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
56. Greene MG, Adelman R, Charon R, Hoffman S. Ageism in the
medical encounter: an exploratory study of the doctor-elderly patient
relationship. Lang Commun. 1986;6:113–24.
57. Waitzkin H. Information giving in medical care. J Health Soc Behav.
58. Hall JA, Stein TS, Roter DL, Rieser N. Inaccuracies in physicians’
perceptions of their patients. Med Care. 1999;37:1164–8.
59. Golin C, DiMatteo MR, Duan N, Leake B, Gelberg L. Impoverished
diabetic patients whose doctors facilitate their participation in
medical decision making are more satisfied with their care. J Gen
Intern Med. 2002;17:857–66.
60. Tennstedt SL. Empowering older patients to communicate more
effectively in the medical encounter. Clin Geriatr Med. 2000;16:61–
61. Brody DS, Miller SM, Lerman CE, Smith DG, Caputo GC. Patient
perception of involvement in medical care: relationship to illness
attitudes and outcomes. J Gen Intern Med. 1989;4:506–11.
62. Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP.
Improving physicians’ interviewing skills and reducing patients’
emotional distress. A randomized clinical trial. Arch Intern Med.
63. Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians. 2nd ed.
Philadelphia, Pa: Lippincott Williams & Wilkins; 2000.
64. Lazare A, Putnam SM, Lipkin M. The three functions of the medical
interview. In: Lipkin M, Putnam SM, Lazare A, eds. The Medical
Interview: Clinical Care, Education, and Research. New York, NY:
65. Beckman HB, Frankel RM. The effect of physician behavior on the
collection of data. Ann Intern Med. 1984;101:692–6.
66. Burack RC, Carpenter RR. The predictive value of the presenting
complaint. J Fam Pract. 1983;16:749–54.
67. Floyd M, Lang F, Beine KL, McCord E. Evaluating interviewing tech-
niques for the sexual practices history. Use of video trigger tapes
to assess patient comfort. Arch Fam Med. 1999;8:218–23.
68. Gmel G, Lokosha O. Self-reported frequency of drinking assessed
with a closed- or open-ended question format: a split-sample study
in Switzerland. J Stud Alcohol. 2000;61:450–4.
69. Ivis FJ, Bondy SJ, Adlaf EM. The effect of question structure on
self-reports of heavy drinking: closed-ended versus open-ended
questions. J Stud Alcohol. 1997;58:622–4.
70. Devine DA, Fernald PS. Outcome effects of receiving a preferred,
randomly assigned, or non-preferred therapy. J Consult Clin Psych.
71. Oberst MT. Methodology in behavioral and psychosocial cancer
research. Patients’ perceptions of care. Measurement of quality and
satisfaction. Cancer. 1984;53(10 suppl):2366–75.
72. Brown R, Dunn S, Butow P. Meeting patient expectations in the
cancer consultation. Ann Oncol. 1997;8:877–82.
73. Gerbert B, Berg-Smith S, Mancuso M, et al. Video study of phys-
ician selection: preferences in the face of diversity. J Fam Pract.
74. Baddeley AD. The Psychology of Memory. New York, NY: Basic
75. Capitani E, Della Sala S, Logie RH, Spinnler H. Recency, primacy,
and memory: reappraising and standardising the serial position
curve. Cortex. 1992;28:315–42.
76. Yunker RM, Levine MK, Sajid AW. Freestanding emergency cen-
ters and the patient population of internists. South Med J.
77. Yunker RM, Levine MK, Sajid AW. Free-standing emergency centers
and the patient population of family physicians. J Fam Pract.
78. Rylko-Bauer B. The development and use of freestanding emer-
gency centers: a review of the literature. Med Care Rev.
79. Lo B, Quill T, Tulsky J. Discussing palliative care with patients.
ACP-ASIM End-of-life Care Consensus Panel. American College of
Physicians-American Society of Internal Medicine. Ann Intern Med.
80. Towle A, Godolphin W. Framework for teaching and learning
informed shared decision making. BMJ. 1999;319:766–71.
81. Sheridan SL, Harris RP, Woolf SH. Shared decision making about
screening and chemoprevention. A suggested approach from the U.S.
Preventive Services Task Force. Am J Prev Med. 2004;26:56–66.
82. Platt FW, Gordon GH. Field Guide to the Difficult Patient Interview.
Philadelphia, Pa: Lippincott Williams & Wilkins; 1999.