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3. Doctor John and the Surreptitious Assessment—Part 1

Updated: Jul 27, 2023

An introduction to patient-provider interpersonal communication models

Though most of The Plucky Patient blog postings will examine the nature of the relationship between patients and the life science industry using an observational and critical approach, I will, on occasion, bring in my own personal health experience as a lens for interpreting the broader health ecosystem. This is one of those posts. In social science research, this type of exploration is referred to as autoethnography [1].

I recently started seeing a new primary care physician. I found him having done research online, though it took me over 18 months for my first appointment as he rarely took new patients. Like many people who identify as part of a minority, I was seeking a physician with whom I could relate and who understood the health experiences of a Gen-X gay man. I’m fortunate to live in a large city with doctors that cater to different communities within the LGBT umbrella. Having such an opportunity exemplifies the value of personalized care—a topic that will be of frequent discussion in The Plucky Patient. My new doctor is also gay and I discovered him on a physician review site having Googled “gay doctors in Chicago”. The testimonials and ratings for him were very impressive and his office was located in the larger of the two gayborhoods of the city, colloquially known as Boystown.

Starting from my first impression in which he introduced himself by his first name—Hi, I’m John—I knew that this was not going to be a typical patient-physician interaction. While we reviewed my medical history in a fairly conventional fashion, most of our conversation was a very detailed and candid discussion of the needs and healthcare issues most relevant to urban gay man—sexual practices, HIV and STI screening and prevention, drug and alcohol use (gay men are at significantly higher risk than straight men for substance abuse [2]), and most importantly, the gym where I worked out. John recognized that the manner in which he engaged with his patients was not common to most medical practitioners. In fact, toward the end of our visit he even stated, “I’m sure you noticed that I don’t talk with my patients the way most doctors do”, to which I agreed while stealthily adding in that I had a doctorate in patient-provider interpersonal communication. In that moment, John paused, looked up from his monitor and asked in a serious tone “Well, how am I doing?” It was at this point that he realized that the entire time he was assessing me, I was simultaneously assessing him.

Now, we expect our healthcare providers to evaluate us—our physical condition and our mental state. We also recognize that a good HCP is also constantly assessing our actions and attitudes while making assumptions and predictions about our behavior… i.e., our ability to be adherent to a prescribed therapy, our level of honesty...

"Sure Jan, You state that you only have three to four drinks a week, but your body language clearly demonstrates it’s more like six to eight

and our willingness to disclose intimate personal health information. In fact, there is an entire theoretical framework devoted to that last behavior called Communication Privacy Management [3] which will be the main topic of an upcoming blog post. But we sometimes forget that the patient-provider encounter is a relationship in which both parties need to establish a trust bond for it to succeed. This means that we, as patients, are often surreptitiously evaluating the way our HCPs connect with us…

Is he making eye contact with me or is his face hidden behind the computer screen the entire time?”
“Does she answer my questions completely and in detail? Will she ask me if I have questions?”
"Why is he treating me like a child?”

Health communication scholars have noted how different types of HCP communication styles can influence the relationship and type of engagement that develops between the HCP and patient. For instance, Emanuel and Emanuel [4] categorized the patient-provider interpersonal communication process into four models.

Humorous example of the paternalistic model of patient-provider interpersonal communication

The paternalistic model is one in which the HCP assumes leadership and management of the dynamic and thereby makes decisions based on what he or she feels is in the best interest of the patient. While this style is waning, it is still often the preferred model by rural and/or older generations of physicians AND patients, including my parents. The inverse of paternal is the informative model in which the HCP simply provides information while the patient assumes leadership and management of decisions. The interpretive model, like the informative model, recognizes the need for the physician to provide technical information. However, while the patient is still the decision maker, he or she allows the provider to elucidate their values and assist in the guidance of therapies and medical decisions. Lastly, there is the deliberative model, which is when the patient not only requires technical advice from the HCP, but also solicits help in determining what values are necessary to guide the decision-making process. The provider empowers the patient with both technical knowledge and values, and through dialogue, helps the patient make medical decisions. It was clear from my experience that John valued encounters that were reflective of the interpretive or deliberative approach, not surprising given his younger age and urban setting.

So, what does all this mean for pharma, biotech, payor and advocacy groups? Good question.

Click here to go to part 2 of this post to find out.

[1] Tracy, S. J. (2013). Qualitative research methods: Collecting evidence, crafting analysis, communicating impact. Wiley-Blackwell. [2] [3] Petronio, S. (2002). Boundaries of privacy: Dialectics of disclosure. State University of New York Press. [4] Emanuel, E. J., & Emanuel, L. L. (1992). Four Models of the Physician-Patient Relationship. JAMA: The Journal of the American Medical Association, 267(16), 2221



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