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How does communication heal? Pathways linking clinician–patient
communication to health outcomes
Richard L. Street Jr.
a,b,
*, Gregory Makoul
c
, Neeraj K. Arora
d
, Ronald M. Epstein
e
a
Texas A&M University, College Station, TX, United States
b
The Houston Center for Quality of Care and Utilization Studies and Baylor College of Medicine, Houston, TX, United States
c
Saint Francis Hospital and Medical Center, Hartford, CT, United States
d
Outcomes Research Branch, ARP, DCCPS, National Cancer Institute, Bethesda, MD, United States
e
Department of Family Medicine, Psychiatry and Oncology, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
1. Introduction
Oneof themost interesting,but leastunderstoodfindingsin health
communication is provided by studies that have established an
association between clinician–patient communication and patient
healthoutcomes [1–6]. Yet, researchers seldomtry to test hypotheses
explaining how communication might impact patient health.
The purpose of this article is three-fold. First, we offer a brief
critique of current approaches to the study of communication and
health outcomes. Second, we identify specific pathways through
which communication can lead to better health. Finally, we
propose a research agenda to discover mechanisms that can
explain and influence ways in which communication affects
health. Relevant health outcomes include disease markers (e.g.,
blood pressure, tumor markers), survival, and quality of life (e.g.,
functioning and well-being in physical, psychological and social
domains).
2. Clinician–patient communication and outcomes: the state of
the science
Research linking communication to improved health outcomes
typically falls into two categories. First, a number of RCTs have
examined the effects of interventions designed to alter clinician
and patient communication and decision-making in medical
encounters [7,8]. In a review of these studies, Griffin et al. [8]
demonstrated that communication interventions generally pro-
moted physician and/or patient communication behaviors thought
to be desirable and effective (e.g., patients asking more questions;
physicians using more patient-centered communication), but less
than half (44%) of the studies were associated with improved
outcomes. Moreover, similar interventions had different effects
across studies, likely because the outcomes were measured
differently and were associated with small sample sizes.
Patient Education and Counseling 74 (2009) 295–301
ARTICLE INFO
Article history:
Received 31 July 2008
Received in revised form 19 November 2008
Accepted 24 November 2008
Keywords:
Physician–patient communication
Health outcomes
Disease management
ABSTRACT
Objective:
Although prior research indicates that features of clinician–patient communication can
predict health outcomes weeks and months after the consul tation, the mechanisms accounting for these
findings are poorly understood. While talk itself can be therapeutic (e.g., lessening the patient’s anxiety,
providing comfort), more often clinician–patient communication influences health outcomes via a more
indirect route. Proximal outcomes of the interaction include patient understanding, trust, and clinician–
patient agreement. These affect intermediate out comes (e.g., increased adherence, better self-care skills)
which, in turn, affect health and well-being. Seven pathways through which communication can lead to
better health include increased access to care, greater patient knowledge and shared understanding,
higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient
agency and empowerment, and better management of emotions.
Conclusion: Future research should hypothesize pathways connecting communication to health
outcomes and select measures specific to that pathway.
Practice implications: Clinicians and patients should maximize the therapeutic effects of communication
by explicitly orienting communication to achieve intermediate outcomes (e.g., trust, mutual under-
standing, adherence, social support, self-efficacy) associated with improved health.
ß2008 Elsevier Ireland Ltd All rights reserved.
* Corresponding author at: Department of Communication, Texas A&M
University, College Station, TX 77843-4234, United States.
Tel.: +1 979 845 0209; fax: +1 979 845 6594.
E-mail address: r-street@tamu.edu (R.L. Street Jr.).
Contents lists available at ScienceDirect
Patient Education and Counseling
journal homepage: www.elsevier.com/locate/pateducou
0738-3991/$ – see front matter ß2008 Elsevier Ireland Ltd All rights reserved.
doi:10.1016/j.pec.2008.11.015
The second group consists of cross-sectional, descriptive
studies that have reported correlations between physician and
patient communication behaviors and different health outcomes.
For example, various features of patient-centered communication
– physicians’ clear explanations, physician compassion, active
patient participation, and patient involvement in decision-making
– have correlated with lower blood pressure [9], less patient
anxiety [10], less organ damage among patients with systemic
lupus erythematosus [11], and higher quality of life among breast
cancer patients [12]. However, other studies have found null to
mixed results regarding relationships between communication
and health outcomes [12–14].
The inconsistency of these findings from both RCT and cross-
sectional studies is likely due to a number of factors. First, research
to date has failed to explicate processes and fundamental
pathways linking communication to outcomes. As most of the
research is correlational, causal explanation can only be inferred.
For example, in one of our own early studies [15], patients with
diabetes had poorer metabolic control after consultations with
nurses who used more controlling communication (e.g., interrup-
tions, directives, disagreement). One might infer that the nurses’
dominance prevented patient involvement in decision-making
which in turn led to less adherence and understanding of the
treatment regimen. However, an alternative explanation may be
that nurses were more controlling with less cooperative and
adherent patients (i.e., patients at higher risk of poor control). Thus,
it is not clear which came first, patient lack of follow-through or
nurse’s controlling behavior, or whether this represented a cycle of
escalating dysfunctional communication.
Second, it remains unclear what elements of communication
are associated with specific outcomes. Several researchers have
identified key functions of patient-centered communication
including information exchange, managing uncertainty, enabling
patient self-management, responding to emotions, fostering the
clinician–patient relationship, and making decisions [3,16,17].
However, the manner in which a particular communication
function might or might not lead to improved health remains
untested. For example, in a RCT of a clinician communication
intervention to promote physician active listening and negotiation
skills with their patients with diabetes, patients in the intervention
group reported greater satisfaction with communication and
greater well-being. However there was no effect on metabolic
control, and these patients tended to gain more weight than the
control group [18]. In short, the intervention led to patients having
better feelings about their health, but no improvement in clinical
markers of disease and poorer management of risk factors. Thus, a
general statement that better outcomes are associated with better
communication would be uninformative because it fails to specify
which elements of communication are associated with which
health outcomes.
Third, researchers rarely address, if even acknowledge, the need
to situate clinician–patient communication within the broader
context of physiological, personal, and social determinants of
health. Once the patient leaves the consultation any number of
factors may affect subsequent health. The communication that led
to a decision to undergo chemotherapy would be associated with a
positive health outcome if the patient had transportation to receive
the treatment, could afford the treatment, was able to tolerate the
treatment, and the treatment was effective in curing the cancer.
Yet, that same communication might not lead to a good outcome if
the patient terminated treatment because of side effects, had
unreliable transportation, substituted questionable herbal reme-
dies for chemotherapy, or the cancer did not respond to treatment.
Research to date has not adequately examined how the relation-
ship between communication and health may be mediated
through the effects of communication on behavior change,
adherence, and self-efficacy or how communication might
moderate the relationship of well known social determinants of
health, the nature of which will depend on the clinical context.
Fourth, measurement matters. At the most basic level, different
operational and conceptual definitions of the variables to be
measured are problematic. For instance, two recent reviews
revealed that there is no shared definition of shared decision-
making [19,20]. Further, different methods of measuring commu-
nication (e.g., self-report vs. observer coding) may generate very
different assessment of the behavior [21]. For example, even
though an observer coding system indicated that the clinician
provided treatment information, it may not have been understood
by the patient, or perceived as having been informative [22].
Similarly, patient reports of involvement in decision-making may
not correspond with observers’ judgments about whether parti-
cipation had occurred [23].
Explaining how and why communication contributes to health
outcomes requires a deeper understanding of how specific, well-
defined aspects of communication are linked to specific outcomes,
as well as an understanding of how contextual factors – within the
clinical setting as well as family and social factors extrinsic to the
clinical setting – moderate or mediate the effects of communica-
tion on health. This requires that investigators move beyond
descriptive conceptual frameworks to formulate theoretical
explanations linking communication to health. Moreover,
researchers must also recognize and try to account for the fact
that outcomes, especially those related to cancer and chronic
disease, are likely less influenced by a single clinician–patient
encounter, and more by the cumulative effect of the patient’s
communication over time with their physicians, others on the
health care team, families, and friends.
3. Linking communication to improved health
3.1. What improves physical health?
Physical health status includes pain and other symptoms,
disease markers (e.g., hemoglobin A1C, blood pressure, weight,
prostate-specific antigen), functional capacity (e.g., ability to
walk) and subjective self-ratings of health. There are essentially
four types of therapeutic regimens that lead to improved physical
health—chemical (e.g., medication), mechanical (e.g., surgery),
behavioral (e.g., smoking cessation, diet) and psychological (e.g.,
placebo effects, cognitive therapy). For example, a patient could
experience improved physical health because he or she received
medication that controlled the disease, received necessary
surgical intervention (e.g., a stent), adopted healthier exercise
routines, or believed that the treatment was effective [24,25].
Thus, communication could lead to better physical health if
conversation between clinician and patient helped to identify the
correct diagnosis and appropriate treatment plan, led to following
through with treatment or self-care, and/or affected patients’
health beliefs.
3.2. What improves psychosocial aspects of health?
Psychosocial health is a function of the degree to which an
individual has more positive beliefs and feelings, harbors fewer
negative beliefs and feelings (e.g., worry, anger, anxiety, fear,
despair), and has a well-functioning social network. Psychological
well-being, vitality, self-efficacy, and social functioning [26] are
typically measured by patient (sometimes family) self-report.
Positive psychosocial outcomes can be the direct result of
communicative encounters (including those with clinicians) from
which patients feel known, validated, hope, worthy, reassured, and
comforted [27,28] and indirectly through diagnosis and treatment
R.L. Street Jr. et al. / Patient Education and Counseling 74 (2009) 295–301
296
of mental disorders (e.g., depression) and reinforcing social
support.
4. Communication pathways to improved health outcomes
To understand why communication may lead to better or worse
health outcomes, researchers must identify the pathway through
which communication influences health and well-being. As shown
in Fig. 1, the pathways through which clinician–patient/family
communication can influence health outcomes may be direct. For
example, talk can be therapeutic in that a physician who validates
the patient’s perspective or expresses empathy may help a patient
experience improved psychological well-being—fewer negative
emotions (e.g., fear, anxiety) and more positive ones (e.g., hope,
optimism, and self-worth) [10,29,30]. Talk may affect physical
symptoms as well. In one study, for example, empathic commu-
nication lowered physiological arousal and pain in patients with
irritable bowel symptoms [31]. Finally, nonverbal behaviors, such
as touch or tone of voice, may directly enhance well-being by
lessening anxiety or providing comfort [32–34].
However, in most cases, communication affects health through a
more indirect or mediated route through proximal outcomes of the
interaction(e.g., satisfaction with care,motivation to adhere, trust in
the clinician and system, self-efficacy in self-care, clinician–patient
agreement, and shared understanding) that could then affect health
or that could contribute to the intermediate outcomes (e.g.,
adherence, self-management skills, social support) that lead to
better health (see Fig. 1)[1,3]. For example, a clinician’s clear
explanations and expressions of support could lead to greater
patient trust and understanding of treatment options (proximal
outcomes). This in turn may facilitate patient follow-through with
recommended therapy (an intermediate outcome), which in turn
improves a particular health outcome (e.g., disease control,
emotional well-being). Or, patient participation in the consultation
could help the physician better understand the patient’s needs and
preferences as wellas discover possible misconceptions the patient
might have about treatment options. The physician can then
communicate risk information in a way the patient understands
which in turn could lead to a mutually agreed upon, higher quality
decision that best matches the patient’s circumstances.
In a recent NationalCancer Institute monograph [3],we proposed
that clinician–patient communication can contribute to improved
health through at least seven ‘pathways’—access to needed care,
increased patient knowledge and shared understanding, enhancing
therapeutic alliances (among clinicians, patient, and family),
enhancing emotional self-management, activating social support
and advocacy resources, increasing the quality of medical decisions
(e.g., informed, clinically sound, concordant with patientvalues, and
mutually endorsed), and enabling patient agency (self-efficacy and
empowerment). Although these pathways were explored with
respect to cancer care, they are certainly applicable to other health
conditions as well.
4.1. Access to care
In the USA, access to care is poor for many patients, particularly
for poorer, less health literate, and uninsured patients [35]. While
barriers to care often are economic, they also involve other factors.
For example, many patients may not be aware that a problem
requires medical attention. Many more may need assistance
navigating a complex health system. Clinicians can contribute to
improved access to care by not only communicating the need for a
test or treatment, but also providing information about where to
get specific health services, facilitating collaboration among health
professionals, and advocating on behalf of the patient for needed
clinical and community services [35–37]. Patients, in turn, may
need coaching to disclose barriers to access (e.g., lack of
transportation, family resistance) and engage with clinicians in
suggesting potential solutions.
4.2. Patient knowledge and shared understanding
Patients must have an understanding of illness, risks, and
benefits of various treatment options in order to make informed
decisions about medical care [38]. Clinicians also need to under-
stand a patient’s values, preferences, and beliefs about health.
However, achieving a shared understanding can be difficult
because clinicians and patients often understand health and
illness through different lenses [39,40]. Clinical evidence is
typically in the form of probabilities applicable to populations,
not individual patients [41]. Patients’ understandings are idiosyn-
cratic and based on the combination of personal experiences,
interpretation of scientific evidence (e.g., acquired through the
mass media or internet), and ‘common sense’ understandings of
Fig. 1. Direct and indirect pathways from communication to health outcomes.
R.L. Street Jr. et al. / Patient Education and Counseling 74 (2009) 295–301
297
health and illness [42] (e.g., hypertension medicines are taken
when feeling tense [43]; surgery can spread cancer [44]). Similarly,
clinicians’ ‘truths’ are a mixture of personal experience, unex-
amined heuristics, and clinical evidence.
Both clinicians and patients need the skill to present their own
frame-of-reference, and see the others’ point of view, as well as the
ability to explore their own health beliefs, understand relevant
clinical evidence, and articulate their values and preferences [45].
When successful, effective management of information can
increase satisfaction [46], facilitate participation in the consulta-
tion [47], increase the patient’s ability to cope with illness [48],
promote greater trust in their clinicians [49], all of which could
increase the patient’s commitment to treatment [50].
4.3. Enhancing the therapeutic alliance
The therapeutic alliance includes the interrelationships among
the patient and multiple health care professionals, friends, family
members, and caregivers [51,52]. Indicators of a strong therapeutic
alliance include mutual trust among all parties, coordinated and
continuous health care, and the patient’s perception of feeling
respected and cared for [3]. These alliances are ‘therapeutic’
because the quality of these relationships can affect health
outcomes in two respects. First, a patient’s perception that he or
she has good care, will not be abandoned, and is understood can
promote emotional well-being [53–55], especially when facing
serious and life-threatening illness [56]. Second, a patient’s trust in
his or her clinicians and the health care system can have an indirect
effect through better continuity of care, patient satisfaction with
decisions, and patient commitment to treatment plans [57–60].
The clinician–patient alliance is enhanced when clinicians are
optimally informative and show empathy with the patient’s
circumstances, when patients have an opportunity to express their
concerns, and when the patient receives consistent messages and
coordinated care from the clinical team [3].
4.4. Enhancing patients’ ability to manage emotions
A patient’s concernsabout health may elicit a number of negative
emotions (anger, sadness, fear, worry) that can threaten emotional
well-being and even physical health [61,62]. Clinicians can help
patients manage these emotions in ways that directly or indirectly
attenuate or alleviate suffering. First, providing clear and thorough
explanations about health and treatment options can help patients
gain a greater sense of control, be more hopeful, and manage
uncertainty [30]. Second, eliciting, exploring, and validating
patients’ emotions can reduce patient anxiety and depression
[10,63–65]. Third,communication that enhances the patient’s sense
of worth, confidence, and hope may confermeaning, motivation,and
energy needed to pursue work or leisure activities, and allow the
patient to enjoy greater quality of life despite the disease [66].
Success in helping patients manage negative emotions is often
difficult because clinicians are not particularly good judges of the
emotions patients are experiencing [61,62,67,68], patients often try
to hide or mask theirdistress, and some patientsthink the discussion
of negative feelings fall outside the boundaries of clinician–patient
relationships[69–71]. Clinicians can facilitate the patient’s ability to
manage emotions by presenting diagnostic and treatment informa-
tion clearly and honestly [72], by showing interest in the patient’s
life [73], by attentive listening, and by validating patient’s
expressions of feelings [65,74].
4.5. Improving family and social support
Social support consists of patient’s access to emotional, fiscal,
and tangible resources within their social network [75]. Social
support can affect physical health and quality of life in several
ways. First, the perception of having social support may directly
affect physiological processes such as lowering arousal and
reversing the effects of overactivation of hypothalamic-pituitary
axis and psychologically induced immunomodulation [76,77].
Social support can enhance a patient’s emotional well-being by
providing a sense of connectedness with others and opportunities
to discuss difficult situations [78]. Social support networks can also
provide instrumental help (e.g., transportation), financial
resources, encouragement, and advocacy in gaining access to
needed health services [79,80].
Although social support typically is treated as a resource
external to clinical settings, clinician–patient communication can
contribute to social support in several ways. First, the clinician’s
communication itself is a form of support that can offer
encouragement, praise, reassurance, advice, and advocacy [3].
Second, clinicians can talk with patients about ways to strengthen
existing social networks to provide tangible help, emotional
support; they can also suggest new sources of support such as
online support networks [81]. Finally, clinicians could potentially
counter, or at least help address the effects of ‘negative’ social
support (e.g., peer pressure to engage in unhealthy behaviors;
well-intentioned nagging) [82].
4.6. Enhancing patient empowerment and agency
Clinician–patient communication also can improve health by
empowering patients to be active, capable agents in managing
their health. Patient ‘agency’ requires skills across the spectrum of
participation in care, ranging from active participation in medical
encounters and decision-making to self-care skills for managing
everyday health-related activities [83]. Patient involvement can
lead to higher quality decisions that are better suited to the
patient’s unique needs and circumstances. Clinicians can facilitate
patient involvement in the decision-making process by helping
patients actively seek information, clarify treatment goals [84,85],
and express concerns and feelings [86]. Topics discussed during the
clinician–patient conversation could focus on autonomy, self-
efficacy, specific skills in managing one’s health, and where to get
access to self-care resources (e.g., websites, community groups)
that in turn lead to greater ability and motivation to solve health-
related problems, cope with complications, and follow-through
with treatment [87–90]. The importance of enhanced patient
agency has been demonstrated in several studies. For example,
cancer patients’ sense of control over disease has been linked to
emotional well-being and coping during survivorship [12,91].In
diabetes, more effective self-management has led to better
metabolic control and improved functioning [92].
4.7. Higher quality decisions
Patients will more likely experience better health when they
and clinicians reach decisions that are based on the best clinical
evidence, are consistent with patient values, are mutually agreed
upon, and are feasible to implement [3,93,94]. Charles et al. [47]
propose that medical decision-making proceeds through three
stages—information exchange, deliberation, and making the
decision. Information exchange consists of sharing clinician and
patient perspectives, such as the clinical evidence pertinent to the
patient’s condition and the patient’s expression of beliefs, values,
preferences and expectations. Deliberation involves discussion
focused on finding common ground, reconciling differences of
opinion and beliefs, addressing uncertainty, and achieving a shared
understanding of the patient’s health status and the risks and
benefits of different treatment options. The final stage is making
the decision. Although Charles et al. contend that these three
R.L. Street Jr. et al. / Patient Education and Counseling 74 (2009) 295–301
298
stages are distinctively different with respect to paternalistic,
informed, and shared decision-making styles, we [3] argue that
there can be considerable flexibility as one proceeds through these
stages. For example, some patients may be actively involved in
information exchange and deliberating, but choose to defer the
decision to the clinician; other patients may be relatively passive
by listening to the clinician’s information and opinions, but choose
to make the decision themselves.
Clinician and patient efforts to achieve high quality decisions
often face challenges. First, many decisions are complicated by the
lack of clinical evidence or evidence that is ambiguous or
inconsistent [45]. For example, different experts may give
conflicting recommendations (e.g., surgeons favor surgery for
prostate cancer, while radiation oncologists favor radiation
therapy), and patients may be forced to choose among different
sources of authority. Second, many patients have difficulty in
understanding clinical information, and clinicians may struggle to
place that information in the context of the patient’s unique health
situation. Finally, clinicians and patients often understand risk
differently. Clinicians typically approach risk analytically by
focusing on epidemiological evidence, while patients may perceive
risk based on personal experience and associational meanings [95].
Lack of shared understanding of risks and benefits associated with
different treatments and how the treatment options fit within the
patient’s values and life circumstances may lead to medical errors,
treatment plans that are not feasible, and lower patient commit-
ment to treatment [96].
Thus, the decision quality pathway to better health requires
clinical encounters where patients (and families) and clinicians
present and understand one another’s perspectives, find common
ground, reconcile differences, achieve consensus on treatment and,
when differences cannot be reconciled, negotiate a mutually
acceptable plan.
5. Directions for future research
Future research on the relationship between communication
and outcomes should strive to identify the particular pathways
through which the events of the consultation can affect subsequent
health and well-being. In fact, researchers might be advised to
identify the outcome of interest first, then work backwards to
ascertain the relevant proximal and intermediate outcomes which
should be measured, and finally determine what aspects of
clinician–patient communication should be analyzed to predict
the success of that pathway. Consider examples of how this might
be done.
5.1. Hypertension control
In a study of hypertensive patients, researchers might assume
that hypertension medications taken appropriately effectively
lower blood pressure to normal levels thereby reducing the
patient’s risk of cardiovascular mortality and morbidity. One
pathway through which clinician–patient communication could
lead to this health outcome is patient adherence to the appropriate
medication regimen. To test this pathway, researchers would
determine the key proximal outcomes that influence adherence
such as clinician–patient agreement on the patient’s risk and the
medication as well as patient understanding of the treatment plan.
Clinician–patient communication that enhances the likelihood of
achieving these proximal outcomes might be physician-specific
communication behaviors such as nonverbal attentiveness to
signal interest in the patient’s perspective and clear, jargon free
explanations about clinical risk, the need for treatment, treatment
goals, and side effects. Important patient communication beha-
viors might be sharing beliefs about hypertension, expressing
concerns about side effects, and being actively involved in the
decision-making. Other communication responses of importance
for both interactants might be periodic checks for understanding,
negotiating a specific treatment plan, and explicit statements of
agreement on the plan.
5.2. Pain management in cancer care
Patients with cancer often experience pain that has a negative
effect on quality of life. Thus, the primary health outcomes a
researcher might be interested in would be the patient’s self-report
on pain control and the degree to which pain interferes with
functioning. An intermediate outcome would be the patient’s skills
for managing pain. Proximal outcomes of the consultation that
could lead to pain management skills might be the patient’s
confidence in his/her ability to use pain medication effectively
(e.g., without worry of dependency), understanding the dosage and
how to titrate dosage to avoid over medicating, and learning
strategies to minimize or cope with constipation (e.g., use of
laxatives). With respect to the clinician, proximal outcomes might
include understanding of the patient’s beliefs about pain, the
patient’s concerns about pain medication (fear of addiction,
unwanted side effects), and confidence in the patient’s ability to
use pain medication appropriately. Clinician–patient communica-
tion behaviors that could accomplish these proximal outcomes
include discussing the severity of the patient’s pain, eliciting the
patient’s beliefs (and possible misconceptions) about cancer pain
(e.g., ‘just have to live with it as part of having cancer’) and
medications (‘I do not want to get addicted’), clear explanation of
what to expect from pain medication and possible side effects,
clinician support and encouragement, active patient participation
in formulating the treatment plan, and communication that
confirms mutual agreement on treatment plan.
5.3. End-of-life care
The decision to change focus from disease-modifying treatment
to comfort care places considerable stress on patients and their
families. Health outcomes pertinent to end-of-life care include the
emotional well-being of the family as well as the comfort of the
patient. Two pathways that can contribute to these outcomes are
(a) an enhanced therapeutic alliance of physicians, skilled nurses,
hospice workers, pastoral care, and family and (b) activating the
social support system of the patient and family. Proximal outcomes
of the consultation that can contribute to these outcomes include
trust in the clinicians and health care facilities, patient and family
‘feeling heard and known’ regarding fears and concerns, and
patients feeling reassured about not being abandoned. The
communication that contributes to these proximal outcomes
would include responding and validating patient/family emotions,
describing the coordination of care the patient will receive,
attentive listening, addressing the uncertainty of prognostic
information in terms of time left, and discussing social support
resources with the patient/families social network.
6. Conclusion
In this article, we focus on the relationship between commu-
nication and health outcomes. We have tried to illustrate ways in
which theory can inform communication practice and assist with
the design of studies that examine the relationship between
specific communication behaviors and proximal and intermediate
outcomes that contribute to health outcomes that are meaningful
to patients. We have proposed a simple, pragmatic model that can
inform hypotheses to guide future research; specifically, commu-
nication can influence health outcomes by direct and indirect
R.L. Street Jr. et al. / Patient Education and Counseling 74 (2009) 295–301
299
pathways, and there are relevant intrinsic and extrinsic contextual
modifiers of these relationships. Although we have proposed a
number of pathways through which communication can lead to
improved health, we also recognize that the relative importance of
a particular pathway will depend on the outcome of interest, the
health condition, where the patient is in the illness trajectory, and
the patient’s life circumstances. Yet, these factors must be taken
into account when hypothesizing the means through which
communication can contribute to improved health and well-
being. More rigorous approaches to integrating theory, context,
and measurement are needed if we are to make significant gains in
our understanding of how clinician–patient communication
contributes to healing and well-being.
Acknowledgements
This work was in part supported by a contract to the senior and
lead authors from the Outcomes Research Branch of the Applied
Research Program in the Division of Cancer Control and Population
Sciences, National Cancer Institute, NIH and in part by the Houston
VA HSR&D Center of Excellence (HFP90-020).
Conflict of interest
The authors have no conflict of interest in the authoring of this
manuscript.
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