Elsevier

Social Science & Medicine

Volume 53, Issue 10, November 2001, Pages 1335-1350
Social Science & Medicine

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

https://doi.org/10.1016/S0277-9536(00)00413-5Get rights and content

Abstract

For life-threatening illnesses such as cancer that require a long-term treatment regimen, communication is particularly important between doctors and patients. While it is assumed that the more serious the illness, the greater the need to relieve patients’ anxiety, physicians’ communication styles can directly influence patients’ anxiety levels. The purpose 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 Trait Anxiety Inventory before and after the consultation. The Perceived Physician's Communication Style Scale was developed 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. The inter-correlation for overall scale items was 0.95. Patient satisfaction with the medical encounter was also measured to validate 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's satisfaction. After the consultation, the patients’ anxiety levels dropped 5.0±1.5 points (p<0.001), and the physician's communication 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 an advanced disease status. Also, the findings showed that patients’ post-consultation anxiety levels remained low even among those patients with unfavorable examination results if the patients evaluated their physician's communication style 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 news to patients.

Introduction

Physician–patient communication has been recognized 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 psychological 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 and Hall (1992), the exchange with a doctor significantly affects a patient which is reflected by the fact that it is frequently recited, often word for word, to family members and friends.

For life-threatening illnesses such as cancer that require a long-term treatment regimen, communication is particularly important between doctors and patients (Greenwald & Nevitt, 1982; Taylor, 1988; Siminoff & Fetting, 1991). Ford, Fallowfield, & Lewis (1976), Ben-Sira (1980) suggested that the physician's style of communication becomes more critical when the patient becomes more emotionally involved in the illness, and when the physician's affective behavior toward the patient focuses on reducing the patient's anxiety. For more serious illnesses, the doctor’s role becomes increasingly important in achieving lower patient anxiety levels through his or her communication skills.

However, there have been few studies focused on the relationship between physicians’ communication styles and patient health outcomes in oncology settings (Ford, Fallowfield, & Lewis, 1996; Ong et al., 1998). Even in different medical fields, the results of similar studies do not satisfactorily determine the association of physicians’ communication styles and patient health outcomes (Stewart, 1984; Bertakis, Roter, & Putnam, 1991). The problem with previous studies is that they only 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) and within Japanese society, either through the more commonly used observational interaction analysis or, as in this case, patient’s judgement. First, the patients’ subjective feelings of improvement will in large measure be determined by the effectiveness of the physicians’ communication styles in relieving their anxiety (Ben-Sira, 1980). Second, in Japanese society, a relatively 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 of interpersonal communication (Ishii, 1984). Also, a person who is good at intuitively perceiving another person's thoughts and feelings is highly praised and revered in Japanese society (Barnlund, 1975). This kind of 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. Several scales assessing doctor–patient interaction have already been developed in Western countries, but some elements cannot be applied to Japan because of cultural differences. For example, in the Western version, some elements deal with patients expressing their feelings in front of their physicians. In Japan, however, patients do not express their feelings, nor do they believe that they should do so in front of their doctors. Therefore, in order to assess the effectiveness of physicians’ communication styles in Japan, it becomes necessary to alter the evaluation items.

In this study, we first developed a scale to measure the effectiveness of the physicians’ communication styles. Then, we examined the relationship between outpatients’ perceptions of physicians’ communication styles and the anxiety levels of the patients in oncology settings.

Section snippets

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 attitudes are formed or modified by interaction. When the topic of communication is emotion-filled, exchange through verbal 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

Subject

This study was conducted at the National Cancer Center Hospital, a medium-sized research hospital in Tokyo, Japan. Thirteen physicians participated in this study. Twelve were male, of which eight were oncology internists and five were oncology surgeons. The mean age 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.

Results

There were 25 patients who reported an encounter with their doctor of less than 5 min, while nine patients reported that it was more than 20 min. Among the patients who reported that they had received examination results during the encounter, more than half the patients had “good” results, and about 20% of the patients had “bad” or “unclear” results. For the physical status of the patients, 22 patients reported “very much” impairment or pain (Table 4). The score of patient satisfaction with the

Perceived physician’s communication style scale

We developed a perceived physician's communication style scale that can be used during medical encounters in Japan. It was developed on a group of breast cancer patients, however, no significant difference was observed among cancer types. In this respect, it is appropriate to use all of the subjects in this study. Alpha coefficients demonstrated that the 27 items are internally consistent and that the reliability is acceptable. The distribution of total and each sub-scale scores was moderately

Acknowledgements

This research was supported by a grant from Grant-in-Aid for Scientific Research (A)(1)-07309019. We are grateful 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 to Prof. Sakurai and Dr. Shimozuma for their comments on this article. An earlier version of this paper was presented at the Fourth International Congress of Psycho-Oncology.

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