Relationship between outpatients’ perceptions of physicians’ communication styles and patients’ anxiety levels in a Japanese oncology setting

Social Science & Medicine 53 (2001) 1335–1350

Relationship between outpatients’ perceptions of physicians’communication styles and patients’ anxiety levels in a

Japanese oncology setting

Tomoko Takayamaa,*, Yoshihiko Yamazakia, Noriyuki Katsumatab

aDepartment of Health Sociology, School of Health Science and Nursing, Graduate School of Medicine, The University of Tokyo,

7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, JapanbDepartment of Medical Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuou-ku, Tokyo 104-0045, Japan

Abstract

For life-threatening illnesses such as cancer that require a long-term treatment regimen, communication isparticularly important between doctors and patients. While it is assumed that the more serious the illness, the greaterthe need to relieve patients’ anxiety, physicians’ communication styles can directly influence patients’ anxiety levels. Thepurpose of this study was to examine the relationship between outpatients’ perceptions of physicians’ communication

styles and the patients’ anxiety levels in oncology settings. Patient anxiety level was measured using the State TraitAnxiety Inventory before and after the consultation. The Perceived Physician’s Communication Style Scale wasdeveloped in this study. Analysis of responses to the scale resulted in four factors } ‘‘acceptive’’, ‘‘patient-centered’’,

‘‘attentive’’, and ‘‘facilitative’’ } of the physician’s communication style and explained 63.7% of the variance. Theinter-correlation for overall scale items was 0.95. Patient satisfaction with the medical encounter was also measured tovalidate the physician’s communication style scale. Moderate correlation between the physician’s communication style

and satisfaction was observed and confirms the relationship between a favorable communication style and a patient’ssatisfaction. After the consultation, the patients’ anxiety levels dropped 5.0� 1.5 points (p50:001), and the physician’scommunication style was shown in many cases to be linked to patient anxiety levels after the consultation. The effect of

the physician’s communication style on patients’ post-consultation anxiety levels was small among the patients with anadvanced disease status. Also, the findings showed that patients’ post-consultation anxiety levels remained low evenamong those patients with unfavorable examination results if the patients evaluated their physician’s communicationstyle as high. This study suggested that the physician’s communication style is important not only for moderating

patients’ anxiety, but could also be helpful for moderating physicians’ own stress levels when communicating bad newsto patients. # 2001 Elsevier Science Ltd. All rights reserved.

Keywords: Physician–patient communication; Patient’s perception; Cancer; Anxiety

Introduction

Physician–patient communication has been recog-nized as important to the practice of clinical medicine.It has been noted that certain aspects of physician–

patient communication seem to have an influence on

patients’ satisfaction with care, physical and psycholo-gical health outcomes, and even reductions in health

care costs (Cater, Inui, Kukull, Kukull, & Haigh, 1982;Inui, Cater, Kukull, Kukull, & Haigh, 1982; Stewart,1984; Buller & Buller, 1987; Chewning & Sleath, 1996;

Kaplan, Greenfield, & Ware, 1989; Kaplan, Greenfield,Gandec, Rogers, & Ware, 1996; Suchman, Markakis,Beckman, & Frankel, 1997). As described by Roter andHall (1992), the exchange with a doctor significantly

affects a patient which is reflected by the fact that it is

*Corresponding author. Tel.: +81-3-5841-3514; fax: +81-3-

5684-6083.

E-mail address: [email protected] (T. Takayama).

0277-9536/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 4 1 3 - 5

frequently recited, often word for word, to familymembers and friends.

For life-threatening illnesses such as cancer thatrequire a long-term treatment regimen, communicationis particularly important between doctors and patients

(Greenwald & Nevitt, 1982; Taylor, 1988; Siminoff &Fetting, 1991). Ben-Sira (1976, 1980) suggested that thephysician’s style of communication becomes morecritical when the patient becomes more emotionally

involved in the illness, and when the physician’s affectivebehavior toward the patient focuses on reducing thepatient’s anxiety. For more serious illnesses, the doctor’s

role becomes increasingly important in achieving lowerpatient anxiety levels through his or her communicationskills.

However, there have been few studies focused on therelationship between physicians’ communication stylesand patient health outcomes in oncology settings (Ford,

Fallowfield, & Lewis, 1996; Ong et al., 1998). Even indifferent medical fields, the results of similar studies donot satisfactorily determine the association ofphysicians’ communication styles and patient health

outcomes (Stewart, 1984; Bertakis, Roter, & Putnam,1991). The problem with previous studies is that theyonly measured health outcomes at one point in time

rather than throughout the treatment continuum.In order to assess doctor–patient communication, it is

crucial to evaluate patients’ perceptions of physicians’

communication styles both within oncology settings(Roberts, Cox, Reintgen, Baile, & Gibertini, 1994) andwithin Japanese society, either through the morecommonly used observational interaction analysis or,

as in this case, patient’s judgement. First, the patients’subjective feelings of improvement will in large measurebe determined by the effectiveness of the physicians’

communication styles in relieving their anxiety(Ben-Sira, 1980). Second, in Japanese society, a rela-tively low value is placed on verbalization which is in a

striking contrast to the high value placed on rhetoric,eloquence, and self-assertion in Western cultures.Japanese unconsciously use a style of communication

in which, although not every idea is expressed verbally,every idea is expected to be understood in the process ofinterpersonal communication (Ishii, 1984). Also, aperson who is good at intuitively perceiving another

person’s thoughts and feelings is highly praised andrevered in Japanese society (Barnlund, 1975). This kindof interpersonal communication is better to be evaluated

by patients’ perceptions.Furthermore, communication style can be culturally

impinged (Hall, 1976; Norton, 1983) and therefore it

should be evaluated in the same cultural context. Severalscales assessing doctor–patient interaction have alreadybeen developed in Western countries, but some elements

cannot be applied to Japan because of culturaldifferences. For example, in the Western version, some

elements deal with patients expressing their feelings infront of their physicians. In Japan, however, patients do

not express their feelings, nor do they believe that theyshould do so in front of their doctors. Therefore, inorder to assess the effectiveness of physicians’ commu-

nication styles in Japan, it becomes necessary to alter theevaluation items.In this study, we first developed a scale to measure the

effectiveness of the physicians’ communication styles.

Then, we examined the relationship between out-patients’ perceptions of physicians’ communicationstyles and the anxiety levels of the patients in oncology

settings.

Theoretical tools

Physicians’ communication styles

Communication is the process by which information,decisions, and directives are transmitted among people

and the way in which knowledge, opinions, and attitudesare formed or modified by interaction. When the topicof communication is emotion-filled, exchange throughverbal as well as non-verbal methods such as facial

expression and voice tone are particularly important(Dimatteo, Hays, & Prince, 1986). At this point,physician’s communication style can be defined as the

process of verbal or non-verbal interaction with apatient. We operationally defined a physician’s commu-nication style in terms of three components of physi-

cian’s behavior } task-oriented, affective, andpartnership-building } which are considered to berelated to patient health outcomes (Ong, De Haes,Hoos, & Lammes, 1995).

Task-oriented behavior can be defined as ‘‘technicallybased skills used in problem solving, which compose thebase of ‘expertness’ for which the physician consul-

ted’’(Hall, Roter, & Kats, 1987). Both professionalcompetence of the doctor and the doctor’s style of givinginformation are considered to increase patients’ satisfac-

tion and compliance (Roter, Hall, & Kats, 1987; Hall,Roter, & Kats, 1988). Patients almost always want asmuch information as possible and their needs for

information is especially great when cancer is concerned(Chaitchik, Kreitler, Shaked, & Schwartz, 1992).Patients must continue to manage their own diseasefor a long period after their primary treatment.

Adequate information must be given about the handlingof their disease.Affective behavior is defined as the doctor’s commu-

nication style in terms of socio-emotional content.Cancer can lead others to avoid the patient, to closeoff communication about difficult emotional topics

(Dunkel-Schetter, 1984). For cancer patients, physiciansare one of the important sources of support and

T. Takayama et al. / Social Science & Medicine 53 (2001) 1335–13501336

physician’s emotional support is seen as especiallyhelpful. Physician’s behaviors showing concern, friendli-

ness, empathy, warmth, respect, emotional support, andattentive listening (Ben-Sira, 1976, 1980; Buller & Buller,1987; Hall et al., 1988; Roberts et al., 1994; Bertakis

et al., 1991; Thom & Campbell, 1997) are also importantand considered to increase patients’ satisfaction, com-pliance, and health outcomes.The advent of multimodal treatments that combine

surgery, radiation therapy, and chemotherapy hasmarkedly improved the prognosis of many forms ofcancer (Cella et al., 1993). However, this has simulta-

neously increased the importance of the physicianencouraging patient participation in the care process,because each treatment has a different effect on patient’s

quality of life. Partnership-building behavior, as definedby Roter and Hall, ‘‘represents the physician’s attemptsto engage the patient more fully in the medical dialogue.

These attempts may be considered to activate thepatient, perhaps directed at particularly passive ornoncommunicative patients’’ (Roter & Hall, 1992), asit also involves a less controlling or dominant role for

physicians (Hall et al., 1988). Using partnership-buildingskills encouraged the patients to ask questions andexpress opinions, feelings, and concerns (Cox, Holbrok,

& Rutter, 1981; Hall et al., 1988; Street, 1991, 1992;Wissow, Roter, & Wilson, 1994; Street, Voigt, Geyer,Manning, & Swanson, 1995), therefore physicians’

partnership-building behavior could have a positiveeffect on patients.

Patient satisfaction with medical encounter

Patient satisfaction is by far the most recognized andwidely used measure for gauging the effectiveness of

physician–patient communication (Kaplan et al., 1989;Bertakis et al., 1991; Greene, Adelman, Friedmann, &Charon, 1994), or for validating a physician’s commu-

nication behavior scale (Baker, 1990; Cockburn et al.,1991). Nonetheless there is argument about measuringpatient satisfaction as it provides only limited under-

standing of the way that patients evaluate their care(Williams, 1994; Avis, Bond, & Arthur, 1997), it is stilluseful if we measure satisfaction focused on specific care(Williams, Coyle, & Healy, 1998). Studies have investi-

gated the impact of task-oriented and affective behaviorson patient satisfaction (Hall et al., 1988; Bertakis et al.,1991). Both behaviors are related to patient’s satisfac-

tion, however, the affective behaviors are a moreimportant factor in determining patient’s satisfaction(Bensing, 1991; Lewis, 1994).

Patient’s anxiety

Anxiety is the one of the most common types ofpsychological disturbance in cancer patients. In fact, the

anxiety among cancer patients associated with possibledeath, disfigurement, and disability is often greater than

that among patients with other illnesses (Massie, 1990).It is suggested that the greater the patients concern(emotional involvement) about their health, the greater

the patients’ need for emotional support. Patients’feeling of improvement will in large measure bedetermined by the physicians’ success in relieving theiranxiety (concern) (Ben-Sira, 1980).

During a medical encounter there is a two-wayinfluence between the physician and patient. Not onlydoes the physician affect the patient, but the patient also

affects the physician (Tompson, Nanni, & Schwankovs-ky, 1990; Butow, Dunn, & Tattersall, 1995b). In thisstudy, we evaluated the effect of physicians’ commu-

nication styles on patients’ anxiety.

Hypotheses

A patient’s satisfaction with the medical encounter is

assumed to be directly related to the physician’scommunication style (Bertakis et al., 1991; Roter &Hall, 1992). Hall et al. (1988) suggested that task

behaviors carry affective significance but affectivebehaviors do not carry task or technical significance. Ifwe assume only task behavior carries affective signifi-

cance, affective behavior of a physician’s communica-tion style recognized by patients would be evaluatedmore than task behavior. Moreover, if patients areunsatisfied with their medical encounter because they

cannot ask questions or express themselves adequatelyto the physician (Tompson, 1990), a physician’s partner-ship-building behavior would satisfy patients. On the

basis of these studies, we formulated hypotheses:

H1: Patients who rate their physician’s communicationstyle highly are likely to be more satisfied with the

encounter than patients who rate their physicians stylepoorly. Affective behavior and partnership-buildingbehavior are more positively associated with a patient’s

satisfaction with the medical encounter.

If the physician’s behavior influences a patient’spsychological health (Ben-Sira, 1976, 1980), thepatient’s level of anxiety will be low when the physician’s

communication style is evaluated as high. However, it isnecessary to consider the patient’s physical conditionbecause a patient’s anxiety level is also affected by

physical conditions such as disease status or pain.

H2: Controlling for the anxiety level before themedical encounter and a patient’s physical condition

(including the disease status of the cancer), theanxiety levels of those patients who evaluate theirphysician’s communication style highly are likely to be

lower than those patients who rate their physicianspoorly.

T. Takayama et al. / Social Science & Medicine 53 (2001) 1335–1350 1337

There is no evidence that physician’s communicationstyle has different effects on patients according to the

extent of the disease. Patient’s emotional involvement intheir illnesses, however, has been suggested to be greaterif the cancer advanced compared to no signs of

recurrence (Brady et al., 1997). Also, it is suggested thatthe physician’s style of communication becomes morecritical when the patient becomes more emotionallyinvolved in the illness (Ben-Sira, 1976, 1980). If the

progression of cancer leads to more emotional involve-ment by patients in their illnesses, then a physician’scommunication style will have even more effect on

patients’ anxiety levels.

H3: A physician’s communication style is likely to havemore effect on patients with advanced cancer comparedwith patients with localized disease.

Method

Subject

This study was conducted at the National CancerCenter Hospital, a medium-sized research hospital in

Tokyo, Japan. Thirteen physicians participated in thisstudy. Twelve were male, of which eight were oncologyinternists and five were oncology surgeons. The meanage was 41.5 (range: 32–60) and the mean length of

medical experience was 15.5 years (range: 7.5–31.5).Patients were eligible for the study if they had cancer,met their doctor more than once, and did not have a

debilitating condition. All the patients in this studyknow their diagnosis. Two hundred patients wereeligible during a 3-month period of the survey.

This study was conducted with the approval of theNational Cancer Center Hospital Medical Institution’sJoint Committee on Clinical Investigation.

Sampling procedures

Before participating in the study, verbal consent wasobtained from both patients and physicians. At least 10patients from each physician were systematically en-

rolled in the study. However, there were not enoughpatients eligible to enroll for three of the physiciansduring the period of survey. Consequently, there were5–18 patients enrolled in the study for each physician. A

researcher approached and explained the study toeligible patients in the waiting area prior to them seeingtheir doctor. Patients were told that this study involved a

self-administered questionnaire and an audiotape re-cording during the medical interactions between thephysician and the patient, and that the purpose of this

study was directed toward finding ways of improving thecommunication skills of doctors. Patients were also told

that all of the data were being collected anonymouslyand would not be shared with their physicians. Both

doctors and patients were told, however, that they werefree to consult as usual.

Survey procedures

The study includes three parts: a questionnaire before

the encounter, an audiotape recording during theencounter, and a questionnaire after the encounter.Before the encounter, patients completed the State-TraitAnxiety Inventory scale (STAI) which measures anxiety

level. After the encounter, patients completed the StateAnxiety section of the STAI, and the PerceivedPhysician’s Communication Style Scale which was

developed for this study to evaluate the physician’sbehavior toward patients during the visit.Visits were audiotaped using a cassette recorder

openly placed in the examining room by a researchassistant at the start of the visit. Patients and doctorswere told they could turn the tape recorder off at anytime. No tape recorders were turned off by either

doctors or patients.One hundred seventy-two (172) of the 200 eligible

patients agreed to complete the questionnaire and 150

patients agreed to the audiotape recording. The mostcommon reason cited for refusing the audiotape record-ing was that patients would not be able to talk to their

doctors as normally. The analysis for the scale develop-ment was conducted on the 147 patients who completedboth the questionnaires of a physician’s communication

style and the audiotape recording (sample a). Theanalysis of the relationship between the perception of aphysician’s communication style and a patient’s anxietylevel was conducted on 138 patients (sample b), because

of the incompleteness of the questionnaires. There wasno statistical difference between sample a and b.Two types of clinical data } type of cancer, and

disease status of the cancer } were collected from theclinical records. Demographic and clinical characteris-tics of these patients are shown in Table 1.

Perceived physician’s communication style scale

The perceived physician’s communication style scalewas developed in order to assess the patient’s percep-tions of his or her physician’s behavior during themedical encounter. After a review of the literature, we

also collected opinions about the physician’s commu-nication style from 25 cancer patients by using an open-ended questionnaire by mail. The questionnaires were

distributed through a self-help group of patients withbreast cancer. For there is a high probability ofobtaining straightforward or clear opinions about both

good and bad doctors’ communication styles from thesepatients, instead of obtaining patient’s opinions in


hospitals through doctors. An initial item pool fromboth the literature review and patients’ opinions werecontent-analyzed and categorized into three clinicallyrelevant dimensions of a physician’s communication

style: task-oriented, affective, and partnership-buildingbehavior.Task-oriented behavior consisted of the professional

competence of the doctor and the doctor’s style of givinginformation to the patients. Professional competenceitems referred to the physician’s behaviors during

medical examinations and their behaviors when theyresponded to patient questions. Information giving styleitems were employed from two aspects: the amount ofinformation (i.e. whether or not enough information

was given) and the quality of information (i.e. whetheror not the information was understandable to thepatient). Affective behavior included the physician’s

behaviors in showing concern, friendliness, empathy,warmth, respect, emotional support, and attentivelistening. Partnership-building behavior referred to the

physician’s behavior in asking patients’ opinions, thusprompting explanations about their disease, and con-firming with the patients whether they understand what

they were told by the physician. Sixty items weregenerated in the first version of the scale.To evaluate the content validity of the items, 114

nurses working for the National Cancer Center Hospital

were chosen because they have a better understanding of

both the physician’s and patient’s perspectives of amedical encounter. The items that over 90% of allnurses agreed should be performed by a physicianduring a medical interview were adapted to the pre-

testing scale. As a result, only one item was eliminated.During the pre-testing, the 59 items were validated by

70 patients with breast cancer. Items were selected or

integrated based on the Chronbach’s alpha of each ofthe three dimensions of physician’s communication stylewith non-answer items eliminated. Finally, 30 items were

chosen for the Perceived Physician’s CommunicationStyle Scale.The response form with the items included a five-point

Likert-type scale, ranging from 1: strongly disagree, to

5: strongly agree, with neutral as the center opinion. Inscoring, negatively worded items were reversed so that ahigh value indicated high appraisal of the doctor’s

communication style. The total score was obtained byequally weighing each factor score and then adding themtogether. When examining it as binary data, high and

low, an evaluation score above the median is judged ashigh, and a score below the median in determined to below.

To evaluate concurrent validity, 30 tapes, wererandomly chosen from the 147 samples. Two researchassistants listened to the tapes and evaluated physicians’communication styles separately. It was feasible to judge

22 out of the 30 items from the tapes. The average

Table 1

Demographic and clinical characteristics of patients

Department Internal (N ¼ 79) Surgical (N ¼ 68) Total (N ¼ 147)

Mean�SD Mean� SD Mean�SDAge 55.6� 10.1 60.0� 11.7a 57.6� 11.1

N (%) N (%) N (%)

Sex

Male 22 (27.9) 27 (39.7) 49 (33.3)

Female 57 (72.2) 41 (60.3) 98 (66.7)

Education

Junior High School 9 (11.4) 9 (13.2) 18 (12.2)

High School 41 (51.9) 27 (39.7) 68 (46.3)

Junior College 12 (15.2) 14 (20.6) 26 (17.7)

University 14 (17.7) 16 (23.5) 30 (20.4)

Missing 3 (3.8) 2 (2.9) 5 (3.4)

Cancer type

Gastric cancer 16 (20.3) 29 (42.7)b 45 (30.6)

Breast cancer 45 (57.0) 29 (42.7) 74 (50.3)

Lung cancer 13 (16.5) 9 (13.2) 22 (15.0)

Other cancer 5 (6.3) 1 (1.5) 6 (4.1)

Disease status

Postoperative disease free 23 (29.1) 58 (85.3)c 81 (55.1)

Recurrent status or metastatic disease 56 (70.9) 10 (14.7) 66 (44.9)

ap50.05.bp50.01.cp50.001.


correlation between the two assistants was 0.93. Theaverage correlation between the assistants and the

patients was 0.75. The patients’ evaluation was slightlyhigher than the assistants’ evaluation, 4.36 and 4.16,respectively (range: 1–5).

Factor analysis using varimax procedure was repeatedfor the sample of 147 patients to evaluate constructvalidity (Table 2). An item was included on a factor if itsprimary loading was greater than 0.50 on that factor. As

a result, three items were removed. A four-factorsolution was obtained, with the first factor explaining45.0% of the variance and the second to fourth factors

each contributing considerably less explanation (8.6, 5.7,and 4.4%, respectively). With those four factors, 63.7%of the variance was explained. We labeled the four

factors of the doctor’s communication style as,‘‘acceptive’’, ‘‘patient-centered’’, ‘‘attentive’’, and‘‘facilitative’’.

For the sub-scale items, we used an item in the casethat primary loading was greater than 0.50 and thedifference between primary and the other loading wasmore than 0.15. The highest score among the four sub-

scales was ‘‘acceptive’’, and the lowest was ‘‘facilitative’’(Table 3). The reliability of the questionnaire wasassessed using a test of internal consistency, Cronbach’s

alpha. Alpha reliability of all 27 items was 0.95 andalpha reliabilities of the four sub-scales was between0.73 and 0.90. One-way univariate ANOVAs were used

to determine if the physician’s communication style scaledistinguish among the doctors and the consultations.The total score and each of the four sub-scale scoresexcept ‘‘facilitative’’ style, were significantly different

among doctors (F1;145¼ 3:5026:30; p¼ 0:0620:01).Also, the total score and each of the four sub-scalescores were significantly different among consultations

(F1;145¼ 3:20210:01; p¼ 0:0820:002).

Other measures

Patient satisfaction was measured in order to assesspatient satisfaction with their medical consultation and

with talking to the physician during the encounter in thisstudy. There are many instruments to assess patient’ssatisfaction (Wolf, Putnam, James, & Stiles, 1978;

Baker, 1990), but the items of patient’s satisfactioncombine the patients’ perception of the medical en-counter itself (e.g. consultation length time) and thephysician’s behavior. Also, there is no validated

satisfaction questionnaire focused on medical encoun-ters in Japan. We adopted four items of patient’ssatisfaction from 25 cancer patients’ opinions by the

same method used in the development process of thephysician’s communication style scale. Two itemsreferred to general satisfaction: ‘‘I am satisfied with the

medical interview today’’, ‘‘I think something couldchange to improve today’s medical interview’’. Two

referred to the satisfaction focused on talking with thephysician: ‘‘I have something related to my health

concern I wanted to talk to my doctor but didn’t,’’ ‘‘Ifelt a sense of relief from talking with the doctor today.’’The response form with the items included a five-point

Likert-type scale. We used aggregated scores as one-dimensional patient satisfaction scores so a high valueindicates more satisfaction. Alpha reliability of the fouritems was 0.78.

Patient anxiety was measured using the State-TraitAnxiety Inventory (STAI). The STAI is used to measurethe transitory (state) and dispositional (trait) types of

anxiety. The STAI is one of the most widely used andsensitive scales for measuring patient anxiety in clinicalresearch (Bowling, 1995). Because medical encounters in

Japan can be very short, sometimes less than 3 min for aconsultation, it must be sensitive. In order to examinethe change in patient anxiety level, we measured the

patient’s state anxiety level twice, before and after theconsultation. We call those two measurements pre-anxiety level and post-anxiety level, respectively.The STAI consists of 20 items each for measuring trait

anxiety and state anxiety. The scores for each arebetween 20 and 80 where a high score indicates a higherlevel of anxiety (Spielberger, Gorsuch, & Lushene,

1970). Alpha reliability of trait and state anxiety was0.91 and 0.92 respectively, in this study.Control variables were employed for both dependent

(i.e. patient’s anxiety) and independent variables (i.e.physician’s communication style). Patient’s dispositionaltype of anxiety was employed for control variablesbecause this is not a major predictor of the change in

anxiety level, but it also affects physician’s behavior(Street, 1991).Physical status, such as signs or symptoms, affects the

physician’s behavior (Blanchard, Lebrecque, &Ruckdeschel, 1990; Bertakis, Callahan, Helms, Azari,& Robbins, 1993) and patient’s anxiety level. Patient

involvement in consultation would be greater if he/shehas physical signs and symptoms. For example, if apatient has severe symptoms, he tries to show his

physician what was happening to his body, and try toget more information from the physician. Physical statusof patients were assessed according to the patient’sfunctional impairment in daily life and pain, with four

response options ranging from ‘not at all’ to ‘verymuch’.Disease status, such as recurrent status of cancer, is

the clinical indicator to predict disease stage, is alsoassumed to affect both patients’ perception ofphysician’s style and their anxiety level. We adapted

patient physical status and disease status as controlvariables separately, because a patient with a severeprognosis does not always have physical sighs or

symptoms, and physical symptoms do not always agreewith a severe prognosis. Disease status of patients were


Table 2

Factor loading of doctor’s communication style


assessed according to the stage of the cancer andrecurrent status (i.e., postoperative disease-free vs.

recurrent status or metastatic disease).Duration of the medical encounter (Buller & Buller,

1984) and the examination result presented in a

consultation may be factors changing physician’sbehavior as well as patient’s anxiety level (Blanchardet al., 1990; Hall, Roter, Milburn, & Daltroy, 1996). Forexample, if a physician has to inform a patient of a bad

result, he may spend more time and show empathicbehavior to reduce the patient’s anxiety. Also the type ofexamination result may be a factor of the patient being

conscious of a physician’s behavior. Patients may try tonot miss a piece of information not only verbal but fromnonverbal behavior of the physicians. We asked patients

the duration of medical encounter with four responseoptions ranging from ‘less than 5 minutes’ to ‘more than20 minutes’, and the examination results with fourresponse options, no examination, good results, unclear

results and bad results.Patient’s demographic data, such as age, gender and

education have been identified as having a different

effect on the physician’s behavior (Cassileth, Zupkis,Sutton-Smith, & March, 1980; Blanchard et al., 1990;Hall, Irish, Roter, Ehrlich, & Miller, 1994) and were

included in the control variables. Also, each physicianhas his own consultation style (Ford et al., 1996).Physicians were assigned an ID of 1–13, and were

included in the analysis as a dummy variable.Three variables } cancer type, physician’s specialty

(internist or surgeon), presence of another person duringthe medical encounter } were removed because these

variables highly correlated with other variables. We alsoremoved ‘‘confidence with doctor and hospital’’ since itwas skewed with the majority of subjects.

Design and statistical analyses

To determine hypothesis 1, Spearman correlationcoefficients were used to examine the relationship

between patient satisfaction and each sub-scale of aphysician’s communication style obtained from factor

analysis. Before analyzing hypotheses 2 and 3, pre-liminary analysis was performed to identify the factors

related to both dependent and independent variables.This analysis included correlation analysis, chi-squaretest, t-test, and one-way analysis of variance. We

analyzed the effect of physician’s communication styleon both pre- and post-anxiety levels of the patients.Because we are studying the communication style of thephysician for a specific encounter, a physician’s com-

munication style should not affect pre-anxiety levelseven if patients had already felt that their physician’scommunication style was good (or bad) in their previous

encounter. To determine how well all the independentvariables explained variations in the dependent variable,ANOVA with mixed model was chosen (SAS Institute

Inc., 1996). This analysis considers ‘‘doctor’’ as arandom effect variable. In our study, a particular doctordoes not cause a certain level of patient anxiety, butpatients of one doctor may tend to have more or less

anxiety than patients of other doctors. ANOVA withmixed model is a valid statistical analysis method whenthe sample has been split by several variables (i.e.

doctor).

Results

There were 25 patients who reported an encounterwith their doctor of less than 5min, while nine patientsreported that it was more than 20min. Among the

patients who reported that they had received examina-tion results during the encounter, more than half thepatients had ‘‘good’’ results, and about 20% of thepatients had ‘‘bad’’ or ‘‘unclear’’ results. For

the physical status of the patients, 22 patients reported‘‘very much’’ impairment or pain (Table 4). The scoreof patient satisfaction with the medical encounter

was positively skewed like other satisfaction scales(Kinnersley, Stott, Peters, Harvey, & Hackett, 1996),and there may have been some ceiling effects. Trait

anxiety and both pre- and post-anxiety levels of patientswere lower than the clinically high anxiety level but

Table 3

Mean scores and alpha reliability of perceived physician’s communication style scale (N ¼ 147)

Sub-scale Mean� SD Minimum Maximum Range a

Physician’s style

(a) Acceptive 4.8� 0.4 3.0 5.0 (1–5) 0.90

(b) Patient-centered 4.2� 0.8 1.3 5.0 (1–5) 0.90

(c) Attentive 4.1� 0.8 2.0 5.0 (1–5) 0.73

(d) Facilitative 3.3� 1.1 1.0 5.0 (1–5) 0.76

Total [(a)+(b)+(c)+(d)] 16.4� 2.4 10.3 20.0 (5–20) 0.95


slightly higher than the general population level in thisstudy (Nakazato & Shimonaka, 1989).

Hypothesis 1

The correlations between the sub-scales of a physi-cian’s communication style and patient satisfactiontoward the medical encounter are shown in Table 5.

Each of the four sub-scales was moderately associatedwith patient satisfaction. Contrary to our hypothesis,the ‘‘facilitative’’ style of a physician had the weakestcorrelation with satisfaction among the four sub-scales.

Hypothesis 2

The mean scores of a patient’s anxiety level before andafter the medical encounter were 41.7� 11.5 and

36.7� 10.6, respectively. The anxiety levels of thepatients were reduced significantly after the encounter.The mean score reduction after the encounter was5.0� 1.5 points (p50:001). Sixty-seven percent of

patients had reduced anxiety levels.Table 6 shows the factors related to anxiety level

before and after the encounter. The factors related to

both pre- and post-anxiety levels were disease status,physical status, and trait anxiety level (model a and b). Itwas found that the physician’s communication style was

only related to the anxiety level after the encounter. Toconfirm that the physician’s communication style was

related to the patient anxiety level, we added the pre-anxiety level as a covariate and the examination results

as a factor during the consultation (model c). Even afterentering the two factors, the physician’s communicationstyle was still significantly related to the post-anxiety

level. In the same way, we entered each sub-scale ofphysician’s communication style separately. Two of thefour physician’s style, patient-centered and facilitativestyle, were significantly related to the post-anxiety level

(Table 7).

Hypothesis 3

The mediating effects of the physician’s communica-

tion style are shown in model d (Table 6). The post-anxiety levels by each patient’s disease status andexamination results in model d were also shown inFigs. 1 and 2. Among the patients with postoperative

disease-free status, who evaluated their physicians’communication style as high, their anxiety levelremained significantly low. On the other hand, among

the patients with recurrent status or metastatic disease,the difference was not significant.As shown in Fig. 2, there was a significant difference

between the physician’s communication style and theexamination results, although the outcome was notconsistent. If the patients evaluated their physicians’

communication style as high, their post-anxiety levelsstayed low even among the patients with bad examina-tion results.In addition, the mediating effects of each sub-scale of

a physician’s communication style on post-anxiety levelswere examined (Table 7). Regardless of disease status,patient’s post-anxiety level remained low, if the patients

evaluated their physician’s style as high (not shown inthe figure). Two physician’s styles, patient-centered andfacilitative style, had significant mediating effect on the

anxiety levels. The mediating effect of patient-centeredstyle was observed only among patients with

Table 4

Response profiles of patients (N ¼ 138)

N (%)

Duration of Medical Encounter

Less than 5min 25 (18.1)

5–9min 61 (44.2)

10–19min 43 (31.2)

More than 20min 9 (6.5)

Examination results informed from the doctor

No exam 41 (29.7)

Good 72 (52.2)

Unclear 15 (10.9)

Bad 10 (7.2)

Physical status (functional impairment in daily life and pain)

Not at all 16 (11.6)

A little bit 47 (34.1)

Somewhat 53 (38.4)

Very much 22 (16.0)

Mean�SD Range

Satisfaction with medical encounter 4.5� 0.6 (1–5)

Trait anxiety level 40.6� 10.9 (20–80)

Pre-state anxiety level 41.7� 11.5 (20–80)

Post-state anxiety level 36.7� 10.6 (20–80)

Table 5

Correlation of Physician’s communication style sub-scales with

satisfaction (N ¼ 138)

Sub-scale No. of items Satisfaction

Physician’s communication style ra

(a) Acceptive 9 0.687b

(b) Patient-centered 8 0.618b

(c) Attentive 3 0.446b

(d) Facilitative 3 0.368b

Total 27 0.630b

aSpearman’s correlation coefficient.bp50.001.


postoperative disease-free patients (t105 ¼ 2:24;p ¼ 0:02), and facilitative style was observed amongboth postoperative disease-free status (t105 ¼ 1:80;p ¼ 0:07), or with recurrent status or metastatic disease(t105 ¼ 2:31; p ¼ 0:02). Also the examination results andthe two physician’s styles, patient-centered and facil-itative style, had significantly different effects on thepost-anxiety levels. The difference was observed for a

patient-centered style with bad examination results(t105 ¼ 2:24; p ¼ 0:02), and for a facilitative style withno examination (t105 ¼ 3:13; p ¼ 0:002) and with badexamination results (t105 ¼ 2:80; p ¼ 0:006). For thesedifferences, a positive evaluation of a physician’s styleleads to less anxiety levels.

Discussion

Perceived physician’s communication style scale

We developed a perceived physician’s communication

style scale that can be used during medical encounters inJapan. It was developed on a group of breast cancerpatients, however, no significant difference was observed

among cancer types. In this respect, it is appropriate touse all of the subjects in this study. Alpha coefficients

demonstrated that the 27 items are internally consistentand that the reliability is acceptable. The distribution

of total and each sub-scale scores was moderatelyskewed, with more than half of the cases falling in theupper 75% of the scale. This skewed distribution is

very similar to the other published physician’s commu-nication style scales (Buller & Buller, 1987; Roberts etal., 1994). Studies suggested that this distribution of

patient’s perception of physician’s communication stylescores may result from patient’s reluctance to criticizetheir own doctor or from patient’s inability to have abasis to compare physicians (Butow, Dunn, & Tatter-

sall, 1995a). Also, the doctor–patient relationship is verydifferent from other contracts of nonequal positions(Freidson, 1970; Chaitchik et al., 1992). Moreover, since

the study was conducted on patients who were seeingtheir doctor on a continual basis, it is assumedthat unsatisfactory scores would be low or non-existent.

If a patient were unsatisfied, they would havechanged physicians. These reasons may contribute tothe positive skewed scores of physician’s communication

styles.The four sub-scales, ‘‘acceptive’’, ‘‘patient-centered’’,

‘‘attentive’’, and ‘‘facilitative’’ styles, obtained from thefactor analysis, are in well accordance with our

definition of physician’s communication style proposed

Table 6

Physician’s communication style and patient state anxiety: pre- and post-anxiety level (N ¼ 138)a

Model

Pre-anxiety level Post-anxiety level

(a) (b) (c) (d)

df F-value p F-value p F-value p F-value p

Disease status 1 3.74 0.0558 7.10 0.0088 2.83 0.0953 2.96 0.0885

(0: postoperative disease free, 1: recurrent

or metastatic disease)

Physical status (functional impairment

in daily life and pain)

1 8.23 0.0049 10.69 0.0014 5.34 0.0227 5.01 0.0273

(1: not at all – 4: very much)

Duration of medical encounter 3 0.94 0.4257 0.18 0.912 0.07 0.9743 0.09 0.9666

(1: less than 5min – 4: more than 20min)

Trait anxiety level 1 75.92 0.0001 54.62 0.0001 12.01 0.0008 9.67 0.0024

(range 20–80)

Physician’s communication style 1 0.56 0.4569 6.03 0.0156 4.29 0.0407 5.10 0.0260

(0: low, 1: high)

Examination results 3 0.75 0.5234 0.72 0.5401

(0: no exam, 1: good, 2: unclear, 3: bad)

State anxiety level before the encounter 1 19.54 0.0001 22.21 0.0001

(range 20–80)

Physician’s communication style� disease status 1 0.76 0.3865

Physician’s communication style� examination results 3 2.76 0.0459

aNote (1) Using mixed procedure and ‘doctor’ as a random effect. (2) The table shows after patients’ sex, age, and education level

were adjusted and (3) physician’s communication style evaluation score above the median is judged as high, and a score below the

median in determined to be low.


earlier. The scores of both total and each sub-scale wereobserved to be significantly different not among theconsultations but among the doctors. Also, researchers

independently evaluated the physicians’ communicationstyles and the correlation between assistants andpatients was statistically high. These results indicate

that the Perceived Physician’s Communication Style

Scale scores accurately reflect the patients’ evaluationsand could differentiate between effective and ineffective

physician’s communication style.We also tried to validate the perceived physician’s

communication style scale by establishing a relationship

between the scale and satisfaction with the medical

Table 7

Four dimensions of physician’s communication style and patient state anxiety: post-anxiety level (N ¼ 138)a

Post-anxiety level

df F-value p F-value p F-value p F-value p

Disease status 1 1.67 0.1990 4.42 0.0380 4.29 0.0407 4.11 0.0451

(0: postoperative disease free, 1: recurrent or metastatic

disease)

Physical status (functional impairment in daily life and pain) 1 5.72 0.0186 4.93 0.0286 4.08 0.0459 7.04 0.0092

(1: not at all – 4: very much)

Duration of medical encounter 3 0.31 0.8196 0.19 0.9027 0.09 0.9654 0.10 0.9608

(1: less than 5min–4: more than 20min)

Trait anxiety level 1 9.19 0.0031 10.38 0.0017 10.05 0.0020 8.48 0.0044

(range 20–80)

Physician’s communication style sub-scales (0: low, 1: high)

(a) Acceptive 1 0.24 0.6219

(b) Patient-centered 1 5.70 0.0187

(c) Attentive 1 0.42 0.5172

(d) Facilitative 1 6.44 0.0126

Examination results 3 1.27 0.2869 1.16 0.3287 1.03 0.3844 2.13 0.1010

(0: no exam, 1: good, 2: unclear, 3: bad)

State anxiety level before the encounter 1 22.93 0.0001 20.83 0.0001 22.79 0.0001 21.72 0.0001

(range 20–80)

Physician’s communication style� disease status 1 0.28 0.5964 0.66 0.4168 0.00 0.9731 0.13 0.7187

Physician’s communication style� examination results 3 2.06 0.1093 2.71 0.0489 1.77 0.1567 6.11 0.0007

aNote (1) Using mixed procedure and ‘doctor’ as a random effect. (2) The table shows after patients’ sex, age, and education level

were adjusted and (3) physician’s communication style evaluation score above the median is judged as high, and a score below the

median in determined to be low.

Fig. 1. Effect of physician’s communication style evaluation

and disease status on post-anxiety level. (1) Anxiety levels are

least-squares means which are adjusted by all the variables

shown in Table 6. (2) Physician’s communication style

evaluation score above the median is judged as high, and a

score below the median in determined to be low. and (3)

*:p50:05.

Fig. 2. Effect of physician’s communication style evaluation

and examination result on post-anxiety level. (1) Anxiety levels

are least-squares means which are adjusted by all the variables

shown in Table 6. (2) Physician’s communication style

evaluation score above the median is judged as high, and a

score below the median in determined to be low. and (3)

*:p50:05.


encounter. Moderate correlations were observedbetween each sub-scale of a physician’s communication

style and patient satisfaction. In addition, the correla-tion between all 27 items and satisfaction was alsomoderate. This agrees with previously published reports

(Tompson et al., 1990; Bertakis et al., 1991; Roter et al.,1997) and confirms that a good communication style bya physician is associated with patient’s satisfaction.Task-oriented behavior was not obtained from the

factor analysis. However, the physician’s ‘‘acceptive’’,‘‘patient-centered’’, and ‘‘attentive’’ styles were consid-ered to be the physician’s affective behavior. Accord-

ingly, we cannot discuss hypothesis 1 which states thatonly task behavior carries affective context and thatrelationally affective behavior is more significant than

task behavior for the patients. In our study, subjectswere patients with various types of cancer and thedoctors from both internal and surgical departments.

The task-oriented behavior, from the patients’ perspec-tive, might differ by department or type of cancer. It ispossible that the physician’s speciality is one of thefactors affecting patients’ evaluations (Buller & Buller,

1987). Both internists and surgeons have outpatients butthe way physicians conduct medical interviews and thecharacteristics of their patients are different in our study

sample. Surgeons tend to spend less time with theirpatients because most of them have less severe physicalconditions and primarily come to see the doctor for

routine check-ups. On the other hand, internists spendmore time with their patients because they have moresevere physical conditions and require various prescrip-tions for treatment. These differences may lower the

chances of obtaining elements related to task-orientedbehavior.Another reason for not obtaining elements related to

task-oriented behavior might be a result of the fact thata physician’s task-oriented and affective behavioroccurred simultaneously. Heszen-Klemens and Lapinska

(1984) showed that a patient’s recollection of thephysician’s instructions was better when the informa-tion-giving and emotional attitude from the physician

were higher. Also, it is suggested that patients cannotdistinguish task-oriented behavior from other behaviors(Lewis, 1994; Etter & Perneger, 1997). For these reasons,task-oriented behavior was difficult for the patients to

assess and only affective behavior was highly perceived.The ‘‘facilitative’’ style from the factor analysis was

considered to be the physician’s partnership-building

behavior. Doctor’s facilitative style was also correlated,but not as strongly as we expected, with patientsatisfaction. Previous research conducted in the USA

showed that, among task-directed, interpersonal, atten-tiveness, partnership and emotional support skills, thestrongest correlation with patient satisfaction was

the task-directed skill of the doctor and next, was thepartnership-building skill (Bertakis et al., 1991).

Although, in Japanese culture, expressing patient’srights in medical situation is increasing, patients still

expect doctors not only to have professional compe-tence, but also to accept responsibility for the patient’swelfare (Nilchaikovit, Hill, & Holland, 1993). In other

words, patients tend to rely on and give wholeheartedconfidence to doctors. Also, litigation is still not popularin Japanese medical situations. As a consequence,patients would not be conscious of physicians’ attempts

to prompt patient opinions or questions, or they do notconsider such attempts as important. Conversely, in theUSA, there are many malpractice claims and claims for

patients rights (Levinson, Roter, Mullooly, Dull, &Frankel, 1997). As a result, patients might be moreaware of their doctor’s partnership building skills. In

future research, it would be interesting to make a crosscultural comparison of American and Japanese ratingsof the same consultations to test this hypothesis.

Physician’s communication style and patient’s anxietylevel

The results show that the anxiety level droppeddramatically after a medical encounter. Physician’scommunication style was only related to the post-

anxiety level. When we interpret the observed results, wemust consider that both participants contribute in thedoctor–patient relationship. Physicians try to reduce

patient anxiety by spending more time with thosepatients with a serious condition (Waitzkin, 1985; Street,1991), and patients also try to obtain information or

their doctor’s opinion in order to reduce their ownanxiety (Molleman, Krabbendam, Annalas, Koops, &Vermey, 1984). Also, a good medical report affects apatient’s feelings regarding a physician’s communication

style. The results show, however, that the physician’scommunication style was only related to the post-anxiety level, and this did not change with the patient’s

characteristics and individual patient’s examinationresults. These results support hypothesis 2 where thephysician’s communication style to some degree affects a

patient’s anxiety level. Moreover, physician’s patient-centered and facilitative styles were suggested to beespecially effective in lowering the patient anxiety level.

Contrary to hypothesis 3, the effect of the physician’scommunication style was small among the patients withadvanced status in this study (Fig. 1). While only thefacilitative style, one of the four dimensions of the

physician’s style, was observed to have a mediatingeffect on patients among those with or without advancedstatus. The individual results of the other three styles

were similar to the total score of the physician’scommunication style. It is not that the physician’scommunication style is unimportant among patients

with severe conditions. In fact, in either disease status, ifpatients evaluated their physician’s communication style


as high, their post-anxiety levels were reduced comparedto their average of the pre-anxiety level (41.7). It is not

that patients with severe conditions do not need relieffrom anxiety, rather there are other factors that neitherdoctors nor patients can control. As their condition

deteriorates, patients might suffer from other psycholo-gical, social, and economic factors during the treatmentprocess. Scheier et al. suggested that the disease course isimportant when considering the impact of psychological

factors on disease outcomes (Scheier & Bridges, 1995).Both person variables and biological factors mayinfluence disease outcomes at disease onset. As the

disease progresses, the influence of biological factorsmay increase and become almost complete determinantsof the end stage of an illness. On the other hand, the

personal variables of a healthier patient might beexpected to be more pronounced. Therefore, it issuggested that the effect of the physician’s communica-

tion style is greater among patients without recurrence.The anxiety levels tended to remain low among

patients who evaluated their physicians’ communicationas high except when the examination results were

unclear. It is not surprising that post-anxiety levels werelow among patients with good examination results. Itshould be emphasized that patients’ post-anxiety levels

remained low even among patients with bad results. Forthe patients with bad results or no examination, asignificant difference was found between good and bad

communication, with the latter leading to higheranxiety.An opposite trend, where high communication skills

increased anxiety, was observed among the patients with

unclear examination results, although the anxiety levelwas only slightly larger. One of the reasons that thepatients with unclear examination results were more

anxious } even among the patients where theirphysicians’ communication style was high } is sug-gested to be that the statements of unclear examination

results indicate the uncertainty of their future life andtherefore threaten them. For one patient who judged herexamination results as unclear, the doctor said ‘‘From

the results of a liver ultrasonography, I can see bothgood parts where the tumor seems to have disappearedand bad parts where there seems to be new tumorgrowth.’’ This kind of information apparently makes

patients anxious. Proper medical support is also neededfor patients when information is unclear as well as bad.However, we have to be careful how we interpret these

results, because the samples of unclear and badexamination results were small. The results were shownafter we controlled the expected confounding variables,

but there may be other factors that affect bothphysician’s communication and patient’s anxiety level.However, compared with the patient’s average pre-

anxiety levels, if patients evaluated their physician’scommunication style as high, their post-anxiety levels

were smaller. This indicates that physician’s goodcommunication style potentially affect the reduction of

patient’s anxiety levels, even among patients with badexamination results.This investigation has several implications for clinical

practice. First, the perceived physician’s communicationstyle scale scores can accurately reflect the patients’evaluations and could differentiate between effective andineffective physician’s communication style. Self-report

questionnaires are less expensive and can be used morebroadly than observational interaction analysis ofaudio- or video-tapes (Street et al., 1995). Also, it would

be possible to monitor the acquired skills by this scale,because the correlation between patients’ and re-searchers’ rating of perceived physicians’ communica-

tion style was high. As a result, this scale for assessingthe quality of consultation can be quite useful. Toconfirm this suggestion, it would be of benefit to do

more research addressing actual communication. Thiswould include investigating actual communicationbehavior related to patient’s perception of physician’scommunication style, and if the perception of his/her

physician’s communication style was different, how thepatient reacts differently to the physician. We areconducting further analysis of these questions. The

analysis includes the use of the audiotape recording.Secondly, physicians should consider the importance

of consultations for outpatients with respect to patients’

anxiety level. Patient’s anxiety levels could be influencedby a physician’s communication style. Particularly,patient-centered and facilitative styles can be effectivein reducing a patient’s anxiety level. Studies have shown

that the communication skills may be acquired throughtraining (Roter et al., 1995; Maguire, Booth, Elliott, &Jones, 1996; Fallowfield, Lipkin, & Hall, 1998). These

skills could be taught to physicians. Communicationskill training has just started to include in medicaleducation, but still limited to only a few medical schools

in Japan. The effectiveness could be improved byadministering a training program.Finally, not only will it benefit patients, it could also

be helpful for physicians. Relaying bad news is alsoperceived as stressful by physicians (Greenwald &Nevitt, 1982; Taylor, 1988). Physicians’ stress can besuppressed if patients’ anxiety levels are lowered. Our

study indicated that physicians’ good communicationstyles related to a lower anxiety level in the patients evenamong the patients with bad examination results. The

physicians’ communication style is essential not only formoderating patients’ anxiety but also for moderatingphysicians’ stress when relaying bad news.

There are some limitations to generalizing theseresults to all hospitals and cancer patients in Japan.This study was conducted at only one hospital and the

physicians studied were volunteers in a study ofcommunication skills and may not have been


representative of physicians in general. The studies needto be conducted at other hospitals for cross validation.

Also, the physicians might act differently during theirencounters with patients because the method includedan audiotape-recording process. Although there is the

possibility that physicians changed their communicationstyles because they were being studied, over 90% of thepatients said the doctor’s communication style did notchange from the time before the study started. Finally,

targeting patients who have never met their physicianmay yield better results because the patients have noprevious experience and may be able to judge their

doctor more objectively.In conclusion, with this research, we hope to create

more awareness about doctor–patient relationships in

Japan. By stimulating awareness, we hope to demon-strate the need to facilitate better communicationbetween physicians and patients. To foster better

communication skills, we hope that physicians willrealize the need and participate in classes designed todevelop their communication skills.

Acknowledgements

This research was supported by a grant from Grant-in-Aid for Scientific Research (A)(1)-07309019. We aregrateful to the patients and clinicians from the National

Cancer Center Hospital and to Prof. Ohashi and Dr.Watanabe for their assistance. We are also grateful toProf. Sakurai and Dr. Shimozuma for their commentson this article. An earlier version of this paper was

presented at the Fourth International Congress ofPsycho-Oncology.

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Documents

Relationship between outpatients’ perceptions of physicians’ communication styles and patients’ anxiety levels in a Japanese oncology setting