Physician-Patient Communication: A Dyadic Approach To C.C. Amd P.S.


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Physician-Patient Communication: A Dyadic Approach To C.C. Amd P.S.

  1. 1. Running head: CULTURAL COMPETENCY & PHYSICIAN-PATIENT COMMUNICATION Physician-Patient Communication: A Dyadic Approach to Cultural Competence and Patient Satisfaction Max J. Smith Arizona State University
  2. 2. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  2 Abstract The dyad between Doctors and Patients, as it applies to patient satisfaction, has been along discussed topic in the field of both communication and medicine. Much speculation hasbeen made as to what affects patient satisfaction in the psychology of the physician-patient dyad,and to what correlative degree. As global communities mobilize in greater breadth and deptheach day, the ‘face’ of outpatients is becoming more culturally diverse. Attributable toglobalization, more and more scholars speculate cultural competency/awareness of physiciansmay affect the satisfaction of their patients. The following proposal aims to locate a correlationbetween a physician’s cultural competency, as perceived by patients, and a patient’s satisfaction.First, the proposal properly addresses the imminent need for cultural competency in a patient-physician dyad. Using standpoint theory as a framework, the proposal continues with a synthesisof literature on cultural assimilation between patients and doctors and its effects on the patientsatisfaction. The literature displays the gap in research regarding cultural competency and itseffects on patient satisfaction. After this review, the proposal moves to a methodological analysisof how to sample, measure, and evaluate the correlation between perceived cultural competency(of physicians) and patient satisfaction, proposing to administer a post-test survey accruing 200participants from a major hospital near the Southwestern United States. The data is projected tohelp provide a focus for the research question (RQ1), does a physicians culturalawareness/competency, as perceived by patients, correlate to patient satisfaction within thephysician-patient dyad?  Arizona State University – Hugh Downs School of Communication – Smith 
  3. 3. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  3 Physician-Patient Communication: A Dyadic Approach to Cultural Competence and Patient Satisfaction According to Seedhouse, “Patient satisfaction and well-being is a maxim of all healthcaremodels, global or individual” (p. 121); patient satisfaction, is a model of measuring how a personin a given medical in-patient/out-patient situation rated the comfort of their experience. Crucialto this satisfaction in the western model or biomedical model of healthcare is the communicationbetween physicians and their patients (physician-patient, patient-physician, doctor-patient,patient-doctor, etc.). This communication is vital in the diagnosis and preventing of disease, as itmakes up more than 73% of a patients total communicative visit (Zayts & Kang, 2010; Peskin,&Weyrauch, 1995): meaning, if person goes to a clinical physician, almost 3/4s of his or hertime communicating will be spent with the doctor. Current research on the patient-doctorrelationship (within the scope of patient satisfaction) is focused on patient-doctor similaritiesassimilations and time-elapse proxemics. With the changing global landscape attention to culturein the patient-doctor relationship may prove informative (Dutta, 2008). In order to do sohowever, a link to a doctor’s cultural competency and a patients satisfaction must be noted, thisstudy proposes to do such. The role of this examination is to discuss the doctor-patientrelationship by examining the doctor’s cultural competency, as perceived by the patient, and itscorrelation to a patient satisfaction. Planning to do so by, providing a background of doctor-patient communication and its influence on patient satisfaction. In addition, this study will alsoaddress possible implications to perceived cultural competence and patient satisfaction. Prior to discussing the research regarding doctor-patient communication, the importanceof patient satisfaction and the physician-patient relationship in regards to cultural sensitivity mustbe noted.  Arizona State University – Hugh Downs School of Communication – Smith 
  4. 4. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  4 Globalization, or the process by which autonomous economies, societies, and culturesbecome integrated through a global network, makes for the greater displacement of regionalcommunities worldwide; allowing a greater diversity of culture and gender to spread worldwidethan ever before (Dutta, 2008). As the global landscape changes, becoming more culturallyconglomerate, some critical academics speculate the biomedical model cannot accommodatepatients culturally, from a doctor-patient perspective (Dutta, 2008; Zayts & Kang, 2010; Peskin,& Weyrauch, 1995). The biomedical model of healthcare is the most widely used form ofnationalized healthcare in the world (Rees, Knight, & Wilkinson, 2009). This model ofHealthcare subscribes to the Hippocratic view of disease as a biological problem with aims ofpatient treatment first and patient satisfaction second; the model itself ascribing to the belief thatpatient satisfaction is rooted in biology, not holism. It encompasses the norms and regulationswhich medical professionals are trained to ‘view-in’ and ‘perform under’ (Dutta, 2008). One ofthese norms understood to impact patient satisfaction is the communicative process between aphysician and patient. The doctor-patient relationship, rooted in the very early tenants of medical ethics, iscentralized around the Hippocratic Oath and the pillars of most Abrahamic religions (Dutta,2008). This dyadic communication is pivotal in the diagnosis and prevention of disease (Dutta,2008; Wood, 2005). The quality of communication between a patient and doctor plays a largerole in the overall health experience of a patient. For instance, a study conducted in WashingtonState showed 40% of patients who expressed their doctors “used open ended questions,” alsostated their health experience was more satisfactory than those with physicians who “useddominant conversation styles’- regardless of physical ailment (Ishikawa, Takayama, Yamazaki,& Katsumata, 2002); compared to biological issues, the interpretation of doctor’s communication  Arizona State University – Hugh Downs School of Communication – Smith 
  5. 5. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  5plays a superlative role. In addition to this study, patients in a nationwide examination who werevictims of malpractice were a third less likely to sue their physician if their doctor had attendedtwo 7.5 hour communication-tactic seminars (Peskin, &Weyrauch, 1995); helping to reveal thebenefit for both doctors and patients through an increasingly communicative environment. Inspecific, current communication research on the patient-doctor relationship shows factors linkedto doctor-patient parallels, which often correlate to patient satisfaction (Peskin &Weyrauch,1995; Ishikawa, Takayama, Yamazaki, & Katsumata, 2002; Blanquicett, Amsbary,Mills & Powell, 2007). The following is a review of literature which shows how cultural doctors and patientsaffect patient satisfaction. The first section reveals how cultural determinants (age, race, gender)shared between doctors and patients increase patient satisfaction. The second section will framethe findings of section using Stand-Point Theory in a pragmatic fashion. The review willconclude with the cultural implications for the patient-doctor relationship and the proposal of aresearch question connecting perceived cultural sensitivity to patient satisfaction.Doctor-Patient Commonalities and Patient Satisfaction In the doctor-patient relationship, similarities between a doctor and their patient haveshown to increase patient satisfaction in regards to age, race, and gender. For instance, patientsfound within ten years of their doctor’s age resulted higher satisfaction in their medical visit ascompared to their patients who were not (Blanquicett, Amsbary, Mills & Powell, 2007; Bischoff,Bovier & Hudelson, 2008). In a study of 400 participants which gauged patient-satisfaction inrelation to nonverbal factors, those between 40-49 (%) and 50-59 (%) with a doctor within adecade of their age were 30 (%) more likely to rate their medical experience a (7+ /10, ten likert-type scaling). In a similar study patients under 45 years of age seeking psychiatric help were  Arizona State University – Hugh Downs School of Communication – Smith 
  6. 6. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  6found to be more satisfied with their care if their physician was also under 45 (Blanquicett,Amsbary, Mills & Powell, 2007; Jagadeesan, Kalyan, Lee, Stinnett, & Challa, 2008). On top ofage, patients who also share racial similarities with their physician have a greater satisfactionthan those who do not. In a recent study regarding cancer oncology, ethnic concerns, and patientsatisfaction; patients with cancer “who shared, or appeared to share” racial or ethnic backgroundswere more likely to be satisfied than those of a doctor with a different ethnic background (Jean-Pierre, Fiscella, Griggs, Joseph, Morrow, & Carroll, 2010). The study explained more simplythat Caucasian patients experienced higher satisfaction if their doctor was Caucasian andAfrican-American patients experienced greater satisfaction if their doctor was African-American(Jean-Pierre et al., 2010). In 2001, a survey was administered to 2000 Mexican-nationals near theborder of Arizona and Mexico to show patient comfort in relation to the ethnic backgrounds ofphysicians and their staffs. The results showed that clinics that employed more Mexican-American doctors had higher rates of outpatient satisfaction than their counterparts who did not(Rees, Knight, & Wilkinson, 2009; Clucas & St. Claire, 2008). In addition to race, similarities ingender between doctors and patients have had an effect on the patient-doctor relationship. In a1992 Schneider and Tucker performed a study on the relational effects of interpersonalcommunication in physician-patient satisfaction (p.10). In Alabama, a similar study was done inwhich patient’s satisfaction was interpreted via video playback by randomized participants(Blanquicett, Amsbary, Mills & Powell, 2007). In both the studies, male patients were found toexperience more satisfaction if they were attended by a male physician; the same microcosmapplies to women as in both studies more than half of women preferred a female physician to amale physician (Schneider, & Tucker, 1992; Zayts, & Kang, 2010).  Arizona State University – Hugh Downs School of Communication – Smith 
  7. 7. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  7 Rooted in critical and feminist theory, Standpoint Theory, states that the social positionsin which a person stands provides the vantage point from where he or she experiences the world;social positions include race, age gender, nationality, sexuality or disability. It’s through thesesocial lenses in which people experience the world, a standpoint (Pawloski, 2006). Furthermore,standpoint theory states people with similar “standpoints” can share similar cultural experiencesautonomously. This theoretical idea, shared standpoints, provides a possible explanation for whysimilarities between doctors and patients foster greater patient satisfaction. Patients and doctors,as stated above, who share the similar age, race, or sex has a greater satisfaction rate asoutpatients than those of lesser or no similarity to their physician (Wood, 2005; Pawloski, 2006).Based on standpoint theory all of the patients and doctors who share these similarities view theworld in a similar way, creating a shared experience amongst the dyad (age, race, sex), whichmay provide leeway to greater patient satisfaction (as shared experiences can lead greatercommunicative disclosure) (Wood, 2005: Pawloski, 2006). Cultural determinants, age, race andsex, are highly correlated to patient satisfaction, however whether these implications apply to thecultural competency of physicians yet to be shown (Dutta, 2008). Due to the ever increasingglobalized planet and limitations to the current research, the following question has beenfostered. RQ1: Within the physician-patient dyad, does a physician’s cultural awareness/competency, as perceived by patients, correlate to patient’s satisfaction? MethodParticipants Participants involved will complete a post-test survey within 2 weeks of their physicianinteraction. Participant post-tests will accrue for the period of a year, January 18, 2012 to January  Arizona State University – Hugh Downs School of Communication – Smith 
  8. 8. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  818, 2013 to facilitate in acquiring data. Those participating will be (1) completely voluntary, (2)informed of their anonymity, and (3) have information legally protected to the boundaries of thisresearch. In compliance with the Institutional Review Board at Arizona State University(IRBASU) a copy will be submitted for the potential of academic publication. Participant information will be gathered from a single source found in the central urbanSouthwestern United States; a post-test survey will be administered to all out-patients in a majorhospital and medical facility with a sample aim of 200 participants. As other CommunicationResearch has shown voluntary purposive sampling has often equated to subpar results (Brach &Fraserirector, 2000); therefore, to incentivize participants to respond, a menial medical tax willbe waived upon cooperation from the patient. The sampling method is categorized as bothvoluntary and purposive as participants are chosen based on their interaction with a medicalphysician and their participation being completely voluntary. Criteria required for being a participant follows as such: Participants must be over 18years of age and have recently taken part in an outpatient process facilitating the patient-physician dyad. An intermediate comprehension of the English Language is also required:approximately a 6th Grade level is necessary to complete the survey. Additionally, in compliancewith the American Hippocratic Association and the Federal Government, all participants mustalso be in the United States legally and lawfully. A single PT-group will provide data to evaluate a possible correlation between thecultural competence of a physician and a patients satisfaction. Given the demographics of theSouthwestern United States, participant demographics should closely reflect the following:Hispanic or Latino (40.8%), White (46.5%), Black or African American: (6.5%), Asian (3.0%),Native American (1.7%), Native Hawaiian and Other Pacific Islander (1.6%) and mixed-race  Arizona State University – Hugh Downs School of Communication – Smith 
  9. 9. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  9(0.2%) (USCB, 2010). Additionally, another potentially reflective is the male (52.8%) andfemale (47.2%) demographics of the Southwest (UCSB, 2010). Since standpoint theory is rootedin the cultural dynamics of the non-status-quo; to aid in efficacy, this research will focus onthose not of the status-quo, white men and women. Instead, the research will focus on different,marginalized, (Hispanic, African American, Asian Native American, etc.) ethnicities honingemphasis on a culture-centered-approach to patient satisfaction.Procedures To measure whether a patient’s satisfaction and a physician’s cultural competency arecorrelated a post-test will be administered quantifying patient perceptions. To alleviate humaninfluence by the doctor the post-test will be administered by a non-physician Hospital-mediatedrepresentative. Based on the scale developed by the Truman Medical Center and the UMKCSchool of Medicine (TMC Survey) a likert-type 10-point scale will be used to evaluate culturalcompetency. Similarly the patient’s satisfaction will also be quantified using a likert-type scale; aone signifying “never,” a five signifying “moderate,” and a ten signifying “always.” Following apatient-physician dyad, a survey (post-test) will accompany the patient home, in which he or shewill voluntarily finish the post-test and mail it to be collected (free-postage included). Followingdata collection, a possible correlation will be evaluated using a Pearson’s ‘r’ Analysis to assessthe connection between perceived cultural competency and satisfaction in the doctor-patientdyad.Instrumentation In order to provide data analyzing RQ1, Cultural Awareness, also known as CulturalCompetency, must be gauged. The likert-type scale developed by The Truman Medical Centerand the UMKC, known as the TMC, was chosen because of its adept ability to accurately address  Arizona State University – Hugh Downs School of Communication – Smith 
  10. 10. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  10patients’ cultural perception of others (Hickman & Flores, 2000). The scale was originallydeveloped in 2000 to create a framework for non-medical physicians to help in addressing howpatients perceive the cultural penetrations tactics (e.g. “How often did your physician inquireabout age or age related ailments?,” How often did your physician inquire about your ethnicity orethnic-correlated ailments?”) (Hickman & Flores, 2000). The entire survey is composed of 32questions aimed at addressing whether or not a participant perceives cultural competency in adyadic conversation. The first portion of the questionnaire provides a scope of the patientscultural perceptions in regards to race, age, gender and standpoint (16 items, e.g. “How often didyou physician allude to gender based remedies?,” “How frequently was ethnicity discussed byyour physician in regards to your condition or reason of visit?”). The second portion discusses apatient’s perception of his or her physician’s religious awareness (10 items, e.g. (“At whatfrequency did your physician ask about religious/spiritual preference in regards to your ailmentof reason of visit?”) (Hickman & Flores, 2000). The final portion’s scope is in regards to patientperception of a physician’s holistic awareness. (6 items e.g. “How often did your physicianprovide alternative methods of medical care (i.e. behavior change)?” “How often did yourphysician provide holistic approaches to health prosperity?”). The survey will be gauged on alikert-type scale on a range from one to ten. “One” signifying “never,” alludes to a lower culturalawareness score and thus lower perceived cultural competency; while “Ten” signifying“always,” corresponds to higher perceived cultural awareness of physicians. Measuring Cultural Competency via the Truman and UKMC post-test has proven bothreliable and valid. As prior studies have shown, Cronbach’s α (alpha) coefficients (>.93) wereachieved in studies regarding perceptions of cultural competency in labor workers, and Hispanics(Cervantes, 2009; Cervantes, Duenas, Valdez, & Kaplan, 2011; Beach, Eboni, Tiffany, Karen,  Arizona State University – Hugh Downs School of Communication – Smith 
  11. 11. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  11Robinson, Palacio, Smarth, & Jenckes, 2005). The TMC has also been featured in labor seminarsand conference papers as a tool for increasing cultural awareness (Cervantes, 2009; Beach et al.,2005). Also vital to answering RQ1 is quantifying the satisfaction perceived by outpatients.Patient Satisfaction is the self perception of an outpatient’s well-being after an outpatientprocedure. For the sake of this research, patient satisfaction will be refined to the communicationcontext between patient and physician. Doing so by using questions which disambiguate betweenphysical and mental health satisfactions (e.g. “How did your physician accommodate yourphysical needs regarding your visit?” “How did your physician accommodate to your non-physical needs?”). This disambiguation between satisfaction (mental and physical) is to rule outsatisfaction based on a biomedical cure and focus satisfaction on a cerebral and communicativecontext. By limiting satisfaction due to medicine or medical treatment possible errors from suchare prevented.Data Analytic Strategy Based on researcher expectation, a correlation should be evident between patientperceptions of cultural awareness and patient satisfaction. Because both variables, independentand dependent, are ordered by an interval scale a Pearson’s ‘r’ correlation will be used to testRQ1. In order to confirm a significant relationship, in accordance with the IRBASU, an ‘r’(correlation coefficient) must reflect a strong correlation (positive or negative) between the twovariables, physician’s perceived cultural competency and patient satisfaction (-.95>r >.95).  Arizona State University – Hugh Downs School of Communication – Smith 
  12. 12. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  12 ReferencesBeach, M.C, Eboni, G. P., Tiffany, L.G., Karen, A., Robinson L., Aysegul, G., Palacio, A., Carole, L., Smarth, M. W., & Jenckes, C.F. (2005). Cultural competence: A systematic review of health care provider’s educational interventions. Medical Care Research & Review, 43 (4), pp. 356-373.Bischoff, A., Hudelson, P. P., & Bovier, P. A. (2008). Physician-patient gender concordance and patient satisfaction in interpreter-mediated consultations: An exploratory study. Journal of Travel Medicine, 15(1), 1-5.Blanquicett, C., Amsbary, J., Mills, C., & Powell, L. (2007). Examining the Perceptions of Doctor-Patient Communication. Human Communication, 10(4), 421-435.Brach, C., & Fraserirector, I. (2000). Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research & Review, 57 (4) 181-217.Cervantes, R.C. (2009). Cultural competency in evaluation for Hispanics. Behavioral Assessment AIA Web Conference on Culturally Competent Evaluation.Cervantes, R.C., Duenas, N., Valdez, A., & Kaplan, C. (2011). Measuring violence risk and Outcomes Among Mexican-American Adolescent Females. Journal of Interpersonal Violence, 12(2) 101-131.Clucas, C., & St. Claire, L. (2011). Influence of patients self-respect on their experience of feeling respected in doctor-patient interactions. Psychology, Health & Medicine, 16(2), 166-177.Dutta, M. J. (2008). Communicating Health: A Culture-Centered Approach. Cambridge, UK: Polity Press.Flores, G., & Hickman, T. (2000). Measuring cultural competency: Creating a conceptual,  Arizona State University – Hugh Downs School of Communication – Smith 
  13. 13. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  13 logistic, and interpersonal Model. Social Science & Medicine, 16 (2) 119-138.Ishikawa, H., Takayama, T., Yamazaki, Y., Seki, Y., & Katsumata, N. (2002). Physician-patient communication and patient satisfaction in japanese cancer consultations. Social Science & Medicine, 55(2), 301-311.Jagadeesan, R., Kalyan, D. N., Lee, P., Stinnett, S., & Challa, P. (2008). Use of a standardized patient satisfaction questionnaire to assess the quality of care provided by ophthalmology residents. Ophthalmology, 115(4), 738-743.Jean-Pierre, P., Fiscella, K., Griggs, J., Joseph, J. V., Morrow, G., & Carroll, J. (2010). Race/ethnicity-based concerns over understanding cancer diagnosis and treatment plan. Journal of the National Medical Association, 102(3), 184-189.Pawlowski, D. R. (2006). Who am I and where do I “stand?” Communication Teacher, 20(3), 69-73.Peskin, T., &Weyrauch, K. F. (1995). Malpractice, patient satisfaction, and physician-patient communication. JAMA : The Journal of the American Medical Association, 274(1), 22-3; author reply 23-4.Rees, C. E., Knight, L. V., & Wilkinson, C. E. (2007). Physician-patient satisfaction in near- arizona border towns: a plan for of education. Social Science and Medicine, 65(4), 725- 737.Schneider, D. E., & Tucker, R. K. (1992). Measuring communicative satisfaction in doctor- patient relations: the doctor--patient communication inventory. Health Communication, 4(1), 19.Seedhouse, D. (2001). Health: The Foundations for Achievement, 2nd Edition. Wiley & Sons Inc.: Hoboken, NJ.UCSB: United States Census Bureau. (2010). Population distribution and change: 2000-2010. U.S. Department of Commerce: Economics and Statistics Administration.  Arizona State University – Hugh Downs School of Communication – Smith 
  14. 14. PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE  14Wood, J. T. (2005). Feminist standpoint and muted group theory: commonalities and divergences. Women & Language, 28(2), 61-64.Zayts, O. & Kang, M. (2010) Communication in healthcare settings: Interactional perspectives from Asia. Journal of Asian Pacific Communication, 20 (2):165-168.  Arizona State University – Hugh Downs School of Communication – Smith 