
dilemma. Given that patient-centered communication has
been linked to improved outcomes even among patients
who do not initially prefer it, clinicians may choose to
explain the benefits of a patient-centered approach and
encourage all patients to adopt it.79–82 However, some
patients who prefer a more directive, biomedical style may
view this approach as paternalistic or incompetent. Further
research is needed to elucidate which elements of patient-
centered and biomedical communication patients want in
a specific clinical situation or portion of the interview.
Clarifying these issues will enable clinicians to adopt a
nuanced, flexible approach to the medical interview that
both respects informed patient preferences regarding com-
munication and promotes better patient outcomes.
This work was supported by the Robert Wood Johnson Foundation
Initiative on Strengthening the Patient-Provider Relationship.
The authors gratefully acknowledge the contributions of
Jesse Canchola, MS for his assistance with our data analysis and
Elizabeth Murray, MRCGP, PhD for her valuable comments
and suggestions. We also wish to thank Ralph Gonzales, MD and
Jason Satterfield, PhD for their critical reviews of the manuscript,
Paul Nadler for invaluable assistance with study execution, and
the editors and anonymous reviewers at JGIM for their insightful
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