This document summarizes and analyzes an article that examines how clinician-patient communication contributes to health outcomes. It discusses the article's exploration of indirect pathways from communication to outcomes, and introduces a model for mapping these pathways. The summary also analyzes challenges in past research and outlines conceptual and measurement issues to address.

1. Jack Davidson
04/12/2015
Skye Chernichky
Linking Communication to Improved Health Outcomes
How clinician-patient communication contributes to health improvement: Modeling path-
ways from talk to outcome
Richard L. Street Jr., Department of Communication, Texas A&M University, College Station,
USA
http://www.sciencedirect.com/science/article/pii/S0738399113001845
Summary of Article
The article by Dr. Street I chose for the Analysis Paper #2 examines challenges in the study of
how clinician-patient communication contributes to a patient’s health, explores the indirect
effect of communication influence on observed intervention between the clinicians and pa-
tients, indicates the conundrums in current research from a communicative process perspec-
tive, introduces a research theory that examines the modeling of communication pathways
to improved health, and finally presents the conceptual and measurement challenges in in-
terpersonal communication between clinicians and patients. The analysis provided by Dr.
Street is a concise body of work that attempts to explain the systemic methods of analysis
conducted to date, and exposes the issues related to past research and critically reflects on
differences in perspectives in relational communication study. This article does not attempt
to provide specific research that supports the theory that clinician-patient communication
affects outcomes and how, rather Dr. Street offers expansive perspectives on the interrelated
forces on communication study and offers criteria to consider with future research that more
accurately and measurably connects the communicative experience among clinicians and
patients to their desired health outcomes.
Section 1: Conundrums in Health Outcomes Research
Duggan indicates that a relational approach to patient-centric healthcare communication in-
volves paying more attention to emotional needs and using more nurturing discourse man-
agement, or conversation about the health concern, and emotional expression from both a
verbal and nonverbal perspective during interpersonal health interactions. As researchers
investigate the dichotomy of physician and patient relationship-centered care and observe
the benefits for patients, the communication skills that emerge are information giving, inter-
personal sensitivity, and partnership building. These are the skill areas that are core to the
focus on communication improvement in the physician-patient dyad, and are central to the
educational foundation that still needs to be established as more scientific research is con-
ducted and factual data is collected that supports the communication influence on health
outcomes. Dr. Street argues that communication may directly impact health outcomes, but
more often it will have an indirect effect through its influence on intervening variables such
as patient understanding, clinician-patient agreement on treatment methods and strategies,
and patient adherence to treatment. The outcomes themselves are center to Dr. Street’s

2. Interpersonal Communication Impact on Health Outcomes
analysis, and improvement in outcomes may not be directly related to communication skills,
rather the outcome may be impacted indirectly by influencing the proximal variables that
lead to a change in strategy for treatment which ultimately results in an improved health out-
come.
Dr. Street indicates that previous research conducted in the 1980s, on the surface, demon-
strate that relationships between physician-patient communication and health outcomes in-
dicates that patient-centered care approach leads to better health outcomes. Two examples
of this research shows that Kaplan et. al found that diabetes patients that were more in-
volved and participatory in the physician-patient dyad describing treatment options had
lower blood pressure and improved metabolic control 8-12 weeks after their consultations
compared to patients that were not as engaged in participating in the communication inter-
actions. Similarly, research from Orth et al. found that physicians that gave more informa-
tion to their patients through better explaining, describing, and reporting found that patients
had lower blood pressure two weeks after the visit compared to patients that were not given
more detailed information. Duggan supports this notion, indicating that previous research in
the last decade has established a link between interpersonal communication and outcomes
related to health, but the how and why improvements to the communication processes lead
to better health outcomes.
Not so fast, says Dr. Street, upon re-analysis of the data from the early research studies from
Kaplan et al. points out some interesting facts that reduce the accuracy of these statements.
Contrary to Kaplan et al., patient participation in shared-vision decision making has not
been predictive of metabolic control of diabetic patients after more time goes by from the
point of the initial consultation. Dr. Street also indicates that patient-centric communication
was not directly linked to improved outcomes in lupus patients, physicians who provide their
patients with more information also had patients who reported more health-related func-
tional limitations and lower self-reported health statues, and diabetes patients who ex-
pressed more negative feelings and concerns to their physicians either had better or worse
outcomes. This indicates that the previous research aimed at drawing the conclusion quickly
that communication is directly responsible for improved health outcomes, but when other
factors are taken into account the results of the research begin to vary widely. Dr. Street also
cites an example from research from Kinmonth et al. whereby physicians that receive a
health communication intervention by communication scholars compared to a control group
of physicians who do nor receive the intervention indicate that their diabetes patients report-
ed being happen and generally more satisfied with their healthcare experience and report a
better quality of life, they also tip the scales with having higher triglycerides and higher body
mass indexes when compared with patients of physicians who do not receive this interven-
tion. This explains the conundrums facing research scholars today. Dr. Street summarizes
these research conundrums by indicating the importance of research taking into account ex-
actly what types of outcomes are being measured and when they are measured, and what
elements of communication are being studied, from what perspective, and how these com-
munication elements are being measured.
Interestingly, Duggan points out that research collected in the late 1990’s, shows that female
physicians' medical interactions with patients lasted on average two minutes longer than
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3. Interpersonal Communication Impact on Health Outcomes
male physician interactions, and female physicians engage in more patient-centric communi-
cation through active partnership building, psychosocial counseling, positive and emotional-
ly-focused talk. Relating that to previous study, from Trenholm and Jensen in chapter four
on gender and discourse, the gender of the physician could affect how communication is de-
livered about the health concern to the patient, and how that communication is said could
be reflective of the female gender and their use of their more emotionally-centered vocabu-
lary. Trenholm and Jensen continue by listing the female registers used during communica-
tion such as qualifiers, tag endings, and disclaimers during interaction. Qualifiers help build
empathy with the patient by providing details of the subject but also serve to explain influen-
tial forces that may validate or violate the subject being discussed instead of potentially
omitting a subject all together if the data supporting that subject isn’t 100% validated. Tag
endings are conversational strategies used by females that serve to gain mutual agreement
or shared vision of the subject being discussed, whereas a male physician may omit them al-
together and fail to ask the patient for their agreement or verify their understanding. Dis-
claimers can be seen as a positive approach to the relational communicative approach be-
cause they serve to gain empathy with a patient by increasing the patient’s involvement in
the conversation. These female registers likely account for the two minute longer consulta-
tive communication, but likely serve a purpose in support of the female physician engaging
in more patient-centric empathic communication. The end result, as Duggan points out, is
that patients who are more actively influential in the content and structure of the interaction
experience improved health outcomes, and the relational approach engages the patient in
the communication and encourages their participation, which generally leads to improved
health outcomes from a broad perspective. Gender study may be able to provide cues to in-
terpersonal communication core skills that could serve as foundational building blocks for
improved physician-patient relational communication, and Dr. Street’s study on communica-
tion conundrums, modeling pathways, and measurement challenges could provide a re-
search methodology with a core foundation applying these factors in future research practice
which could improve measurable data.
As Duggan summarizes, health communication scholars explain the communication process
related to measurable health outcomes in physician-patient interactions and the ways pa-
tients needs, preferences, and beliefs surface through shared power and a cooperative team
approach to the health encounter. Dr. Street ties in this overall objective shared by Duggan
into his modeling pathways to desirable outcomes concept.
Section 2: Modeling Communication Pathways
The article indicates that to understand the influential factors that impact desired outcomes,
researchers should employ a method of constructing model pathways through which com-
munication contributes to outcomes of interest. Previous research to date has not been
based on communication pathways throughout the physician-patient interaction, and in or-
der to fully understand the relationship between physician-patient communication and
health outcomes for future research agenda to follow. Beginning with an outcome, there are
multiple direct and indirect pathways from communication to outcome, and Dr. Street indi-
cates that the indirect pathways through mediated routes are linked to improved health. To
explain this concept, Dr. Street provides an example of effective patient communication pro-
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4. Interpersonal Communication Impact on Health Outcomes
ducing immediate outcomes such as better patient understanding of treatment options, the
physician’s understanding of the patient’s goals and objectives, and a mutually-agreed upon
action plan contributes to more intermediate outcomes such as access to needed or neces-
sary care, more adherence and compliance by the patient, and more self-centered care skills
performed by the patient that, as a result, improve the outcome of interest described as
metabolic control, psychological health, and reduced pain. This indirect/direct relationship
of the communication components to the desired outcomes is the focus of the modeling
pathway study.
Dr. Street suggests that researchers should construct the modeling pathway by listing the
steps for research agenda that lead to desired outcomes from top to bottom. These path-
ways begin with the identification of the desired health outcomes and describe the mecha-
nisms for improved health as step one. Step two indicates the model pathway through which
communication leads to improved health. Step three highlights the appropriate measures
for communication variables, proximal (immediate) outcomes, and intermediate (longer
term) outcomes. Finally step four develops the communication interventions to target spe-
cific communication processes to activate that overall mechanism in step one. Dr. Street sug-
gests working backwards from the desired outcome of interest and the mechanism by which
that outcome would be achieved to the indication of the specific communication variables
needed to activate the intervening processes required to achieve the targeted outcome.
Through this bottom-up approach, interventions could be developed that target the specific
communication factors that are required to produce the intended result and these communi-
cation factors will dictate the pathway to improved health and what is needed from a devel-
opmental perspective to ensure the physician-patient communication is following these
guidelines. Returning to Duggan, these pathways described by Dr. Street could be described
as relational communication constructs that explain how the shift to shared power results in
differences in communication processes. Patient adherence and satisfaction, Duggan ex-
plains, are associated with shared power and a perceived reduction in physician control over
the physician-patient relationship through mutual respect, empathetic caring, and relation-
ship-building reassurance. These constructs are center to the proximal outcomes Dr. Street
indicates in communicative styles within modeling pathways, and as Duggan mentions that
the relational approach is illustrated by physicians treating emotional needs of patients with
a higher degree of importance, and the use of nurturant emotional expression yields better
outcome results.
The direct path from a clinician to patient communication limits the longer term favorable
health outcomes because of its limited use of immediate and intermediate outcomes that
translate to the overall intended or desired outcome. The clinician-patient communication
process takes a direct path to the desired outcome and cuts the clinician-patient interaction
down to the minimum required to inform the patient of their diagnosis and prescribed treat-
ment options for achieving the intended outcome. The indirect or mediated path includes
the immediate and intermediate outcomes achieved through communication that relate di-
rectly or indirectly to the targeted health outcome. By using an indirect or mediated path,
chances for success in the outcome are improved because their are more communication
paths present between clinician and patient that offer more opportunity for patient feed-
back, discourse, or health concern with which become actionable data the physician can use
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5. Interpersonal Communication Impact on Health Outcomes
to determine if the current prescribed treatment is still the best course of action or if another
approach may need to be considered. The increase in indirect pathways provide these com-
munication channels from the patient to the physician and these become channels for shar-
ing information about self-observation of health impact from prescribed treatments which,
in turn, translates to data that the physicians can use to make more informative decisions on
the condition treatment course of action.
Now that we understand the difference between indirect and direct communication path-
ways, let’s examine the example provided by Dr. Street using a patient suffering from cancer-
related pain. Utilizing a randomized control trial, or RCT, testing the effectiveness of tailored
education-coaching interventions, or TEC, for pain management among cancer patients who
are experiencing severe to moderate pain. The TEC intervention involved a pre-consultation
pain management education session coupled with an independent third party lay health ed-
ucator functioning as a health coach. The health coach helps patients communicate more
effectively with the physician about their experiences utilizing terminology both the patient
can relate to and the physician can understand in translation. The TEC condition, or tests in-
volving the use of TEC, produced better pain outcomes in weeks 2, 6, and 12 following the
consultation with the lay health educator as compared to a control group of patients who did
not interact with the physician in the presence of the lay educator. The direct effects of the
TEC condition on pain management, however, showed more pain improvement at 2 weeks
compared to the control group, but this condition was not sustained at 6 and 12 weeks. But,
the mechanism through which the TEC interventions contributed to better pain outcomes
was not thought through and fully explored. Using Dr. Street’s approach for model communi-
cation pathways, listing the steps the first step is indicating that the desired outcome is bet-
ter pain control, and one mechanism to achieve that is a change in pain medication is a po-
tential option for step 2. Working backward, thinking through the mechanism (option) of
what would lead to a physician changing the patient’s pain medication, we identify the 3rd
step as having patients communicate more openly about their pain-related issues and ques-
tions. Finally the 4th step in the communication pathway is the direct result of a communica-
tion intervention specifically designed to extract this patient feedback and information
about their experiences with the currently-prescribed pain medication which activates the
patient in the process. The steps are listed as follows:
1. improved pain outcome
2. change in pain medication as an mechanism option to achieve the desired outcome
3. more active dialogue with the patient about pain
4. TEC or communication intervention with a health communication scholar
Dr. Street states that secondary analysis testing of this example found that the TEC interven-
tion was responsible for a greater likelihood of the resulting change in pain medication which
is in turn associated with better health outcomes. This indicates the role of the indirect me-
diated path produced a desirable health outcome by defining the communication content
required to achieve the end result. The results link the communication pathway of an indi-
rect, mediated path through the trailer medication coaching intervention which yielded re-
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6. Interpersonal Communication Impact on Health Outcomes
rect, mediated path through the trailer medication coaching intervention which yielded re-
duced pain experiences and overall a achieved health outcome objective. Interestingly, Dug-
gan also mentions that interpersonal issues are central to the provider-patient relationship
because of influences by communicative interactions in specific ways, and Dr. Street gives us
a pathway model that can be used to explore these influences and their roles in health out-
comes from a scientific research approach. The influences pertaining to this focus should be
considered in future research and they include:
1. accurate diagnoses
2. understanding of the problem
3. likelihood of following treatment
4. recovery processes
5. relationships defined by the health issue (dependent vs. independent)
Duggan explains that communication scholars have the expertise in measuring, implement-
ing, and evaluating interpersonal communication training and intervention needs, mediated
or unmediated, and the medical community would benefit from increased access to hospi-
tals , medical training centers, physicians’ practices, and family conversations in defining
these communication elements that influence model pathways to achieve desirable health
outcomes as described in Dr. Street’s pathways model.
Section 3: Measurement Challenges
Dr. Street explains that there are currently a number of conceptual and measurement chal-
lenges that researchers face today that must be addressed to better understand the influ-
ence of clinician-patient communication and the impact on health outcomes. The communi-
cation process itself is rarely laid out by researchers attempting to link communication influ-
ences and this results in data and research that is difficult to distill because communication
processes are not defined from multiple points of perspective. Communication research
needs to implement clear theoretical modeling employed which will lend interpretations of
data validity from a thorough understanding of the implications or limitations of the models.
Examples of theoretical modeling types used in the articles include the 5A’s (assess, advise,
agree, assist, arrange), Roter Interaction Analysis System, etc. Dr. Street indicates that the
communication process shouldn’t lend itself to the use of one theoretical model or approach
as opposed to others, but issues do emerge such as the assumptions that researchers are
making about the nature of the communication process itself, and the interpretations on the
behavior (what the interactants did), meaning, (how the communication was interpreted by
the participants), and evaluation (how well the communication was performed).
Patient-centered communication is aimed at the following goals as indicated by Dr. Street:
bringing the patient’s perspective into the consultation, knowing the patient as person-in-
context, involving the patient in care to the extend he or she wants or needs to be, shared un-
derstanding of the problem and treatment plan between the patient and physician, and a
contributing role to decisions that are based on clinical evidence and are consistent with pa-
tient values and feasible to implement. Duggan explained the parallels to this approach in
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7. Interpersonal Communication Impact on Health Outcomes
tient values and feasible to implement. Duggan explained the parallels to this approach in
the blackboard reading which highlight the importance of patient communication in the con-
sultation, as depicted by McGee and Cegala’s research that found differences in doctors’ and
patients’ thoughts and feelings along with their perceptions of the information exchange and
relational communication. Duggan continues by mentioning the importance for patient ac-
tivism as indicated in the research from Brashers, Haas, and Neidig testing the reliability and
validity of assessment, assertiveness, and potential for non-adherence. The research shows
the importance of including the patients communication behaviors in future research, and is
consistent Roter’s description of physician-patient interactions as relationship-centered as
opposed to patient-centered. If we return to Dr. Street’s analysis of patient-centered commu-
nication, he begs researchers to question if these attributes are attributed to something an
individual participant in the health encounter does or is it something that through the
process of communication is achieved? Researchers assume, whether correctly or incorrect-
ly, that goals of the patient-centered care are accomplished by participants jointly as op-
posed to an individualized basis, and very little measures in previous research assess the
communication events themselves as interactions rather than as individuals with sole-own-
ership of these interactions (patient or doctor). Duggan mentions that communication schol-
ars are in a prime position to create naturalistic, communication based interventions and to
document how the actual process of communication is conducted and relates to clinical
quality indicators and other external performance measures of improved communication
performance.
Dr. Street cements that point by indicating that different measurement approaches can yield
different conclusion to the same communicative phenomenon, and different measures with-
in the same observations may yield very different interpretations of the extent to which com-
munication was patient centered or not. This point exemplifies the issues surrounding mea-
surement approaches in patient and provider centric interpersonal communication situa-
tions and provides the context for future research to consider to limit or remove the ambigui-
ty of different measurement strategies within research information through the implementa-
tion of a broad-based modeling and measurement framework from which researchers can
choose from and where interpretive results on measurement are fully understood.
Personal Reflection and Conclusion
I thought the Dr. Street article was a thoroughly comprehensive and scientific approach to
explaining the results of previous research on the influences communication has on im-
proved health outcomes, the challenges with the interpretation of the results of previous re-
search and the conundrums that this research, when viewed objectively, presents to current
researchers, and the sponsorship and recommended use of modeling pathways though indi-
rect mediated paths of communication between the physician and the patient with the
shared goal of the intended health outcome. The exploration of achieving a positive health
outcome result through communication from experimentation using this model is informa-
tive for current researchers and lays the foundation for conducting future research analysis
while taking into account critical influential factors that can skew the data as the observa-
tional perspectives change among the participants in the research study. The research by Dr.
Street produces results that are measurable and support the proposed communication path-
ways linking a tailored educational coaching intervention event or program to improve
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8. Interpersonal Communication Impact on Health Outcomes
ways linking a tailored educational coaching intervention event or program to improve
health outcomes. Dr. Street suggests that we reflect critically on what assumptions are being
made about the nature of communication behaviors and how they relate to the processes
being studied including the intended health outcomes, and these assumptions can drive the
appropriate use of modeling and measurement criteria for future study. I feel that this article
supports the blackboard reading from Duggan, who summarizes that researchers are confi-
dent that interpersonal communication in health contexts provide a foundation for future de-
velopment of research theory based on these communication interventions of clinician-pa-
tient interactions. Duggan suggests research topics for future research in each section of her
article, and the modeling pathways and measurement perspectives and challenges present-
ed by Dr. Street encourages the research community to expand their focus and include more
psychometric (theory and technique of psychological measurement) work on improving
communication measurement processes and procedures to account for not only what one
does, but what that means to the overall objective of providing clarity in the data and sup-
porting interpersonal communication intervention educational opportunities and strategies
that result from this clear vision that will ultimately will improve patient health outcomes.
The article I chose certainly validates my expectations of this area of research and supports
some of the main conclusions drawn by Duggan, although the Duggan article is more broad-
based in terms of in introspective evaluation of the progress in determining the influential
factors on desirable health outcomes, and the Dr. Street article is more scientifically ground-
ed in core research principles and anomalies that need to be defined as researchers continue
to explore the health outcome context.
As I’ve mentioned in this weeks discussion posts, I work in the healthcare industry as a man-
agement consultant and I can relate to the broad concept of communication influencing
health outcomes as it relates to hospital and health insurance plan organizations. We have
seen a dramatic shift in government sponsorship and mandating of proactive health out-
reach through the Affordable Care Act, and it’s clear that the federal government has estab-
lished that improvements in proactive care through outreach and communication will, in
time, provide better outcomes for federally sponsored insurance recipients and ultimately
will lower the overall cost of providing healthcare in America with a more proactive patient-
centered approach. Medical institutions, their hospital and provider networks, and health
insurers are now regulated to provide this population outreach in an effort to proactively ad-
dress potential health concerns. The cost for a proactive health action, initiated by the
provider or payer, is marginally lower than if the patient waits until the health concern mani-
fests itself into an emergency or life-threatening condition. The federal government has cre-
ated programs to support this community outreach, specifically Medicaid Incentive Rosters
and Provider-level incentive Rosters which are lists of patients that a provider is responsible
for, broken down by the patients’ known ailments or conditions, and the lists are generated
by Health Plans and supplied directly to Medicaid (MA) insurance member populations and
the healthcare providers themselves (doctor’s offices, clinicians, GP’s, and specialty care fa-
cilities) with the goal being incentivizing healthcare professionals to outreach to patients to
proactively engage them in health coaching, awareness, and preventative maintenance for
known conditions or diseases. By creating a financial incentive award system this gives the
providers the ability to cash in on improved interpersonal communication and outreach
through empathetic concern with the goal of reducing the number of reactive patient visits
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9. Interpersonal Communication Impact on Health Outcomes
through empathetic concern with the goal of reducing the number of reactive patient visits
when a health concern has already manifested itself. The Affordable Care Act believes that
the high cost of providing healthcare in this country is attributed in part to the reactive ex-
pense of treatment when a problem exists is greater than the expense of proactive health
maintenance behaviors at the provider level. By mandating programs such as these and re-
quiring them within the ACA, the goal is to reduce healthcare costs at the federal level which
will lower the cost of providing healthcare on a per-member basis, at the provider level, and
rolling up to the national or federal level. This cost computation is one which each provider
takes seriously and constantly measures, it’s simply the ratio of administrative costs to clini-
cal costs per dollar spent. Therefore if a health system takes this measurement across all of
it’s lines of business and calculates the data, if for example their Administrative costs are .70
cents on the dollar, that means that for every dollar spent by a member, 30 cents of that dol-
lar go to clinical costs of the actual treatment of the health concern, but 70 cents of that dol-
lar applies to the administrative costs internal to the health system to service that member.
These administrative costs are associated with processing, member communications, state-
ment and invoice production, Information Technology spend, etc., purely administrative
costs not directly related to the doctor-patient interaction.
Interpersonal communication and a relational approach to provider/patient communication,
from Duggan, rests at the core of this principle and validates what we’ve read from Duggan
and now Dr. Street in terms of influential factors affecting positive health outcomes. This is a
difficult subject to try to explain to people who do not have a vested interest in healthcare or
who are not currently experiencing a health issue themselves, but the concept is at the core
of what the federal government has figured out already, that proactive outreach and patient
oriented communication from a relational perspective is a real and tangible weapon to use
to improve the overall health of the citizens of the USA along with lowering the huge financial
burden the cost of health care places on our economy.
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