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Patient Perceptions of Patient-Physician Communication withAllopathic and NaturopathicPhysiciansWilliam E. Arnold a & Janet H. Shirreffs ba Arizona State University , USAb Arizona State University , West, USAPublished online: 02 May 2012.

To cite this article: William E. Arnold & Janet H. Shirreffs (1998) Patient Perceptionsof Patient-Physician Communication with Allopathic and Naturopathic Physicians,International Journal of Listening, 12:1, 1-11, DOI: 10.1080/10904018.1998.10499015

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Patient Perceptions of Patient-Physician Communication with Allopathic and Naturopathic Physicians

WILLIAM E. ARNOLD Arizona State University JANET H . SHIRREFFS Arizona State University - West

The purpose of this study was to assess patient perceptions of physician compe- tence, listening behavior and patient-centered communication using allopathic and naturopathic physicians. Results demonstrated the naturopathic physician was perceived as a more empathic listener than the allopathic physician. Naturo- pathic and allopathic physicians did not differ on technical communication com- petence. Patients believed that both types of physicians could be more patient- centered and more empathic with them. The ideal communication behavior was statistically different from the actual behavior on all measures.

he relationship between a physician and patient is central to the pro- cess of delivering health care. In turn, communication is the funda- T mental means through which physicians and patients relate to each

other in order to achieve improved health care outcomes. Over the past decade, scholars have recognized the need to understand and improve com- munication between physicians and patients (Schneider & Tucker, 1992). In fact, as Cassata (1978) points out, there is solid agreement that good physician-patient communication is essential to effective health care.

Allopathic - or conventional - medicine has, until recently, assumed a reductionistic perspective. Allopathic medicine has come under increased criticism recently due to its tendency toward fragmentation of care and excessive specialization and for its lack of concern for the whole person. Conversely, naturopathic medicine focuses on a biopsychosocial under- standing of the patient as a whole person. Naturopathic physicians (N.D.s) are general practitioners trained as specialists in natural medicine. They are educated in the conventional medical sciences, but they are not con- ventional medical doctors (M.D.s). Naturopaths combine and tailor a wide variety of natural therapeutics (e.g., clinical nutrition, herbal medicine, ho- meopathy, and physical medicine) to the needs of the individual based on a

International Journal of Listening, V01.12, 1998, 1-11 0 International Listening Association 1

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Arnold, Schirreffs / PATIENT PERCEF’TIONS 2

cogent philosophy that acknowledges the patient as a “participant” in his or her own health care (American Association of Naturopathic Physicians, 1995).

There are several compelling reasons to measure the effectiveness of (and to identify ways to improve) physician-patient communication. Re- search suggests that patients are sensitive to the manner in which their phy- sician relates interpersonally to them, and that their level of satisfaction with their physician’s behavior impacts their willingness to continue the relationship (Hall & Dornan, 1988). The study described in this article at- tempts to assess whether there are differences in the perception of patients as to the communication behaviors of conventional physicians and holistic physicians.

BACKGROUND

Patient satisfaction is an important outcome of patient-physician inter- actions and is a key measure of quality of care. A number of studies have examined the relationship between patient satisfaction and patient-physi- cian communication (Lane, 1983; Krupat, 1986; Kaplan, Greenfield, and Ware, 1989). In general, these studies have found that good physician-pa- tient communication is essential to effective health care and that patients not only expect doctors to exhibit technical competence but also to com- municate about the nontechnical dimensions of health care. Effective com- munication in physician-patient exchanges has been shown to be essential to patients’ satisfaction with the care they receive. Poor communication is the most common reason for patient dissatisfaction with a physician’s care and a decision to terminate the physician-patient relationship (DiMatteo, 1994; Hall, Roter, & Katz, 1988).

In addition to satisfaction, improved communication between physi- cians and patients will lead to improved health care outcomes including increased patient compliance with treatment regimens (Burgoon, Birk, & Hall, 1991; O’Hair, O’Hair, Southward, & Krayer, 1987; Kaplan et al., 1989), less malpractice litigation (Beckman, Markakis, Suchman, & Frankel, 1994), and improved relationship satisfaction (Epstein, Campbell, Cohen-Cole, McWhinney, & Smilkstein, 1993). In turn, effective physi- cian-patient communication has been associated with shortened hospital stays and improved recovery from surgery (Mumford, Schlesinger, & Glass, 1982), as well as improvement of symptoms (Brody, Miller, Lerman, Smith, & Caputo, 1989) and better management of chronic conditions (Greenfield, Kaplan, Ware, Yano, & Frank, 1988).

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It is estimated that fifty-six to eighty-five percent of diagnoses in pri- mary care medicine can be made by taking a complete history and listening to what patients have to say (DiMatteo, 1994). However, research suggests that physicians spend very little time listening to patients and tend to limit patients’ communication of information (Freemon, Negrete, Davis, & Korsch, 1971; Putnam, Stiles, Jacob, & James, 1985). Patients seem to be suggesting that they need physicians to display communication that takes on a dual role, technical and interpersonal. There is a widely shared belief in medicine that communication between physicians and patients is less about the transfer of information and more about emotional reassurance, support, and understanding; however, there is little empirical support for this notion (Kaplan et al., 1989).

Several serious limitations have been found to exist in the realm of communication between patients and their physicians. Among these are physicians’ use of medical jargon; patients’ perceptions that they have not received as much information as they desire to make treatment decisions; and limited listening on the part of physicians to what patients have to say. Health care consumers (i.e., patients) seem to be saying that physicians are not listening very well (Epstein et al., 1993) and that there has been dete- rioration in the physician-patient relationship (Nazario, 1992).

The interpersonal role of the physician can be subsumed under two distinctive communication styles - the physician-centered style and the patient-centered style. In this context, style refers to what is communicated as well as how information is communicated. The physician-centered style is characterized by an “I’m in charge” communication approach. This ap- proach has also been called position-centered communication. It emanates from authority, and position-centered communicators are less likely to ad- dress multiple communicative objectives. They rely on commands, behav- ioral directives, and the invocation of rules as their primary means of con- trol (Kline & Ceropski, 1984). This style derives from a reductionistic-, disease-, or biomedically-oriented view of health care. The goal of the phy- sician-centered style is to establish a relationship between the patient’s com- plaint and some form of organic pathology (Arnold & Valentine, 1989).

In contrast, in the patient-centered clinical method, the physician at- tempts to understand the meaning of an illness from the patient’s perspec- tive as well as interpret it in terms of the medical frame of reference. In this model, which is based on a shared understanding, the patient and physician attempt to find common ground about the problem and its management (Brown, Weston, & Stewart, 1989). The patient-centered communication

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style focuses on the unique motivations, intentions, and feelings of an indi- vidual patient. This approach has also been called person-centered com- munication, since this type of communicator is receptive to the desires of the listeners (Kline & Ceropski, 1984). In interpersonal contexts, person- centered communicators tend to grant freedom to others to express them- selves and their feelings. In physician-patient encounters, this style de- rives from a biopsychosocial view of disease and health care. The goal is to identify and evaluate the stabilizing and destabilizing potential of events and relationships in a patient’s life and then make decisions as to care (Epstein et al., 1993). This approach seeks to understand the meaning of the illness from the perspective of the patient’s life rather than the directive physician perspective.

There is evidence that patients and physicians value interpersonal skills as much as technical competence (Arnold & Valentine, 1989; Epstein et al., 1993; Kline & Ceropski, 1984). This acknowledgment derives from a belief that in order for a successful clinical encounter to take place there must be human engagement. The interpersonal skills that are most relevant in clinical encounters are communicative in nature. Information and mean- ing exchange will only occur if the physician and patient are actively en- gaged in the communication process. Patients seek communication with their physicians that displays empathy, concern, active listening, and friend- ship (Frankel, 1995). This interpersonal communication expresses warmth and caring (Lane, 1983).

If the literature were correct, we would expect the allopathic physi- cians and the naturopathic physicians to communicate equally in terms of technical competence. We would expect the naturopathic physicians to be more effective than allopathic physicians in terms of empathy since they receive training in that area. The literature supports the notion that patients prefer a patient-centered, empathic physician. Studies to date have focused on allopathic physicians and their listening behavior and have not looked at naturopathic physicians at all. The purpose of the study reported in this article was to identQ whether patients perceive differences in the communi- cation listening behavior of two types of physicians (allopathic and naturo- pathic) .

In addition we wanted to know if both physician types could do a bet- ter job than they are currently doing. Using the Zimmerman and Arnold (1991) approach, this study sought to determine if there are differences in actual physician versus ideal physician communication and listening be- haviors. The following questions emerged:

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RQ, Is there a difference in patients’ perceptions of actual communicating and listening behaviors of an allopathic physician and a naturopathic physician?

RQ, Is there a difference in patients’ perceptions of what constitutes the ideal communicating and listening behaviors of an allopathic physician and a naturopathic physician?

METHOD

Instrumentation

To assess patient-physician interaction, two separate measures were utilized. The Smith-Falvo patient satisfaction questionnaire, also known as the Patient-Doctor Interaction Scale, (PDIS) (Smith, Falvo, McKillip, & Pitz, 1984) was used in this study to assess two aspects of physician behav- ior: general health care delivery (which included positive and negative as- pects of interpersonal, informational, and technical components of physi- cian behavior) and inappropriate interpersonal communication (defined by the absence or surplus of communicative interactions). It consists of seven- teen items using a five-point, Likert-type scale ranging from (1) strongly agree to (5) strongly disagree. It contains six items focused on interper- sonal communication and eleven items on general health care delivery. The PDIS was designed to be administered directly to patients. Reliability for the PDIS was assessed by Cronbach’s alpha. The alpha coefficient on the PDIS was .82 for the actual physicians and .88 for the ideal PDIS, which indicates high reliability.

The second survey was the Physician Empathic Listening Scale (PELS) (Zimmerman & Arnold, 1991) used to assess patients’ perceptions of phy- sician competence and empathic listening. The physician competence scale consists of three items. The empathic listening scale consists of four items. To be consistent with the PDIS, the response format of the PELS was changed from a semantic differential scale to a five-point, Likert-type scale ranging from (1) strongly agree to (5) strongly disagree. Reliability for this PELS was assessed by Cronbach’s alpha and was .89 for the actual and .90 for the ideal physician.

Factor analyses of the PDIS and the PELS were computed, confirming previous results. Analysis of the PDIS resulted in a single scale accounting for forty-eight percent of the variance. This was consistent for both the real and ideal responses. Therefore, the scale was not divided in the analysis. The PELS confi ied previous results with two factors that account for

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sixty-eight percent of the variance. Therefore, separate scores were com- puted for the components of the PELS scale.

Procedures

Two health care providers, an M.D. specializing in Obstetrics and Gy- necology and an N.D., or Naturopathic Physician, agreed to participate in the study and to have their patients complete the study instruments at the completion of office visits. A questionnaire packet was given to each of the health care providers, which included a cover letter explaining the purpose of the study, instructions for administering the questionnaires, and the PDIS and PELS questions. Patients were asked to voluntarily complete the survey.

Respondents were asked to complete the first part of the questionnaire in terms of their own physician. The second part repeated the items by asking the patients to identify what they perceived to be ideal physician communication behavior. Confidentiality of participants’ responses was assured. Respondents were instructed to place completed questionnaires in a box in the physician’s office.

Data Analysis

T-tests were used to compare the perceptions on the two types of phy- sicians on the PDIS and the PELS. T-tests were also used to compare the real versus ideal on the same scales for all patients.

RESULTS

Of the 100 questionnaires administered to the allopathic physician’s patients, there was a 100 percent response rate. The patient sample con- sisted of 100 percent females. Their ages ranged from twenty-four years to sixty-nine years, with a mean age of 3 1.52 years.

Of the 100 questionnaires administered to the naturopathic physician’s patients, there was a 90 percent response rate. These patients ranged in age from twenty-five years to sixty years, with a mean age of 32.0 years. Of those reporting, there were 17 males.

On examination of the t-tests comparing the two physicians types, only one of the tests proved significant. Naturopathic patients rated their physi- cians (M = 4.27) higher than allopathic patients (M = 4.13) ( t = 5.96 p c .Ol) on the empathy dimension. Patients of the two physicians did not

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differ on the PDIS or the competence dimension of the PELS scales. We then combined the data for both physicians to compare the patient’s

perception of their real physician versus ideal physician on each of three dimensions. Table 1 reports these results. In every case, the patients rated the ideal as more communicative, empathic, and competent than their ac- tual physician.

Since we did not get a diverse sample on age, gender, and marital sta- tus, we did not conduct additional tests.

TABLE 1 Actual Physician Versus Ideal Physician Scores

Source Mean t (combined) p (combined)

Communication (Actual) 4.36 Communication (Ideal) 4.57 5.58

Listening Competence (Ideal) 4.43 2.27 Empathic Listening (Actual) 4.21 Empathic Listening (Ideal) 4.41 4.89

Listening Competence (Actual) 4.34 .ooo

.02

.ooo

DISCUSSION

The results of this study confirm previous research on patient-physi- cian communication and physician listening behavior. In this study, pa- tients did not perceive a difference between allopathic and naturopathic physicians on the competence component of their communication. Naturo- pathic patients rated their physicians as more empathic than allopathic pa- tients. This result could by explained by the patient-physician communi- cation that occurs in the context of a dynamic, reciprocal relationship found in the naturopathic encounter. Contemporary theory, termed the patient- centered approach, suggests that physicians need to develop communica- tion skills including listening and empathy. Research evidence suggests that patients want a more active role in their medical care (Vertinsky, Thompson, & Uyeno, 1974; Haug & Lavin, 1979) and that they want both more information and more listening from their physicians (Cassileth, Zupkis, Sutton-Smith, & March, 1980). Our finding supports the notion that naturopathic physicians are perceived to be more empathic.

Even though all patients rated their physicians high on all three scales,

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they recognized a need for further improvement. All patients rated their ideal physicians as more patient-centered, more competent, and more em- pathic than their own. This result confirmed the previous work by Zimmerman and Arnold (1991). Patients, when given a preference, would prefer a more patient-centered physician regardless of the type of physi- cian they use.

We have found support in the literature that supports the two roles of physicians and how they could do better. The relationship a physician establishes with a patient during a clinical encounter is considered to be the heart of medicine (Epstein et al., 1993). As referred to above, physicians’ interaction with patients in clinical encounters can be divided into two roles, technical and interpersonal. The technical role includes data-gathering, possessing medical and scientific knowledge, psychomotor tasks (e.g., ex- amination skills, surgical skills, etc.) and decision-making (DiMatteo & DiNicola, 1981). The technical role focuses on gathering data and under- standing the patient’s problem in order to remedy the problem or effect either a cure or a palliative treatment. The interpersonal role involves the communication style of the physician as well as the physician’s bedside manner. Physicians, according to Epstein et al., (1993) need to listen with both ears, that is, using one ear to receive biomedical and the other ear to receive psychosocial information.

The next step is to further examine outcome measures of effective com- munication and listening behaviors by physicians. Novak’s (1987) excel- lent review of the literature supports the idea that empathy is consistently related to desired outcomes of health care. Stiles et al. (1979) found that patients’ satisfaction with their physicians was associated with the physi- cians’ ability to clarify problems and assist the patients in identifying ac- ceptable solutions. The results of a study by DiMatteo, Taranta, Friedman, and Prince (1980) demonstrated that patients’ satisfaction was related to how sensitive they perceived their physicians to be as well as how able the physicians were in expressing their feelings. In a study by Wasserman, Inui, Barriatua, Carter, and Lippincott (1984), women health professionals were rated as conveying much more empathy then their male counterparts. This study also found that empathy was associated with patient satisfaction and reduced health care utilization. In a related vein, there is some evi- dence that a lack of empathy and support on the part of a physician is associated with patient dissatisfaction (Goleman, 1991).

Two issues temper these results. First, the subjects volunteered to par- ticipate in the study, so dissatisfied patients may not have filled out the

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questionnaire. Clearly, the high mean scores suggest that the patients were quite happy with their physicians. Second, only one of each type of physi- cian was used so they do not represent the class of physicians.

Additional research should be conducted with greater subject variabil- ity and more physicians. Different medical specialties should be included, as we may have different expectations for a neurosurgeon than an OB- GYN or a family practitioner. Patient and physician gender differences should be considered.

In conclusion, we find that patients prefer patient-centered physicians who are perceived as competent and practice empathic listening. Naturo- pathic patients appear to have more empathic physicians than do allopathic patients. Both types fall short of the ideal physician. We now need to look at issues of compliance, satisfaction, and health outcomes as they relate to physician type.

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