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

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

PHYSICIAN-PATIENT COMMUNICATION AND CULTURAL COMPETENCE 2

Abstract

The dyad between Doctors and Patients, as it applies to patient satisfaction, has been a

long discussed topic in the field of both communication and medicine. Much speculation has

been 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 depth

each day, the ‘face’ of outpatients is becoming more culturally diverse. Attributable to

globalization, more and more scholars speculate cultural competency/awareness of physicians

may affect the satisfaction of their patients. The following proposal aims to locate a correlation

between 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 synthesis

of literature on cultural assimilation between patients and doctors and its effects on the patient

satisfaction. The literature displays the gap in research regarding cultural competency and its

effects on patient satisfaction. After this review, the proposal moves to a methodological analysis

of 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 200

participants from a major hospital near the Southwestern United States. The data is projected to

help provide a focus for the research question (RQ1), does a physicians cultural

awareness/competency, as perceived by patients, correlate to patient satisfaction within the

physician-patient dyad?

Arizona State University – Hugh Downs School of Communication – Smith


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 healthcare

models, global or individual” (p. 121); patient satisfaction, is a model of measuring how a person

in a given medical in-patient/out-patient situation rated the comfort of their experience. Crucial

to this satisfaction in the western model or biomedical model of healthcare is the communication

between 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 it

makes 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 her

time communicating will be spent with the doctor. Current research on the patient-doctor

relationship (within the scope of patient satisfaction) is focused on patient-doctor similarities

assimilations and time-elapse proxemics. With the changing global landscape attention to culture

in the patient-doctor relationship may prove informative (Dutta, 2008). In order to do so

however, a link to a doctor’s cultural competency and a patients satisfaction must be noted, this

study proposes to do such. The role of this examination is to discuss the doctor-patient

relationship by examining the doctor’s cultural competency, as perceived by the patient, and its

correlation 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 also

address possible implications to perceived cultural competence and patient satisfaction.

Prior to discussing the research regarding doctor-patient communication, the importance

of patient satisfaction and the physician-patient relationship in regards to cultural sensitivity must

be noted.



Globalization, or the process by which autonomous economies, societies, and cultures

become integrated through a global network, makes for the greater displacement of regional

communities worldwide; allowing a greater diversity of culture and gender to spread worldwide

than ever before (Dutta, 2008). As the global landscape changes, becoming more culturally

conglomerate, some critical academics speculate the biomedical model cannot accommodate

patients 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 of

nationalized healthcare in the world (Rees, Knight, & Wilkinson, 2009). This model of

Healthcare subscribes to the Hippocratic view of disease as a biological problem with aims of

patient treatment first and patient satisfaction second; the model itself ascribing to the belief that

patient satisfaction is rooted in biology, not holism. It encompasses the norms and regulations

which medical professionals are trained to ‘view-in’ and ‘perform under’ (Dutta, 2008). One of

these norms understood to impact patient satisfaction is the communicative process between a

physician and patient.

The doctor-patient relationship, rooted in the very early tenants of medical ethics, is

centralized 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 large

role in the overall health experience of a patient. For instance, a study conducted in Washington

State showed 40% of patients who expressed their doctors “used open ended questions,” also

stated their health experience was more satisfactory than those with physicians who “used

dominant conversation styles’- regardless of physical ailment (Ishikawa, Takayama, Yamazaki,

& Katsumata, 2002); compared to biological issues, the interpretation of doctor’s communication



plays a superlative role. In addition to this study, patients in a nationwide examination who were

victims of malpractice were a third less likely to sue their physician if their doctor had attended

two 7.5 hour communication-tactic seminars (Peskin, &Weyrauch, 1995); helping to reveal the

benefit for both doctors and patients through an increasingly communicative environment. In

specific, current communication research on the patient-doctor relationship shows factors linked

to 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 patients

affect patient satisfaction. The first section reveals how cultural determinants (age, race, gender)

shared between doctors and patients increase patient satisfaction. The second section will frame

the findings of section using Stand-Point Theory in a pragmatic fashion. The review will

conclude with the cultural implications for the patient-doctor relationship and the proposal of a

research 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 have

shown to increase patient satisfaction in regards to age, race, and gender. For instance, patients

found within ten years of their doctor’s age resulted higher satisfaction in their medical visit as

compared 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 in

relation to nonverbal factors, those between 40-49 (%) and 50-59 (%) with a doctor within a

decade 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



found 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 of

age, patients who also share racial similarities with their physician have a greater satisfaction

than those who do not. In a recent study regarding cancer oncology, ethnic concerns, and patient

satisfaction; patients with cancer “who shared, or appeared to share” racial or ethnic backgrounds

were 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 simply

that Caucasian patients experienced higher satisfaction if their doctor was Caucasian and

African-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 the

border of Arizona and Mexico to show patient comfort in relation to the ethnic backgrounds of

physicians 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 in

gender between doctors and patients have had an effect on the patient-doctor relationship. In a

1992 Schneider and Tucker performed a study on the relational effects of interpersonal

communication in physician-patient satisfaction (p.10). In Alabama, a similar study was done in

which patient’s satisfaction was interpreted via video playback by randomized participants

(Blanquicett, Amsbary, Mills & Powell, 2007). In both the studies, male patients were found to

experience more satisfaction if they were attended by a male physician; the same microcosm

applies to women as in both studies more than half of women preferred a female physician to a

male physician (Schneider, & Tucker, 1992; Zayts, & Kang, 2010).



Rooted in critical and feminist theory, Standpoint Theory, states that the social positions

in 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 these

social lenses in which people experience the world, a standpoint (Pawloski, 2006). Furthermore,

standpoint theory states people with similar “standpoints” can share similar cultural experiences

autonomously. This theoretical idea, shared standpoints, provides a possible explanation for why

similarities 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 as

outpatients 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 the

world in a similar way, creating a shared experience amongst the dyad (age, race, sex), which

may provide leeway to greater patient satisfaction (as shared experiences can lead greater

communicative disclosure) (Wood, 2005: Pawloski, 2006). Cultural determinants, age, race and

sex, are highly correlated to patient satisfaction, however whether these implications apply to the

cultural competency of physicians yet to be shown (Dutta, 2008). Due to the ever increasing

globalized planet and limitations to the current research, the following question has been

fostered.

RQ1: Within the physician-patient dyad, does a physician’s cultural

awareness/competency, as perceived by patients, correlate to patient’s satisfaction?

Method

Participants

Participants involved will complete a post-test survey within 2 weeks of their physician

interaction. Participant post-tests will accrue for the period of a year, January 18, 2012 to January



18, 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 this

research. 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 urban

Southwestern United States; a post-test survey will be administered to all out-patients in a major

hospital and medical facility with a sample aim of 200 participants. As other Communication

Research has shown voluntary purposive sampling has often equated to subpar results (Brach &

Fraserirector, 2000); therefore, to incentivize participants to respond, a menial medical tax will

be waived upon cooperation from the patient. The sampling method is categorized as both

voluntary and purposive as participants are chosen based on their interaction with a medical

physician and their participation being completely voluntary.

Criteria required for being a participant follows as such: Participants must be over 18

years 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 compliance

with the American Hippocratic Association and the Federal Government, all participants must

also be in the United States legally and lawfully.

A single PT-group will provide data to evaluate a possible correlation between the

cultural competence of a physician and a patients satisfaction. Given the demographics of the

Southwestern 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


http://en.wikipedia.org/wiki/Hispanic_and_Latino_Americans

http://en.wikipedia.org/wiki/Pacific_Islander_American

http://en.wikipedia.org/wiki/Native_American

http://en.wikipedia.org/wiki/Asian_American

http://en.wikipedia.org/wiki/African_American

http://en.wikipedia.org/wiki/Caucasian


(0.2%) (USCB, 2010). Additionally, another potentially reflective is the male (52.8%) and

female (47.2%) demographics of the Southwest (UCSB, 2010). Since standpoint theory is rooted

in the cultural dynamics of the non-status-quo; to aid in efficacy, this research will focus on

those 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 honing

emphasis on a culture-centered-approach to patient satisfaction.

Procedures

To measure whether a patient’s satisfaction and a physician’s cultural competency are

correlated a post-test will be administered quantifying patient perceptions. To alleviate human

influence by the doctor the post-test will be administered by a non-physician Hospital-mediated

representative. Based on the scale developed by the Truman Medical Center and the UMKC

School of Medicine (TMC Survey) a likert-type 10-point scale will be used to evaluate cultural

competency. Similarly the patient’s satisfaction will also be quantified using a likert-type scale; a

one signifying “never,” a five signifying “moderate,” and a ten signifying “always.” Following a

patient-physician dyad, a survey (post-test) will accompany the patient home, in which he or she

will voluntarily finish the post-test and mail it to be collected (free-postage included). Following

data collection, a possible correlation will be evaluated using a Pearson’s ‘r’ Analysis to assess

the connection between perceived cultural competency and satisfaction in the doctor-patient

dyad.

Instrumentation

In order to provide data analyzing RQ1, Cultural Awareness, also known as Cultural

Competency, must be gauged. The likert-type scale developed by The Truman Medical Center

and the UMKC, known as the TMC, was chosen because of its adept ability to accurately address



patients’ cultural perception of others (Hickman & Flores, 2000). The scale was originally

developed in 2000 to create a framework for non-medical physicians to help in addressing how

patients perceive the cultural penetrations tactics (e.g. “How often did your physician inquire

about age or age related ailments?,” How often did your physician inquire about your ethnicity or

ethnic-correlated ailments?”) (Hickman & Flores, 2000). The entire survey is composed of 32

questions aimed at addressing whether or not a participant perceives cultural competency in a

dyadic conversation. The first portion of the questionnaire provides a scope of the patients

cultural perceptions in regards to race, age, gender and standpoint (16 items, e.g. “How often did

you physician allude to gender based remedies?,” “How frequently was ethnicity discussed by

your physician in regards to your condition or reason of visit?”). The second portion discusses a

patient’s perception of his or her physician’s religious awareness (10 items, e.g. (“At what

frequency did your physician ask about religious/spiritual preference in regards to your ailment

of reason of visit?”) (Hickman & Flores, 2000). The final portion’s scope is in regards to patient

perception of a physician’s holistic awareness. (6 items e.g. “How often did your physician

provide alternative methods of medical care (i.e. behavior change)?” “How often did your

physician provide holistic approaches to health prosperity?”). The survey will be gauged on a

likert-type scale on a range from one to ten. “One” signifying “never,” alludes to a lower cultural

awareness 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 both

reliable and valid. As prior studies have shown, Cronbach’s α (alpha) coefficients (>.93) were

achieved in studies regarding perceptions of cultural competency in labor workers, and Hispanics

(Cervantes, 2009; Cervantes, Duenas, Valdez, & Kaplan, 2011; Beach, Eboni, Tiffany, Karen,



Robinson, Palacio, Smarth, & Jenckes, 2005). The TMC has also been featured in labor seminars

and 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 outpatient

procedure. For the sake of this research, patient satisfaction will be refined to the communication

context between patient and physician. Doing so by using questions which disambiguate between

physical and mental health satisfactions (e.g. “How did your physician accommodate your

physical needs regarding your visit?” “How did your physician accommodate to your non-

physical needs?”). This disambiguation between satisfaction (mental and physical) is to rule out

satisfaction based on a biomedical cure and focus satisfaction on a cerebral and communicative

context. By limiting satisfaction due to medicine or medical treatment possible errors from such

are prevented.

Data Analytic Strategy

Based on researcher expectation, a correlation should be evident between patient

perceptions of cultural awareness and patient satisfaction. Because both variables, independent

and dependent, are ordered by an interval scale a Pearson’s ‘r’ correlation will be used to test

RQ1. 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 two

variables, physician’s perceived cultural competency and patient satisfaction (-.95>r >.95).



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