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Healthcare provider-patient communication: exploring barriers to effective communication to increase patient outcomes and provider job satisfaction
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Healthcare provider-patient communication: exploring barriers to effective communication to increase patient outcomes and provider job satisfaction
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Content
Healthcare Provider-Patient Communication: Exploring Barriers to Effective
Communication to Increase Patient Outcomes and Provider Job Satisfaction
Tinamarie Ann Terrasi
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
December 2022
© Copyright by Tinamarie Ann Terrasi 2022
All Rights Reserved
The Committee for Tinamarie Ann Terrasi certifies the approval of this Dissertation
Bryant A. Adibe
Esther C. Kim
Rufus Tony Spann, Committee Chair
Rossier School of Education
University of Southern California
2022
iv
Abstract
Effective healthcare provider-patient communication fosters a trusting provider-patient
relationship and is critical to successful patient outcomes. Increased patient outcomes are directly
linked to healthcare provider job satisfaction (Ha & Longnecker, 2010). This study sought to
generate a better understanding of the healthcare providers’ (HCP) perceived barriers to effective
healthcare provider-patient communication (PPC). The effects of the media, specifically
physician review websites and patient web portals, implicit bias directed both towards the patient
and the healthcare provider, and infrastructural barriers were examined. This study used a
theoretical framework comprised of communication accommodation theory and cognitive load
theory as a lens. A qualitative design consisting of semi-structured interviews with six medical
doctors, three nurse practitioners, and one physician assistant was the methodology for data
collection. The findings showed that the HCPs participating in this study felt that time was the
most significant barrier to effective PPC. Based on the findings and conceptual framework, two
recommendations for practice were generated from this study. Ultimately, this study generated
insights that contribute to addressing infrastructural barriers to PPC, patient outcomes, and HCP
job satisfaction.
v
Acknowledgements
This academic journey would not have been possible without the love, support, and
understanding of my family, friends, and colleagues, old and new, near and far. These people
cheered me on and checked in on me when I disappeared for too long. The friends I have made
during my journey in the Organizational Change and Leadership program at the Rossier School
of Education at the University of Southern California are invaluable. I have learned more from
the conversations in and out of class than from any book or journal article.
I am also forever grateful for my committee, Dr. Rufus T. Spann, Dr. Esther Kim, and
Dr. Bryant Adibe, and for my dissertation advisor Dr. Zachary Unger. All four of these
remarkable educators guided me toward the successful completion of my work with kindness
and compassion. I am also deeply grateful for the encouragement and support of Dr. Douglas
Lynch, who patiently helped me work through the economic analyses of my recommendations.
This study would not have been possible without the 10 healthcare professionals who
graciously gifted me their time to participate in my research. The kindness and candor they
demonstrated during the process allowed for a richer, more human perspective on the findings. In
addition to the participants, I am grateful to Dr. Sanne Henninger and Bryan Walker, PA-C for
their guidance and counsel throughout my dissertation planning and writing journey.
I am forever grateful to have fulfilled the dream of obtaining the distinction of a doctor
while simultaneously living out my dream of living in my favorite city of Boston, Massachusetts.
I wrote large portions of my dissertation and completed all the data analysis in the beautiful
Bates Hall at the main branch of the Boston Public Library. All the research for my literature
review was read while sitting on the Fiedler Dock at the Charles River Esplanade. Countless
miles were walked at the Esplanade to clear my head, move my body, and spark creativity.
vi
This work is dedicated to my parents and my children. I only wish that my father was still
alive to see me finally become a doctor, just not that kind of doctor. I hope that for my children,
this milestone will remind them that no matter what detours or adversities life hands you, you
can do, be, and have whatever you set your mind to. It may take longer than expected and not
look like you imagined; in fact, it may be even better than you could ever believe possible.
While my path had led me to a Doctor of Education degree, not the medical degree I
planned to pursue when I graduated high school, I feel that my research for this dissertation will
help advance medicine in some way. Because of this belief, I feel that the Emily Dickinson quote
I chose for my high school yearbook applies today as it did back in 1992:
If I can stop one heart from breaking,
I shall not live in vain;
If I can ease one life the aching,
Or cool one pain,
Or help one fainting robin
Unto his nest again,
I shall not live in vain.
vii
Table of Contents
Abstract ........................................................................................................................................... iv
Acknowledgements ......................................................................................................................... v
List of Tables .................................................................................................................................. ix
List of Figures .................................................................................................................................. x
Chapter One: Overview of the Study .............................................................................................. 1
Context and Background of the Problem ............................................................................ 1
Purpose of the Project and Research Questions .................................................................. 2
Importance of the Study ...................................................................................................... 3
Overview of Theoretical Framework and Methodology ..................................................... 4
Definitions ........................................................................................................................... 6
Organization of the Dissertation .......................................................................................... 7
Chapter Two: Literature Review ..................................................................................................... 9
Effects of Media and Consumer Health Products on Provider-Patient
Communication ................................................................................................................... 9
Implicit Bias in Healthcare ................................................................................................ 29
Healthcare Provider-Patient Communication .................................................................... 43
Conceptual Framework ..................................................................................................... 54
Summary ............................................................................................................................ 59
Chapter Three: Methodology ........................................................................................................ 62
Research Questions ........................................................................................................... 62
Overview of Design ........................................................................................................... 62
Research Setting ................................................................................................................ 63
The Researcher .................................................................................................................. 65
Data Sources ...................................................................................................................... 66
viii
Validity and Reliability ..................................................................................................... 69
Ethics ................................................................................................................................. 70
Chapter Four: Findings .................................................................................................................. 72
Research Question 1: How Do Online Resources, Including Physician Review
Sites and Patient Web Portals, Influence Healthcare Provider-Patient
Communication? ................................................................................................................ 74
Research Question 2: What Role Does Implicit Bias, in Both the Provider and the
Patient, Have on Healthcare Provider-Patient Communication? ....................................... 82
Research Question 3: What Perceived Barriers Do Healthcare Providers Feel
Exist That Impede Effective Communication With Patients? ........................................... 90
Summary .......................................................................................................................... 107
Chapter Five: Recommendations ................................................................................................ 110
Discussion of Findings .................................................................................................... 110
Recommendations for Practice ........................................................................................ 116
Limitations and Delimitations ......................................................................................... 132
Recommendations for Future Research ........................................................................... 133
Conclusion ....................................................................................................................... 135
References ................................................................................................................................... 136
Appendix A: Participant Enrollment Letter and Informed Consent ............................................ 163
Appendix B: Demographic Questions for Interview Protocol .................................................... 164
Appendix C: Interview Protocol .................................................................................................. 165
Interview Protocol ........................................................................................................... 166
Appendix D: Additional Findings ............................................................................................... 169
ix
List of Tables
Table 1: Participant Demographic Data 64
Table 2: Participant Medical Specialties 65
Table 3: Participant Overview 73
Table 4: Costs and Benefits of Identified Issues 121
Table 5: Assumptions for Cost and Benefits Analyses 123
Table 6: Recommendation 1: Yearly Communication-Focused
Requirement
125
Table 7: Recommendation 2: EMR Integrated LMS Software
Development
126
Table 8: Recommendation 2: EMR Integrated LMS (Hospital System
Utilization)
129
Table 9: Cost-Benefit Analysis for Each Option 130
Table D1: Removing Scheduling Barriers 169
Table D2: Suggested Personnel Changes 171
Table D3: Administrative Work 172
Table D4: Communication Accommodation 174
x
List of Figures
Figure 1: Cognitive Load Theory 56
Figure 2: Conceptual Framework 58
1
Chapter One: Overview of the Study
There is a communication divide between healthcare providers (HCP) and patients. A
study by Ha and Longnecker (2010) clearly illustrates this divide when they found that 75% of
orthopedic surgeons in their study reported having good communication skills, while only 21%
of their patients concurred. This study addresses how the communication problem between the
HCP and the patient affects patient outcomes and job satisfaction. It is well-documented that
HCP communication impacts patient trust, satisfaction, treatment compliance, and overall well-
being (Calderon et al., 2015; Jolles et al., 2012; Parnas & Isobel, 2018; Polonsky et al., 2017;
Street et al., 2015). Effective communication is also an essential factor in creating improved job
satisfaction for the provider (Ha & Longnecker, 2010). Bridging the communication divide, an
aspect of care entirely in the control of the HCP, will create healthier patients and more
professionally satisfied HCPs.
Context and Background of the Problem
The relationship between HCP and patient is the foundation of adequate medical care to
improve the patient’s overall health (Ha & Longnecker, 2010). There are six core competencies
for all HCPs, which include patient care, medical knowledge, practice-based learning and
improvement, professionalism, systems-based practice, and interpersonal and communication
skills (Peregrin, 2014). Shifts in medical education have created a focus on technical learning
which tends to supersede humanistic learning (Peregrin, 2014). This shift is leaving 41-65% of
medical students feeling that their communication training is inadequate (Jolles et al., 2012),
despite training in effective communication skills using actors in role-play (Peregrin, 2014).
Nonetheless, bedside manner is a skill or professional competency learned through continuous
practice and can degrade over time if not used correctly (Ha & Longnecker, 2010). Jolles et al.
2
(2012) found that 53% of physicians identify adequate time with a patient as an obstacle to
effective communication. Peregrin (2014) acknowledges that initiating rapport in the first few
minutes of a visit is essential to favorable outcomes. Nevertheless, when patients sense that the
HCP is rushed, they are less likely to disclose all necessary information (Parnas & Isobel, 2018).
This withholding of information can reduce communication or create miscommunication, thus
hindering successful outcomes and decreasing patients’ involvement in their care (Ha &
Longnecker, 2010).
HCPs who demonstrate a warm, reassuring, and empathic affect tend to have better
patient outcomes. Communication can directly impact a patient’s understanding of their
diagnosis, sets the foundation of trust in the HCP, and is an important factor in treatment
adherence (Jolles et al., 2012; Polonsky et al., 2017; Street et al., 2015). Communication is both
verbal and nonverbal. Verbal communication includes the words that are spoken and vocal tone,
which can influence provider-patient communication (PPC) by creating emotional responses in
patients (Street et al., 2015). Nonverbal communication is interpreted differently from verbal and
is responsible for up to 50% of emotional communication. This type of communication includes
nodding, smiling, posture, and speech patterns (Jolles et al., 2012). The HCP’s ability to
effectively interpret the patient’s verbal and non-verbal cues while being mindful of their affect
is the foundation of effective communication, which leads to more favorable outcomes.
However, the COVID-19 pandemic has placed a unique challenge for HCPs to maintain an
effective bedside manner in telemedicine encounters (Begasse de Dhaem & Bernstein, 2020).
Purpose of the Project and Research Questions
The purpose of this study is to explore the perceptions of healthcare providers on barriers
to effective communication with patients. The study will answer three research questions.
3
1. How do online resources, including physician review sites and patient web portals,
influence healthcare provider-patient communication?
2. What role does implicit bias, in both the provider and patient, have on healthcare
provider-patient communication?
3. What perceived barriers do healthcare providers feel exist that impede effective
communication with patients?
Importance of the Study
This problem is important to solve as the research supports a direct correlation between
patient trust, treatment compliance, satisfaction with care, and HCP communication (Radziej et
al., 2017). “In the absence of curative agents, a strong patient-doctor relationship is regarded as
‘paramount’ for engaging patients, optimizing health outcomes, increasing patient satisfaction,
and enhancing motivation for changing, particularly among treatment-resistant patients”
(Lackner et al., 2020, p. 411). Furthermore, better PPC leads to decreased malpractice claims and
increased HCP job satisfaction (Radziej et al., 2017; van Osch et al., 2017). Provider demeanor,
or bedside manner, is the one factor in medical care that is under the complete control of the
provider. Focusing on improving bedside manner will result in patients feeling safe, less anxious,
and more compliant with treatment, allowing providers to quickly identify a patient’s needs
resulting in more cost-effect treatments and decreased hospital admissions (Ha & Longnecker,
2010; Parnas & Isobel, 2018).
In addition to improving health outcomes, this problem is also important to address as
healthcare has become a business where patients view their HCP as a service provider and
receive care as a business transaction (Stinson & Heischmidt, 2012). This notion of healthcare as
a business transaction has changed the dynamic of provider-patient relationships, with patients
4
becoming consumers who shop online for HCPs (Chan, 2017; Han et al., 2020). Rising insurance
premiums have driven the change in dynamics. Chan (2017) explains that “out-of-pocket costs
for premiums and deductibles have doubled to nearly 9.6% of household income between 2003
and 2013” (p. 14), but incomes have not risen accordingly. Wheelan (2019) expounds on this
theme, noting that in the United States, most insurance companies charge the patient the same
copay for a medical visit or procedure. Therefore, HCPs providing a better patient experience
tend to have more patients and increased revenues. Understanding the perceived and actual
barriers to effective PPC is necessary to create change. Organizational constraints that impact
time, staffing, and financial resources impact health literacy which is directly correlated with less
favorable health outcomes (Bo et al., 2014). The knowledge created through this study will allow
healthcare organizations to address provider emotional and physical exhaustion, which increases
the risk of medical errors and leadership and mindset concerns, thus, allowing for necessary
infrastructural shifts to be made to foster more effective PPC (Moore et al., 2017).
Overview of Theoretical Framework and Methodology
Two theories are appropriate for examining the problem of communication between
HCPs and patients. The first theory is communication accommodation theory (CAT). Giles
(1973) developed speech accommodation theory to investigate how people situationally alter
their speech to be accommodating or non-accommodating and the resulting consequences of
those accommodations. Over time speech accommodation theory was refined to include
nonlinguistic accommodations, thus creating CAT. Farzadnia and Giles (2015) defined the five
proposed sociolinguistic strategies of CAT as approximation, interpretability, interpersonal
control, discourse management, and emotional expression. The “unique feature of CAT is its
5
position that speakers accommodate (or not) where they believe or expect their interactants to be
linguistically” (Farzadnia & Giles, 2015).
The second theory is cognitive load theory (CLT) which focuses on a person’s ability to
process and retain new information based upon the presentation of new information. This
psychological theory states that a person has three types of memory, each with differing abilities
to retain information. The sensory memory retains a duplicate of the information present for a
very brief period of time. The information is then processed through the working memory, which
retains that information for a short time. Retained information then transfers to long-term
memory. While sensory and long-term memories have unlimited capacity, the conduit between
the two, the working memory, has limited capacity (Mayer, 2010).
Effective PPC focuses on verbal tone, language (technical versus layperson), and active
listening. CAT is an appropriate lens for examining PPC because it considers interpersonal
communication’s emotional, motivational, and behavioral aspects. It also emphasizes the
speaker’s ability to adjust their communication style, either consciously or unconsciously, based
on the goals of the conversation (Giles, 2008). CLT is appropriate to examine the problem
because the patient’s understanding of their diagnosis and treatment can directly affect
compliance and health outcomes. The amount and types of information HCPs present to patients
during an encounter and the resulting compliance and outcomes can be examined through CLT.
A qualitative research design with inductive and deductive data analysis was used to
study the problem of healthcare provider-patient communication. Merriam and Tisdell (2016)
define qualitative research as “a type of research that encompasses a number of philosophical
orientations and approaches” (p. 19). Narrative inquiry was used to gain an understanding of
healthcare providers’ lived experiences regarding patient communication. Semi-structured
6
interviews were used to collect narrative qualitative data from HCPs, allowing the researcher to
be guided by a list of questions and the flexibility to expand upon the responses provided
(Merriam & Tisdell, 2016). This research design aligns with the purpose of the study because it
is focused on the HCP’s perspective on the problem of communication.
Definitions
• Cognitive shortcut, also known as a heuristic, is a mental shortcut that allows people
to simplify decision-making based on previous experiences or learnings.
• Consumer health device is any medical device available without a prescription (e.g.,
glucose meter and pulse oximeter), including wearable technology (Fitbit and
smartwatches) and smartphone apps.
• Continuing medical education promotes the maintenance and continuous
improvement of the competence and performance of healthcare providers (Regnier et
al., 2021). Continuing medical education credits are required to maintain
credentialing and board certifications and are earned through conferences, virtual
seminars, online modules, and other types of training (Ghanem et al., 2018).
• Direct-to-consumer advertising refers to print, radio, television, or online advertising
produced by a pharmaceutical company to promote a specific medication or provide
awareness about a specific medical condition.
• Electronic medical record is a digital version of a patient’s medical history that can
be shared across different healthcare settings and institutions.
• Health literacy is “a multidimensional concept covering a range of cognitive and
social skills necessary for participation in health care” (Bo et al., 2014).
7
• Healthcare provider, in this study, is defined as any person who is licensed as a
medical doctor, doctor of osteopathy, physician assistant, or nurse practitioner.
• Healthcare stereotype threat refers to “the threat of being personally reduced to group
stereotypes that commonly operate within the healthcare domain, including
stereotypes regarding unhealthy lifestyles and inferior intelligence” (Abdou et al.,
2016).
• Home genetic testing is any commercial genetic tests using saliva, blood, or cheek
swab samples that are available without prescription and are taken at home and
analyzed at a private laboratory.
• Implicit bias refers to “associations outside of conscious awareness that lead to a
negative evaluation of a person on the basis of irrelevant characteristics such as race
or gender” (Fitzgerald & Hurst, 2017).
• Learning management software is a software application that delivers educational and
training programs.
• Patient web portal is a website that allows patients secure access to their medical
records and facilitates online communication between healthcare providers and
patients.
• Shared decision making is a process where patients actively contribute to the making
of medical and treatment decisions with their healthcare provider.
Organization of the Dissertation
This study is organized into five chapters. This chapter frames the study by introducing
the problem, purpose, key concepts, and importance. Definitions of key terms or concepts
discussed within the study are defined. Finally, the theoretical frameworks by which the research
8
questions will address are also introduced. Chapter Two reviews current literature associated
with healthcare provider-patient communication, including the media and consumer health
products, implicit bias in healthcare, and how HCP communication affects patient outcomes.
Chapter Two also discusses the conceptual framework that has been created through the lens of
communication accommodation theory and cognitive load theory. Chapter Three explains the
study’s methodology, including participant selection, data collection, and analysis. In Chapter
Four, the data and results are assessed based on an analysis of healthcare provider interviews.
Finally, based on the data analysis and literature, Chapter Five provides recommended solutions
for creating changes that foster more effective PPC and suggestions for further research.
9
Chapter Two: Literature Review
A productive healthcare provider-patient relationship creates improved health outcomes
for the patient and increases job satisfaction for the provider (Ha & Longnecker, 2010; Radziej et
al., 2017). Several potential barriers to effective PPC will be explored in this literature review.
The review will begin with the effects of media, including medical television programming,
direct-to-consumer pharmaceutical advertising, consumer health devices, online health
information, social media, and provider review websites. Next will be an exploration of the
effects of implicit bias on provider-patient communication, including gender bias in medical
education and healthcare stereotype threat. The review will conclude with an analysis of
provider-patient communication and patient outcomes, including the effects of health literacy,
shared decision-making, secure messaging through patient web portals, and telemedicine.
Effects of Media and Consumer Health Products on Provider-Patient Communication
PPC is a continuous trust-building exercise for patients and HCPs. Therefore, the effects
of media and consumer health products can either enhance or detract from the relationship and
impact shared decision-making. Media portrayals of HCPs influence patient knowledge,
behaviors, and perceptions of medicine (Hoffman et al., 2017; Painter et al., 2020), but the
proliferation of medical television programming has also been shown to be of educational value
to HCPs (Gross et al., 2012; Haboubi et al., 2015; Stanek et al., 2015). The evidence highlights
that direct-to-consumer advertising (DTCA), home genetic testing (HGT), and consumer health
devices (CHD) influence patient interactions with HCPs and consumer understanding of diseases
(Aikin et al., 2016; Ding et al., 2020; Petit & Cambon, 2016; Rainone et al., 2018; Smetana et
al., 2020; van der Wouden et al., 2016). Furthermore, it is shown that marketing content strongly
influences consumer recall of drug indications, efficacy, and risks (Sullivan et al., 2015). In a
10
time when patients are more actively engaged in their healthcare and “the interaction between
physician and patients is now viewed more as a business transaction” (Stinson & Heischmidt,
2012), online reviews have become a valuable resource for both HCPs and patients (Emmert et
al., 2016; Geletta, 2018; Liu et al., 2019; López et al., 2012). Patients are exposed to ever-
increasing health-related images and information, all of which can impact PPC.
Medical Television Programming
Medical programming may be seen as entertainment for some and educational for others.
For some patients, it can create impactful impressions and influence their views and expectations
of healthcare. With the premiere of City Hospital in 1951, the genre of fictional medical
programming with the physician portrayed as the readily accessible hero was born (Painter et al.,
2020; Stinson & Heischmidt, 2012). Since the release of City Hospital, fictional medical dramas
have become a television programming staple, appealing to viewers based on the perception that
their portrayals accurately reflect reality (Haboubi et al., 2015). In time medical programming
expanded into three distinct forms, fictional, reality, and documentary. The distinction between
reality and documentary is that reality programs are scripted, cast, and edited to achieve a
specific storyline. In comparison, documentaries are filmed from numerous perspectives to gain
an unedited, factual account (VanArendonk, 2020). Numerous studies have shown that medical
programming can passively convey health knowledge to viewers and influence patients and
HCPs (Chung, 2014; Leonard et al., 2021; Painter et al., 2020).
Stanek et al.’s (2015) research into the hidden curriculum of “cultures, processes, and
structures inherent to the practice of medicine” (p. 1) depicted in medical television programs
revealed that this hidden curriculum could have a more significant impact on medical students
than the traditional curriculum. For this reason, medical schools have integrated clips from
11
popular medical dramas as part of their curriculum, especially in communication training (Gross
et al., 2012; Osborne et al., 2021; Ouellette et al., 2021; Painter et al., 2020). As a result of
restrictions on clinical rotations because of the COVID-19 pandemic, medical schools utilized
medical television to bridge the divide in clinical rotations. Osborne et al.’s (2021) study in using
medical reality programming as a teaching tool resulted in students fostering empathy after
becoming invested in the story. These programs also offer a way to present negative examples of
HCP-patient interactions in a neutral setting, allowing students and HCPs to openly discuss their
experiences in the clinical setting (Haboubi et al., 2015). While the researchers acknowledge the
potential for perpetuating unhelpful stereotypes, it was concluded that medical reality shows
could be an effective strategy for communication training, especially when students have limited
access to clinical time.
The concern of medical television programming perpetuating stereotypes is valid since
these shows may be a patient’s primary source of exposure to the medical system. Despite the
entertainment intent of medical television programming, Gross et al.’s (2012) study of physician
communication portrayals in popular medical dramas found that these shows create a robust
frame of reference to physician communication, especially in patients with limited exposure to
medicine. Numerous sources indicate that while medical television programming, both fictional
and reality, is meant solely as entertainment, they undoubtedly affect viewer’s expectations of
HCPs communication, especially examples of PPC in reality shows, patient outcomes, and health
risks (Jain & Slater, 2013; Painter et al., 2020; Stanek et al., 2015). This influence can shape how
patients interact with their HCP (Gross et al., 2012). Documentaries, in particular, allow for a
more accurate portrayal of the complexities and limitations of medicine including the lived
experiences of HCPs which are usually inaccessible to the general public (Chen & Qian, 2017).
12
Medical programming also shapes viewers’ perceptions of the demographics of HCPs. Jain and
Slater’s (2013) review of 101 episodes of medical programming found that male physicians were
represented more than females on reality shows. The researchers also acknowledged an absence
of ethnic diversity and that the gender imbalance might perpetuate a stereotype that the ideal
HCP, more specifically surgeon, is a White man. These findings were corroborated by Painter et
al. (2020) when analyzing medical drama, comedy, and reality shows for examples of PPC. They
found that “none of the television shows accurately represented the distribution of U.S.
physicians in terms of their gender, ethnicity, age, or nationality” (p. 331).
Because medical programming is so influential, it can create adverse effects on PPC.
“Given that reality shows portray purportedly real people having actual procedures with real
physicians on screen, how these physicians communicate on screen could be instrumental in
influencing viewers’ social reality perceptions regarding physician-patient communication” (Jain
& Slater, 2013). When patients see negative portrayals, such as a disrespectful or insensitive
demeanor in any type of medical programming, they can develop an adverse perception of
medical professionals or delay seeking treatment (Ouellette et al., 2021; Stinson & Heischmidt,
2012). More specifically, when patients hold high expectations of their HCP based on portrayals
seen on television, they can become dissatisfied when they do not act as anticipated (Chen &
Qian, 2017; Jain & Slater, 2013). Reality medical programming can become a double-edged
sword that provides patients with depictions of real-life interactions and awareness, but negative
portrayals can do more harm than good. Therefore, the educational value of all medical
programming is questionable.
While most HCPs feel that medical television shows have minimal educational value and
82% feel that the portrayals are unrealistic, many watch medical dramas for entertainment which
13
may or may not cause them to consciously or subconsciously reflect on their own experiences
(Haboubi et al., 2015). The validity of portrayals and health information contained within
medical shows has been the focus of numerous studies. For example, cardiopulmonary
resuscitation (CPR) is commonly depicted in medical dramas. However, the survival rates as
portrayed are grossly inflated (Chung, 2014). Heye et al.’s (2016) study found a 70% survival
rate on television programs compared to actual survival rates that range from 2 to 30%. Hoffman
et al.’s (2017) literature review of medical television programming and health outcomes
increases this divide with a 75% survival rate on television which they state is 10 times higher
than actual CPR survival rates.
CPR survival is not the only medical procedure that is often misrepresented in medical
television. Reality shows portraying pregnancy and birth are popular with women, especially
those pregnant with their first child. These shows tend to show a woman giving birth while
laying on her back, which is not typical for most women. In fact, “only 57% of women deliver in
this position” (Morris & McInerney, 2010, p. 136). The portrayal of radiology procedures in
medical dramas commonly shows patients speaking or moving during the procedure, creating a
false expectation of the procedure to viewers (Heye et al., 2016). While medical dramas and
reality shows provide inaccurate representations of medical procedures, the inaccuracies and
inadequate information delivered on medical talk shows such as Dr. Oz or The Doctors are
perhaps more disconcerting. Korownyk et al. (2014) performed an observational study of
medical talk show recommendations. They found that only 54% of the recommendations were
supported by empirical evidence, and potential conflicts of interest were disclosed less than 1%
of the time. These inaccuracies can lead to fatalistic views of healthcare (Chung, 2014), anxiety,
14
and fear in patients, which can create delays in care, mistrust of HCP, or which can result in poor
outcomes and patient dissatisfaction (Leonard et al., 2021; Morris & McInerney, 2010).
The health information shared in medical programs has been shown to raise awareness
(Heye et al., 2016), and provide information on disease states and health promotion behaviors
(Jain & Slater, 2013). However, medical dramas tend to favor unusual conditions rather than
common chronic health conditions (Chung, 2014) which is a missed opportunity to increase
health literacy on a large scale. “Health literacy refers to a patient’s capacity to obtain, process,
communicate and understand basic health information and services needed to make appropriate
health decisions” (Schillinger et al., 2017, p.1). Medical television strongly influences viewers’
perceptions of healthcare, and it is important for HCP to understand this impact (Stinson &
Heischmidt, 2012) and learn to manage expectations. Patients may expect HCPs to demonstrate
the same PPC portrayed on television, and patients may also ask for tests or treatments that they
see on television, regardless of genre. Cowley et al.’s (2017) review of medication usage in
medical dramas found that while safety checks and dosages of medications are not always
portrayed, when medications are identified, usually by generic name, the indication was accurate
70% of the time. The researchers further reported that “healthcare providers also report that
patients are often raising treatment-related issues that they have seen addressed in popular
television shows” (p. 766). This phenomenon may also be attributed to direct-to-consumer
advertising.
Direct-to-Consumer Pharmaceutical Advertising and Consumer Health Products
The United States and New Zealand are the only two countries where direct-to-consumer
pharmaceutical and medical device advertising (DTCA) is legal (DeAndrea & Vendemia, 2016;
Kornfield et al., 2015; Schaper & Schicktanz, 2018), and since then, it has become a significant
15
source of information in the United States (H. W. Sullivan & Campbell, 2015). Federal Drug
Administration (FDA) regulations allow two types of advertisements: product and help-seeking
advertisements. Product advertising carries the most stringent regulations and requires that the
prescription drug advertised includes product claims, significant side effects, and
contraindications in audio or visual form (Betts et al., 2018). On the other hand, help-seeking,
which only presents disease-related information, is not regulated by the FDA (Aikin et al., 2016;
Kornfield et al., 2015).
Between 1997 and 2016, DTCA expenditures increased from $2.1 billion to $9.6 billion
(Schwartz & Woloshin, 2019). When the FDA changed the regulations in 1997 to allow DTCA,
most of the advertising dollars were spent on television ads (Kornfield et al., 2015). While
spending for DTCA continues to increase, most of the advertising has shifted from television to
online advertising (DeAndrea & Vendemia, 2016; Kornfield et al., 2015). This shift to online
advertisements, especially on social media sites such as Facebook, has created new concerns for
the FDA and HCPs.
DTCA on social media creates a level of complexity in information regulation not seen in
print, radio, or television DTCA. Dangerous or inaccurate information from outside sources,
mainly user comments, and the ability for the pharmaceutical company to manipulate comments
to reflect only favorable ones are significant concerns (Tyrawski & de Andrea, 2015). Seventy-
five percent of adults who are online use social media frequently, and 40% use it specifically to
search for health information (Tyrawski & de Andrea, 2015). DeAndrea and Vendemia (2016)
found that:
More than 70% of Internet users seek health information online for themselves and
others; 55% of all users go online to diagnose ailments, 40% go online to seek
16
information about medical treatments, and over 15% go online to look up drugs they saw
advertised. (p. 2)
Testimonials, which make up most user-generated content, are highly influential (Tyrawski & de
Andrea, 2015). Users tend to trust comments and testimonials left on social media posts more
than traditional advertisements. There tends to be ambiguity about the affiliation of the poster or
commenter, which can influence a user’s perception (DeAndrea & Vendemia, 2016). Therefore,
the concern about DTCA on social media is warranted.
Opponents of DTCA feel that advertisements overemphasize the benefits and
deemphasize the risks of the medication. In contrast, proponents of DTCA feel that it promotes
disease awareness and patient involvement in healthcare (Tyrawski & de Andrea, 2015). While
the appeal of DTCA tends to be with people with less access to healthcare resources, research
shows that people with higher education and incomes levels are skeptical about claims presented
in DTCA. Specifically, an FDA survey revealed that 61% of people feel that DTCA does not
include enough risk information, while 44% feel that information on benefits is lacking. A 2011
National Cancer Institute study finds further mistrust with respondents feeling that DTCA
provides insufficient benefits and risk information with 46% and 52% of responses, respectively
(H. W. Sullivan & Campbell, 2015).
It is no surprise that patients are confused and seek more information, especially if the
advertisement combines both disease and product information. Aiken et al.’s (2016) study
showed that:
Researchers have found that when broad disease information accompanies or is included
in an ad for a specific drug, consumers many mistakenly assume that the drug will
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address all of the potential consequences of the condition mentioned in the ad by making
inferences that go beyond what is explicitly stated in the ad. (p. 229)
In fact, Betts et al. (2018) found that only 17% of people who see a drug advertisement seek
additional information about the medication and that emphasizing the serious and actionable
risks of the medication can help increase patient understanding of the drug’s risk statement.
Sullivan et al. (2015) note that visual presentations of efficacy data can increase patient recall of
how the drug worked and may help patients make more informed decisions.
DTCA may raise awareness of disease states and provide information on potential
treatment options; however, making an informed decision requires input from the patient’s HCP.
The HCP can provide an increased understanding of the risks, benefits, and efficacy of taking a
particular medication (H. W. Sullivan & Campbell, 2015). Research by Kornfield et al. (2015)
shows that DTCA has increased visits to HCPs and requests for specific drugs seen advertised.
However, there is little data to show that DTCA has influenced prescribing practices. “Shifts in
DTCA exposure across indications have the potential to prompt self-diagnosis and drug request
for millions of consumers” (p. 578). This trend towards self-diagnosis resulting from DTCA is
further compounded by the arrival of consumer testing kits and health monitoring devices.
Home Genetic Testing
Advances in genetics due to the Human Genome Project and the ability to obtain results
through saliva testing created a new consumer market for at-home genetic testing (HGT). HGT
emerged in the mid-2000s with an initial focus on traits such as eye color and ancestry but
quickly expanded to testing for clinically significant risk information, including breast cancer,
heart disease, diabetes, and Parkinson’s disease (Petersen & Lefferts, 2020). The rise and
accessibility of HGT prompted the FDA to investigate four HGT companies’ marketing practices
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and claims. This investigation found conflicting results, deceptive marketing practices, and
misleading results, which resulted in a cease and desist issued to one major company, 23andMe
(Nielsen et al., 2017; Petersen & Lefferts, 2020). While all HGT product companies must
comply with FDA approval, HGT marketing is riddled with ethical concerns. Schaper and
Schicktanz’s (2018) study of ethical considerations in HGT revealed that the marketing of HGT
lacks standards, is manipulative, persuasive, and contains evidence not backed by science. These
findings can be interpreted as undermining patient autonomy and ethically problematic. With
“the field projected to continue to grow at a rate of 25% annually, increasing from an estimated
$684.7 million in 2017 to a projected $6.36 billion by 2028” (Petersen & Lefferts, 2020, p. 84),
the ethical and medical concerns of HCPs and policymakers is valid. Breakthroughs in science
have benefitted the field of medicine; however, the introduction of HGT has created a new
concern for HCPs.
The first primary concern is the validity of testing. Proponents of HGT feel that
knowledge is power and knowing what could be lurking in your genetics can allow people to
change behaviors that can ultimately influence their health status. Nielsen et al. (2017) state that
HGT can be viewed as a health education tool with the potential to motivate consumers to
implement dietary and exercise changes, with 30% of study participants making dietary changes
and 26% making exercise changes based on their HGT results. However, not all patients are
encouraged by their results, with some research showing that HGT has little influence on
behavior change (Schaper & Schicktanz, 2018). Regardless, HGT can create anxiety and stress,
especially in patients who receive unexpected results or do not understand the reports provided
despite using third-party resources to interpret the data. In fact, 40% of positive results are false
positives (Petersen & Lefferts, 2020). Smetana et al. (2020) corroborate these findings stating,
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“reliability results may vary, and not all laboratories are of high quality. One study looking at
raw data files from DTC [direct to consumer] testing showed false-positive results 40% of the
time” (p. 568). Most inaccurate results occur in low-risk patients, leading to unnecessary
interventions (McDonald-McGinn, 2018). Knowing what lurks in your genetics can be helpful,
but validity concerns and the large numbers of false positives could potentially cause more harm
than good.
The fact that consumers have access to potentially powerful testing that provides
inconsistent results, incomplete information on deciphering the results, which can cause false
reassurances or undue psychological stress without prescreening genetic counseling, is the
second primary concern with HGT (McDonald-McGinn, 2018; Petersen & Lefferts, 2020). HGT
companies state that prescreening information is provided. However, this information is usually
buried in the terms and conditions statement that the consumer must check as read at the time of
purchase. There is no way to validate if the consumer has read or understood these terms and
conditions (Nielsen et al., 2017). Suppose consumers do not read the fine print. In that case, they
may not be aware of the potential risks of taking an HGT or that the test itself is not diagnostic in
nature (“Consumer Testing for Disease Risk: ACOG Committee Opinion Summary, Number
816,” 2021; Smetana et al., 2020). There are not enough genetic counselors in the United States
to support all people who take an HGT (Petersen & Lefferts, 2020). At the time of McGrath et
al.’s (2019) study, there were 4,244 genetic counselors and 1,302 geneticists in the United States.
The researchers predict that this shortage will not be resolved until 2024 to 2030. The genetic
counseling community question if interpreting HGT results is a valuable use of time and limited
resources (Smetana et al., 2020). Therefore, the onus of HGT results interpretation falls to HCPs
who feel unprepared to do so and feel that it is burdensome and out of the scope of their practice
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(McDonald-McGinn, 2018; van der Wouden et al., 2016). However, “a patient’s perception
(whether correct or incorrect) that the PCP [primary care physician] lacks competence in
genetics could also undermine their trust in their provider, which has been linked to patient
dissatisfaction” (van der Wouden et al., 2016, p. 519). Thus, it behooves HCPs to see the value
of gaining knowledge of basic genetic testing results interpretation.
Due to the rise of HGT and the shortage of genetic counselors, medical schools have
begun to incorporate genetic counseling training into the curriculum. Many HCPs who have
graduated since 2007 have some foundational training, but convincing HCPs graduating before
2007 to engage in professional development on this topic is challenging (McGrath et al., 2019).
This resistance could be attributed to mistrust of HGT, strong opinions on using HGT without
pre-testing education, or an inability or uncertainty in the integration of this information into a
patient’s medical record (McGrath et al., 2019; Smetana et al., 2020). HCPs are the best resource
for patients to interpret HGT results when a genetics specialist is unavailable and needs to be
prepared to provide that interpretation and education (“Consumer Testing for Disease Risk:
ACOG Committee Opinion Summary, Number 816,” 2021; McGrath et al., 2019). Patients may
instinctively feel the HCP’s unease with HGT because many do not share their results with their
HCP (van der Wouden et al., 2016). McGrath et al. (2019) found that only 10-20% of patients
who took an HGT shared their results with their providers. The reason for withholding this
information may vary from person to person. However, Smetana et al. (2020) note that patients
may be reluctant to share HGT results because they do not want it to become a part of their
medical record, fearing employment discrimination or inability to secure health, life, or long-
term care insurance coverage.
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HGT does pose a challenge and added complexity to care for HCPs, and can create
psychological harm to patients; however, it does provide some benefits. While all HGT results
should be confirmed at a clinical laboratory (“Consumer Testing for Disease Risk: ACOG
Committee Opinion Summary, Number 816,” 2021; Smetana et al., 2020), the results can benefit
HCPs by providing enhanced care through targeted screenings, earlier interventions (Nelson,
2018), and educational opportunities (van der Wouden et al., 2016). The research community has
also benefitted significantly from HGT. Petersen and Lefferts (2020) report that 80% of
23andMe’s customers have permitted the use of their data for research. This infusion of data has
accelerated the progress of understanding genetic diseases.
Consumer Health Devices
HGT is not the only way patients are taking control over their health knowledge. The
availability and increased sophistication of consumer health monitoring devices (CHD) have
blurred the lines between fitness products and healthcare (Petit & Cambon, 2016). Consumers
can monitor multiple health indicators through a myriad of devices, including the Apple Watch,
Oura ring, and smart scales. “In 2017, it was reported that more 100,000 mobile health apps and
≥ 400 activity monitors were available for cardiac rhythm checking or monitoring” (Boriani et
al., 2020, p. 2). Cardiac rhythm monitoring is not the only health indicator that a CHD can
measure. For example, the latest Apple Watch released in Fall 2021, which has FDA clearance,
can monitor energy expenditure, blood oxygen, heart rate, including irregular heart rhythm
notification, detect falls, and perform an electrocardiogram (ECG) (Apple Inc., 2021).
Nevertheless, it is not classified as a medical device (Falter et al., 2019). Other devices can
screen for obstructive sleep apnea and hypertension (Varshney et al., 2020). All the data
collected by the Apple Watch and other similar devices are stored within apps that provide
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immediate access to patients and can be shared with HCPs (Ho & Quick, 2018). With the myriad
of CHDs available, the efficacy of these devices is critical to understanding if patients are going
to use the information to make health decisions.
If knowledge is power, but CHDs are not considered medical devices, the question
remains if the data collected by CHD are valid. Numerous studies have tested the validity of the
cardiac monitoring, precisely the ECG capabilities, of CHD, which seems to be the most logical
feature to study since it has the most significant impact on patient outcomes. The ECG
functionality on CHD, including the Apple Watch, is based on an algorithm that interprets 30
seconds of data (Ding et al., 2020). Hahnen et al. (2020) tested the Everest smartwatch and the
Bodimetrics handheld device and found that they did not meet accuracy guidelines for blood
pressure and blood oxygen measurements. Falter et al.’s (2019) study of Apple Watch accuracy
for heart rate and ECG was found to be comparable to medical device measurements, making it
clinically acceptable. The study also tested the accuracy of the exercise expenditure and heart
rate monitoring to find that the exercise expenditure accuracy was not within the acceptable error
range, with results varying based on activity type and intensity. However, the heart rate
measurements were within the acceptable range and were best at peak exercise intensity. The
results seen with the Apple Watch can give some reassurance to those with cardiac conditions.
Not all HCPs are convinced by the accuracy of the studies, mainly because these studies
were not performed in real-world usage scenarios but in clinical and laboratory settings (Ding et
al., 2020). Those HCPs that are not huge fans of CHD claim uncertainty about the data accuracy
and cite the time needed for data interpretation and the potential need for confirmatory testing as
the reason (Ding et al., 2020). Time is not the only factor. In Boriani et al.’s (2020) study, HCPs
raised concerns about CHD most likely being used by subjects with healthier profiles.
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“According to around 65% of respondents, the potential anxiety of people who tested positive at
AF [atrial fibrillation] screening constitutes a major limitation of the use of wearables, and this
concern, including also the risks of false positives” (Boriani et al., 2020, p. 6). Varshney et al.
(2020) also raised the concern of patient misunderstanding of device alerts, a lack of a system to
share these alerts with HCPs, and the risks of increased patient anxiety and medical costs
associated with confirmatory tests that may not have a significant clinical outcome.
Cardiologists appear to be the most prominent proponents of CHD. Those HCPs in favor
of CHD find that they are trustworthy, a helpful communication tool (Holtz et al., 2019), and can
give HCPs and patients insight into health status outside of the clinical setting (Kinast et al.,
2021). Some HCPs recommend CHDs to their patients, primarily if they use CHDs themselves
(Holtz et al., 2019). In Ding et al.’s (2020) study, 62% of respondents recommend that patients
with AF use a CHD, with the Apple Watch being the second most recommended device. Despite
the clinical usefulness of CHD, there can be a financial barrier for patients resulting in the
majority of people using CHD, such as the Apple Watch, being those with lower risk profiles.
Regardless, CHD may improve outcomes in symptomatic patients, but there are concerns about
the cost of the device versus outcomes in asymptomatic patients (Varshney et al., 2020).
CHDs are yet another means of shifting the paradigm of the provider-patient relationship
by allowing patients to be more active participants in their care, increase their knowledge of their
vital signs while exercising, and make better decisions about health-related behaviors (Kinast et
al., 2021; Petit & Cambon, 2016). As with DTCA and HGT, CHD can create tension in PPC.
Patients prone to anxiety or worry may find that the data collected, or device warnings are
counterproductive to their psychological wellbeing. If these patients contact their HCP every
time the device alerts them, this could create an unproductive relationship and erode PPC.
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Furthermore, patients may begin to distrust their HCP if they are dismissed or if the diagnosis
differs from the information gathered by the device (Ho & Quick, 2018). This distrust may lead a
patient to take matters into their own hands and begin to consult online sources for information
or a new HCP.
Effects of Online Health Information, Social Media, and Provider Review Sites
There is a saying that you cannot believe everything you read on the Internet, and this
sentiment is even more true when reviewing online health information. The Internet is an
efficient means of gathering information (Bidmon & Terlutter, 2015) that allows anyone,
anywhere, to access more information than ever. However, it can be very challenging for people
to decipher truth from non-truth and navigate various shades of gray between the two. While
studies show that access to online health information fosters confidence, empowerment, and
optimism, it can also foster misunderstanding and misinformation in those with low health
literacy (Chung, 2013). This misunderstanding or misinformation is concerning to HCPs because
the Internet tends to be the first place patients go to seek health information before seeking
medical attention (Tan & Goonawardene, 2017), preparing for a visit or understanding the
information shared during a visit (Chung, 2013; Waring et al., 2018). When searching online for
health information, 77% of users begin with Google (Waring et al., 2018), generating results that
may include peer-reviewed research to health-related blogs to social media (Tan &
Goonawardene, 2017). How and where patients are gathering health information is strongly
linked to demographics.
Demographics are a clear indicator of who is looking to the Internet for health
information and what that person does with the information when seeing their HCP. The Pew
Internet and American Life Project reports that “gender is one of the most important predictors
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of seeking health information on the Internet” (Bidmon & Terlutter, 2015, p. 2), with women
more likely than men to turn to the Internet for health information (Chung, 2013). Furthermore,
while women are more likely to consult health forums and search engines, men are more likely
to utilize apps (Bidmon & Terlutter, 2015). Gender is not the only distinguishing factor in
Internet use. Other factors include health status, income, education, technology comfort,
ethnicity, and age (Chung, 2013). A 2007 study found that 75% of patients with chronic disease
use the Internet to find disease-related information, and 69% of those patients use that
information to ask their HCP questions (Hall et al., 2015). Another study by Waring et al. (2018)
revealed that 57% of patients hospitalized with acute coronary syndrome searched for health
information online within four weeks of their hospitalization.
Regarding age indicators, Hall et al.’s (2015) inquiry into older adults’ use of online and
offline sources of health information reported that respondents who rely on television or radio for
health information tend to be 75 years or older. Waring et al. (2018) confirm these findings but
point out that their research found that older adults prefer to obtain their health information from
HCPs, pharmacists, and social contacts over radio, television, print, or online sources. The
Internet has given patients a way to increase their health literacy, but only if they look in the
right places.
Online health information can allow patients to become more active participants in their
care (Chan, 2017; Hall et al., 2015; Tan & Goonawardene, 2017). The information can also be
inaccurate or harmful (Waring et al., 2018), leading to feelings of anxiety or poor outcomes
when a patient makes decisions based on wrong or incomplete information (Linn et al., 2020).
Using the Internet to inform decisions, especially concerning surgical procedures, cancer
screenings, and learning about prescribed treatments, is expected as healthcare moves from a
26
physician-reliant to a patient-reliant model (Hall et al., 2015). How an HCP reacts when a patient
shares information they have found online can impact both PPC and health outcomes. In Waring
et al.’s (2018) research into patients hospitalized with acute coronary syndrome, it was found that
one-third of patients studied had discussed the information found online with their HCP, with the
level of education as an indicator of sharing. Education level is not the only indicator. Chung
(2013) confirmed that people who had more difficulty understanding online information were
less likely to share it with their HCP. However, this research also determined that while women
are more likely to search for health information online, men are more likely to share search
results with their HCP. While many patients may feel that using the Internet to learn more about
their health does not adversely affect their relationship with their HCP (Tan & Goonawardene,
2017), this stance could change if the HCP is critical of the information presented (Chung, 2013).
HCP reaction to outside information can strengthen or weaken PPC. Given the range of
information available on the Internet, HCPs find that patients cannot always find relevant,
quality information, creating time management issues during the visit and impacting treatment
adherence and trust (Chung, 2013). These concerns are warranted. Multiple studies show that
when online health information is dismissed or misaligned with the HCP’s diagnosis or
treatment, patient dissatisfaction, mistrust, nonadherence to treatment, or future withholding of
information occurs (Chung, 2013; Linn et al., 2020; Tan & Goonawardene, 2017). However,
Waring et al. (2018) cite that this does not have to be the case:
Providers are encouraged to acknowledge patients’ desires for information, probe what
information received about their health conditions (whether it be from other healthcare
providers, the Internet, or other sources), help patients differentiate between helpful
advice, and steer towards evidence-based online resources. (p. 1979)
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HCPs can positively impact PPC and improve their relationship with patients when they
understand that patients are using online resources to enhance their knowledge and involvement
in their healthcare (Chung, 2013; Linn et al., 2020). When an HCP holds this mindset toward
online health information, there is potential for improved outcomes and better provider-patient
relationships. (Tan & Goonawardene, 2017)
Unfortunately, if a patient loses trust in their HCP, they may go back online to look for a
new provider. The emergence of physician reviews on websites such as Healthgrades and Yelp
has created an environment where patients choose medical providers based on their reviews (Liu
et al., 2019; López et al., 2012). In the United States, consumer use of physician rating websites
(PRW) doubled between 2012 and 2014 from 23% to 42% (Han et al., 2020), thus changing the
power dynamic in the provider-patient relationship (Liu et al., 2019). A study of PRW users by
Emmert et al. (2016) showed that 65% consulted an HCP, and 52% avoided an HCP solely based
on reviews. Not only are patients utilizing the Internet for health information but also for finding
a new HCP. PRW can allow patients to find HCPs in the same way they may find a plumber or
landscaper.
Physician Review Websites
Physician review websites (PRW) democratize patient satisfaction results and make this
information readily available to anyone with internet access. “The LeapFrog Group reports that
selecting the right hospital can reduce the risk of avoidable death by 50 percent” (Chan, 2017, p.
139). Most patient satisfaction data is collected through HCP-generated surveys that generally
have a low response rate making sites such as Yelp a significant source of unsolicited
quantitative and qualitative data that can be categorized by specialty (Geletta, 2018). López et al.
(2012) surmise that online reviews differ from formal surveys by providing unstructured,
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potentially anonymous information unrelated to a specific visit. Moreover, anonymity allows
patients to provide candid feedback without risking retaliation in the form of compromised care.
Low ratings were also seen when patients did not receive the treatment they expected (Emmert et
al., 2016) and for providers who accepted minimal insurance provider options (Geletta, 2018).
Liu et al.’s (2019) qualitative analysis of 806 online reviews revealed that physician demeanor
is most referred to in reviews. This research further comments that physicians can improve their
reviews and medical practices through improved bedside manner by providing clear
communication, showing empathy, or spending adequate time with the patient during the visit.
The ever-increasing competition in healthcare has put a greater emphasis on patient satisfaction
(Geletta, 2018). PRW can be a great source of information not only for patients but also HCPs.
Patient satisfaction is linked to outcomes, and there are four factors to patient satisfaction:
access, cost, availability, and quality of care (Geletta, 2018). Emmert et al.’s (2016) study of
HCP use of PRW data provides essential information on the power of PRWs to affect changes in
patient satisfaction and outcomes. They found that more than one in three HCPs know what
changes can be made to improve patient satisfaction, with 54.66% of respondents reporting that
they used PRW ratings to implement improvements in patient care. The most commonly
implemented changes were communication-related (28.77%), followed by scheduling
enhancements (23.6%). The researchers further reported that specialists, more than general
practitioners, were likely to consult PRW and that over half of HCP users read the comments for
other HCPs. “In terms of health care services, the actual plausibility of using such data for
quality measurement and comparison is an exciting development for professionals who are
involved in the evaluation of healthcare quality outcomes” (Geletta, 2018, p. 103).
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The effects of the media and consumer health products on patients are numerous. Media
portrayals of physician communication can shape a patient’s expectations of PPC and outcomes
of procedures such as CPR. DTCA may increase health literacy but can leave many patients with
an incomplete understanding of the drug’s risks and benefits. The validity of the information
provided by HGT and CHD can create anxiety rather than reassurance or fodder for informed
decision-making. Online health information adds to the confusion if patients cannot determine
which websites provide factual, peer-reviewed data. The overall effects of the media and CHD
can negatively impact PPC and, ultimately, health outcomes if a patient avoids seeking medical
attention due to unrealistic PPC expectations. However, the advent of PRW could decrease
treatment avoidance by giving patients a resource to find a new HCP based on other patients’
reviews.
Implicit Bias in Healthcare
Implicit bias is an unconscious thought or belief that creates a negative viewpoint of a
person based on specific traits such as race or gender. These implicit biases can influence a
person’s ability to perform simple tasks and can affect both patients and HCPs (Fitzgerald &
Hurst, 2017). In medical education, implicit gender bias can impact safety, the effectiveness of
care, and leadership. Even though there is an increased awareness of gender inequalities in
medical texts, implicit gender bias continues. Implicit bias of any type is perpetuated in medicine
due to the very nature of the profession. HCPs are consistently working in stressful conditions.
When a person’s stress responses are activated, they are more likely to fall victim to implicit bias
(Wilson et al., 2021). This implicit bias can lead to healthcare stereotype threat (HCST).
“Healthcare stereotype threat is the threat of being personally reduced to group stereotypes that
30
commonly operate within the healthcare domain” (Abdou et al., 2016, p. 191). Implicit bias and
HCST can prevent effective PPC, which directly impacts patient outcomes.
Implicit and Gender Bias in Medical Education
Medical textbooks shape an HCP’s learning, training, and, ultimately their approach to
patient care (Hunter, 2013). These same texts also perpetuate gender bias by favoring a standard
of male anatomy outside of specific sex-based reproductive illustrations. Dijkstra et al.’s (2008)
review of eleven textbooks recommended by two medical colleges in the Netherlands found that
gender-specific information was difficult to find, especially gender-specific considerations for
medical conditions such as depression, coronary heart disease, and alcohol abuse. This specific
information was not included in chapters dedicated to these disease states but within chapters
specific to women’s health. The consensus from their study is that “textbooks may perpetuate
gender bias, which may influence gender inequalities in health care” (Dijkstra et al., 2008, p.
1026). In a similar study of medical textbooks, Parker et al. (2018) analyzed male-to-female
image ratios while expanding the analysis scope to include the specific narratives implied by the
images. An observational pattern of bias in both images and narratives reveals an inequality of
male-to-female images, with female image narratives more likely to be in a domestic versus
occupational setting. The researchers conclude that women continue to be underrepresented in
medical textbooks creating a male standard that fosters gender bias (Parker et al., 2018). Morgan
et al. (2014) confirm that medical education lags in females’ inclusiveness in anatomy texts
outside of reproductive and gender-specific differences. In two separate studies of gender bias in
medical students, the researchers conclude that the anatomy text representation of the male as a
standard perpetuates implicit bias (Morgan et al., 2014), despite medical students becoming more
conscious of the lack of diversity and equity in medical textbooks (Morgan et al., 2017).
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Hunter’s (2013) content analysis of five popular psychopathology textbooks proved that
bias in education extends beyond gender representation. The study revealed that
psychopathology textbooks perpetuate an unproven hypothesis, fueled by the pharmaceutical
industry, that emotional distress results from biology. This perpetuation creates stigma and bias
in treating emotional distress through the overstated effectiveness of medication and understating
or omitting the adverse effects of medication seen in the textbooks used in the study. Hunter
(2013) found that “overall, the textbooks appeared to vary in the level of over bias and omission
of data. However, all textbooks had significant errors and showed an extreme proclivity toward
promoting the biomedical paradigm to the point of misinformation and partiality” (p. 164).
Gender bias in textbooks does not begin with medical texts. Becker and Nilsson’s (2021) review
of 10 college-level chemistry books found that women were represented in only 30% of the
images. Lawlor and Niiler (2020) uncovered similar representational inequalities of both gender
and race in their review of university physics textbooks. Gender bias is also present in online
science education resources at the primary school level. The impact of this bias is essential to
note as “children’s stereotype consciousness increases rapidly between ages 6 and 10”
(Kerkhoven et al., 2016, p. 2), which can shape future interest in pursuing a career in the health
sciences. Overall, the images in textbooks used throughout a medical student’s education, from
primary to medical school, create a foundation for implicit bias.
The seeds of implicit bias are sowed early in an HCP’s training. Students rely on
textbooks and their educators for their medical education. When these resources provide
misinformation, biases are created, leading to students becoming HCPs who cannot create an
empathic and therapeutic bond with their patients leading to poor outcomes (Hunter, 2013).
These biases created in the classroom continue into residency, where medical students learn how
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to create cognitive shortcuts that allow them to quickly interpret and categorize data to make
quick decisions and foster implicit bias (Sherman et al., 2019). An example of a cognitive
shortcut, also called a heuristic, can be if an HCP has seen several patients that week with fever
and chills and ultimately have positive influenza tests. They may automatically diagnose the next
person they see with the same symptoms as having influenza. Addressing implicit bias early in
medical training is essential (Wilson et al., 2021) to help dismantle structural racism in
healthcare by giving HCPs actionable skills to address implicit bias in their work and personal
lives (Sherman et al., 2019). In medical training, reducing HCST is imperative to decreasing the
racial divide that exists in healthcare. As first studied in academic environments, the effects of
stereotype threat can be linked to a lack of minority representation amongst HCPs. Strategies are
needed to reduce stereotype threat in the MCAT and USMLE tests and create safe environments
that foster dialogues between White and minority medical students (Burgess et al., 2010).
Addressing implicit bias and stereotype threats in medical school before entering the stress of
residency and clinical practice is essential (Wilson et al., 2021), as individual and organizational
biases can perpetuate health disparities (Sherman et al., 2019). Implicit bias, left unchecked, can
become part of the organizational culture.
During residency, new HCPs integrate what they learned in the classroom and internships
into clinical applications and learn the organizational hierarchies of practicing medicine. Hansen
et al.’s (2019) survey of implicit gender bias in Emergency Medicine and Obstetrics/Gynecology
residents determined the existence and ramifications of bias in leadership and patient care. The
results point toward a bias that favors men as leaders, which leaves female residents feeling
stressed when directing care in critical situations such as CPR. Hansen et al. (2019) conclude that
when gender bias occurs in medicine, the safety and effectiveness of patient care suffer. These
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results prove that implicit gender-based bias begins in residency by fostering a viewpoint of men
as leaders. “There is no single magic bullet approach that would eradicate implicit bias;
residencies need to cultivate learning communities where difficult issues like implicit bias will
be openly discussed” (Sherman et al., 2019, p. 679). When these communities are created, all
patients will benefit, and predominantly these benefits will be realized most by minority and
female patients.
Implicit Bias in Women’s Health
Implicit gender bias creates health disparities in women. “Gender bias is defined as the
unintended and systematic neglect of women in healthcare and may take the form of discounting
women’s symptoms, medical concerns, and personal preferences” (Mattocks et al., 2020, p. 114).
Chapman et al. (2013) state that “implicit bias occurs without conscious awareness and is
frequently at odds with one’s personal beliefs” (p. 1504). They further explain that implicit bias
results from an evolutionary effect of the human ability to synthesize information for decision-
making. HCPs exhibit implicit gender-based bias placing women in a vulnerable patient
population. There is evidence of bias in nearly all studies reviewed in Fitzgerald and Hurst’s
(2017) review of implicit bias in healthcare professionals. The level of these biases strongly
correlates with the provider’s socio-demographic status, including their gender, race, and country
of medical training.
The time between the initial presentation of symptoms and definitive diagnosis is critical
to favorable patient outcomes; however, gender bias can create significant delays for women.
These delays can increase morbidity and mortality in women. Colella et al.’s (2015) meta-
analysis of sex bias in cardiac rehabilitation referrals reports a significant disparity in physician
referrals for female patients, a population at higher risk of death within one year of an acute
34
cardiovascular event, by an average of 39.6%. Delgado et al. (2016) reveal a similar bias in
diagnosing chronic obstructive pulmonary disease (COPD) through spirometry, the standard test
for diagnosing COPD. While there is a difference between female and male family physicians
(FP), “a gender difference of 34.5% when the FP was female and 20.7% when the FP was male”
(Delgado et al., 2016, p. 93) proves that women are diagnosed with COPD less frequently than
men. Shorter diagnostic intervals are critical for all diseases, especially in the successful
treatment of cancer. In a study of gender-specific inequalities in cancer diagnosis, Din et al.
(2015) uncovered inequalities in six of the 15 cancers studied with longer diagnostic intervals
associated with age, gender, and symptomology resulting in higher staged cancer diagnoses with
increased treatment complexity. The divide between male and female HCPs and female patient
outcomes is seen in diagnosing and treating COPD, cancer, and mental healthcare. A study by
Mattocks et al. (2020) revealed that female veterans felt more dismissed by male HCPs than
female HCPs. The study also reported that women with a mental health diagnosis comorbidity
were more likely to have their symptoms misattributed to that mental health condition. That
those women in the study “felt that their health complaints were often ignored or chalked up to
hormonal status, or that they were given labels such as ‘hysterical female’ owing to the way they
were experiencing symptoms” (Mattocks et al., 2020, p. 117). This notion of the hysterical
female is also seen in a 2018 study of chronic pain that showed women’s pain was not taken as
seriously as men’s, stating that women were “more easily dismissed as oversensitive or
hysterical” (Saini, 2020, p. 1605). This dismissal of female patients’ symptoms can delay the
determination of a definitive diagnosis.
The most significant effect of gender bias on women’s health is the diagnosis of non-
specific, functional, and somatoform (NFS) syndromes, a diagnostic term used for symptoms not
35
medically explained. Claréus and Rentröm’s (2019) study on the effect of physician gender bias
and NFS diagnosis on provider-patient relations, a critical aspect of favorable patient outcomes,
postulate women are diagnosed with NFS three times more often than men because of gender-
related bias. Their results support the “prevalence of a stereotype that women’s pain is likely to
be medically unexplained” and that the “stereotype could impact diagnostic assessment in
women with pain” (Clareus & Renstrom, 2019, p. 344). The researchers further comment on the
effect of an NFS diagnosis on future physician-patient relations, treatment, and future diagnoses.
They found that stereotypes of symptoms related to a socio-cognitive or psychological nature
may persist even if the NFS diagnosis is revised or the patient presents with new symptomology.
This retention of stereotypes creates a healthcare inequality that impacts a female patient’s
access to unbiased healthcare creating gender-based health disparities.
The intersectionality of female gender and race can be attributed to even more concerning
health disparities in Black women because of HCST. Fitzgerald and Hurst’s (2017) study showed
that those most vulnerable to bias and subsequent adverse outcomes were those patients who
experienced more than one type of bias, such as Black women. Despite socioeconomic status,
access to healthcare is a significant cause of health disparities in Black women, directly resulting
from anxiety and fear of being treated differently in a healthcare setting, which is a direct result
of HCST (Abdou & Fingerhut, 2014). The fear Black women feel can be validated by the
findings of a 2000 survey of physicians referenced by Abdou and Fingerhut (2014) that found
that physicians felt less affiliation with Black patients than White patients. Therefore, HCST can
explain the persistent health disparities in female patients and across diverse patients of various
positionalities and intersectionalities. Implicit and gender bias begins early in education and can
have a ripple effect throughout an HCP’s career, especially in PPC.
36
Health Care Stereotype Threat in Healthcare
PPC is the foundation of trust and safety between the HCP and the patient. PPC quality
can directly influence the quality of care, patient comprehension of diagnosis and treatment,
overall patient satisfaction and health outcomes, and may decrease hospitalizations through
improved chronic disease management (Wilson et al., 2021). However, HCST can create anxiety
attributed to resistance to, avoidance of, or underutilization of care and impair cognitive
functioning, which is linked to treatment adherence and overall outcomes (Abdou et al., 2016).
“Healthcare disparities have been demonstrated across numerous disease states and minority
groups” (Daugherty et al., 2019, Discussion section). Suppose patients are not seeking medical
care or fostering an effective relationship with their HCP because of HCST. In that case, health
disparities will continue in vulnerable populations, including minorities, older adults, and
LGBTQ+ (Abdou et al., 2016), and have a downstream effect on morbidity and mortality rates in
Blacks, Latinx, and the Indigenous (Wilson et al., 2021).
Ethnic identity is comprised of many factors, all of which contribute to health outcomes
(Abdou & Fingerhut, 2014). In dermatology, there is a strong racial divide between Black
patients and the predominantly White medical specialty. Only 3% of dermatologists in the
United States are Black, which leaves Black patients at a disadvantage in finding an HCP with
specific knowledge of the differences in Black skin and hair needs (Wilson et al., 2021). While
Black skin and hair require a different approach to care, there remains an erroneous belief among
HCPs-in-training that Blacks have innate biological differences (Abdou, 2017). This erroneous
belief persists regarding pain tolerance, despite Jennie Joseph’s work proving that increasing the
standard of prenatal care for Black women decreased mortality rates (Saini, 2020). Improving
maternal mortality rates in Black mothers is not the only area of opportunity for improved health
37
outcomes; hypertension has a higher incidence in Black patients, which could be attributed to the
stress caused by stereotype threat. HCST may impede communication because of increased
stress, which creates low patient engagement in care and adherence to treatment, creating a
feedback loop of poor health outcomes due to HCST necessitating interventions to improve
treatment adherence (Daugherty et al., 2019). HCST may also be attributed to increased white
coat hypertension. White coat hypertension is defined as elevated blood pressure readings at the
clinic, which are not seen outside of the clinical setting and can lead to a misdiagnosis of
hypertension, thus resulting in overmedication (Terracciano et al., 2014).
Healthcare Stereotype Threat and Stigmatized Populations
HCST can be experienced simultaneously by various identities and could be one of the
most overlooked reasons for health disparities in minority and stigmatized populations (Abdou et
al., 2016). Specifically, the LGBTQ+ population can experience HCST from multiple avenues,
such as gender, sexual orientation, and ethnicity/race, both individually and simultaneously.
While strides have been made in equal care for all patients, there may still exist subtle
unconscious homophobia in healthcare that prevents LGBTQ+ patients from seeking medical
care or not disclosing their sexual or gender identity with their HCP. A 2013 study shows that
due to HCST, 10% of gay men, 12.9% of lesbian women, 39.3% of bisexual men, and 32.6% of
bisexual women are hesitant to “come out” to their HCP (Fingerhut & Abdou, 2017). This
avoidance or disengagement with healthcare is particularly alarming regarding mental health
treatment.
Ojeda-Leitner and Lewis’ (2021) assessment of HCST in mental health treatment of the
LGBTQ+ population confirmed that LGBTQ+ patients delay seeking mental health services due
to previous discrimination and are fearful of communicating with their HCP if HCST is
38
perceived. The study further revealed the detrimental effects of untreated mental health, with an
estimated 37% to 50% of the gay and lesbian population and 39% of the transgender and
nonbinary population experiencing psychological symptoms (Ojeda-Leitner & Lewis, 2021).
Unfortunately, stereotypes of gay men being effeminate and lesbian women being masculine can
influence how an HCP treats a patient by making uninformed assumptions about that patient
(Fingerhut & Abdou, 2017). Some mental health providers may still hold a misconception that
sexual identity is the reason for the mental health disorder (Ojeda-Leitner & Lewis, 2021).
“Stereotype threat may impact the working relationship a client might have with their provider
by contributing to the avoidance of services, inhibition of communication between client and
professional, and nonadherence to treatment plan” (Ojeda-Leitner & Lewis, 2021, p. 254). Since
stereotype threats are established within the environment, not the individual (Ojeda-Leitner &
Lewis, 2021), those impacted by HCST may avoid the environment where the threat directly
occurs, leading to poorer outcomes (Fingerhut & Abdou, 2017).
Further building upon the identities that can be impacted by HCST either alone or
simultaneously, the rise of age-related stereotype threat has created challenges in reproductive
health and, most recently, the care of older individuals during the COVID-19 pandemic. Age-
based HCST can be seen in the physical environment or culture of both the patient and HCP,
resulting in tension within PPC (Abdou, 2017). An overreliance on age as a clinical indicator
creates an HCST that negatively impacts patient outcomes (Maxfield et al., 2021). More
specifically, HCST has been shown to increase blood pressure, which can impact pregnancy
(Abdou, 2017). In reproductive medicine, which as of 2017 remains a male-dominated specialty
with 64% of practicing obstetricians being men, age-based HCST creates undue physical and
psychological distress for women. This distress results in higher incidences of postpartum
39
depression, which can subsequently affect the child with effects that cascade down through
subsequent generations (Abdou, 2017). While the increased maternal-fetal risk in women over
age 35 is clinically valid, each woman’s fertility and ability to have a successful pregnancy are
unique, and age is not necessarily the only determinant of a healthy pregnancy in advanced
maternal age (Abdou, 2017).
The same oversimplification of health determinants based on patient age has been
especially prevalent during the COVID-19 pandemic. The most common HCST in older adults is
poor physical health due to higher incidences of comorbidities and cognitive decline, which
placed older patients in a high-risk group that was correlated with poorer COVID-19 infection
outcomes (Maxfield et al., 2021). “Age-related stereotypes and judgments during the pandemic
are particularly visible and include media narratives appearing to reflect an attitude of
‘disposability’ of older adults” (Maxfield et al., 2021, p. 573), which was not true for all older
adults diagnosed with COVID-19. A 2014 study suggests that age-based HCST further
compounds other areas of stigmatization, such as ethnicity, race, sexual orientation, and
socioeconomic status (Abdou, 2017). The COVID-19 pandemic amplified this, with one-third of
adults over the age of 50 worrying about being judged by their HCP because of their age
(Maxfield et al., 2021). Fear of stigma is a recurring theme in why patients avoid or disengage
from medical care (Fingerhut & Abdou, 2017). Understanding and addressing the effects of
implicit bias and HCST on PPC is needed to improve health disparities. Implicit bias and HCST
can create significant barriers to favorable patient outcomes that effective PPC can mitigate.
Implicit Bias, Health Care Stereotype Threat, and Provider-Patient Communication
Both patients and HCPs can feel the effects of implicit bias and HCST. Implicit bias and
stereotype threat are barriers to effective PPC and the ability to increase patient’s perception of
40
care, treatment compliance, and outcomes (Chisolm-Straker & Straker, 2017). There are two
aspects of PPC that influence rapport and trust - interpersonal communication, which focuses on
relationship-building, and instrumental, which focuses on exchanging information between the
patient and HCP (Li et al., 2017). Both aspects of PPC are impacted if one or both parties feel the
effects of implicit bias or HCST. Patients are not the only people who experience implicit bias
and stereotype threats. A study by Burgess et al. (2010) reported that White HCPs experience a
stereotype threat of being White racists, creating anxiety and cognitive impairment issues when
treating Black and Latino patients. This stereotype threat may cause them to have difficulty
communicating, impair diagnostic decision-making, and appear distant or fidget during the visit,
which may inadvertently confirm the stereotype (Burgess et al., 2010). White HCPs are not the
only ones who feel the pressure of implicit bias and stereotype threat. “Black providers live in
the same radicalized, prejudiced, discriminatory and racist society as another provider; they too
are trained in a medical system with racist powers in place” (Chisolm-Straker & Straker, 2017, p.
46). Because Black providers can feel the effects of implicit bias and HCST from both the HCP
and patient perspective, the cumulative effect can impact PPC, patient perception of care,
compliance with treatment, and ultimately outcomes (Chisolm-Straker & Straker, 2017). The
result of this stereotype threat is that minority HCPs, which currently make up 6% of physicians
in the United States, can fall victim to HCST, which can influence the recruitment and retention
of minority HCPs (Burgess et al., 2010).
The recruitment and retention of minority HCPs are essential for making strides in
marginalized patient outcomes. It has been shown that patients treated by a race-concordant HCP
have better PPC, which leads to increased satisfaction, treatment adherence, and outcomes
(Palmer Kelly et al., 2021). Studies show that Black and Latinx women are at greater risk for
41
mortality due to breast cancer (Li et al., 2017; Molina et al., 2014; Palmer Kelly et al., 2021).
Black patients overall feel mistrust of the medical community due to historical trauma and
perceived discrimination (Cuevas et al., 2016; Li et al., 2017; Palmer Kelly et al., 2021). The
challenges to PPC in marginalized populations go beyond outer appearances. Further
complicating matters are language barriers between the HCP and the patient. “Approximately
one in five people in the USA speaks a language other than English at home” (Diamond et al.,
2019, p. 1591). Language barriers and limited English proficiency create barriers to health
literacy, patient involvement in their treatment decisions, treatment adherence, and health
outcomes (Diamond et al., 2019; Molina et al., 2014; Palmer Kelly et al., 2021). While
interpreters can help bridge the language gap, interpreters are not always available or cannot
effectively interpret medical jargon into lay terms, thus compounding the effect of the language
barrier and creating adverse outcomes, including nonadherence to treatment (Molina et al., 2014;
Palmer Kelly et al., 2021). Race and language concordance in healthcare can potentially reduce
feelings of HCST in addition to removing language and cultural barriers. Patients who prefer
race-concordant HCPs find the HCP more communicative (Cuevas et al., 2016) and have a
positive patient-HCP relationship (Palmer Kelly et al., 2021). Diamond et al. (2019) reported
reduced health disparities and greater autonomy in patients treated by HCPs fluent in their native
language.
Society is becoming increasingly ethnically diverse, with patients potentially holding
multiple marginalized identities, including race, gender, sexual orientation, and disability
(Palmer Kelly et al., 2021). HCPs need to acknowledge the impact of historical biases and
stereotypes to prevent discounting tensions and power dynamics (Chisolm-Straker & Straker,
2017). The interplay of culture and identity creates complexity and an opportunity for HCPs to
42
focus on cultural consciousness to enhance patient relationships (Palmer Kelly et al., 2021). This
interplay is seen in Li et al.’s (2017) study of the relationship between PPC and quality of life in
Black cancer patients. The research revealed that patients who feel more comfortable asking
questions have an overall better physical and mental quality of life. Palmer Kelly et al. (2021)
expand on this research by reporting that “a shared language and the incorporation of a patient’s
social network (e.g., family members and other influential community members) have been
shown to mitigate racial and ethnic treatment disparities” (p. 7201).
Unconscious social bias is one of the leading causes of health disparities (Byrne &
Tanesini, 2015). However, these biases are the byproduct of an evolutionary mental shortcut that
historically ensured man’s survival by allowing for quick decisions about the safety of situations
based on historical data (Marcelin et al., 2019). Research has shown that people can have low
levels of explicit bias but high levels of implicit bias (Byrne & Tanesini, 2015) based on a us
versus them thought process (Jensen, 2014). Since implicit bias is like a habit, dismantling them
will require sustained cognitive interventions (Jensen, 2014; Marcelin et al., 2019). The practice
of medicine in and of itself relies on the HCP’s decision-making skills. The learning associations
and mnemonics HCPs rely upon for decision-making can inadvertently reinforce implicit biases
or stereotypes and lead to missed diagnoses when the HCP focuses more on the association than
the physical exam or patient history (Abdou & Fingerhut, 2014; Marcelin et al., 2019). These
implicit biases are more prominent when the HCP is under stress, physically tired, or suffering
from decision fatigue (Byrne & Tanesini, 2015). When the HCP is overbooked or running behind
schedule, patients may have longer wait times and feel rushed and unheard in the exam room,
and in the case of patients with marginalized identities can interpret this as a form of
discrimination (Cuevas et al., 2016; Palmer Kelly et al., 2021).
43
Implicit bias is present in all people; however, social and educational cues can perpetuate
negative biases. While multiple studies show that women have better outcomes when treated by
female HCPs (Abdou, 2017) and women outnumber men in first-year medical school classes,
gender disparities in healthcare persist (Marcelin et al., 2019). Since the practice of medicine
relies on the HCP’s ability to make numerous decisions per day, implicit bias can be seen as an
occupational hazard. However, through training and dedication to cultural competency, implicit
bias can be recognized and mitigated (Marcelin et al., 2019). When an implicit bias is recognized
and mitigated, health disparities can be narrowed (Abdou, 2017). Patients who do not feel the
effects of implicit or HCST may experience more effective PPC and better outcomes.
Healthcare Provider-Patient Communication
Communication is the foundation for all relationships, especially one between an HCP
and a patient. Research shows that communication, especially at the time of diagnosis (Polonsky
et al., 2017) can impact therapeutic alliance, shared decision-making, treatment adherence, and
patient outcomes (Lackner et al., 2020; Lederer et al., 2015; Seljelid et al., 2020). For patients,
“the perceived difficulty of discussing problems and feeling understood by the health care
provider may well reflect a lack of time in the consultation, or lack of communication training of
the health care providers.” (Bo et al., 2014, p. 10). Time and communication training are two of
the many potential barriers to effective PPC. Other potential barriers include a patient’s health
literacy level and ability to recall information that can impact their ability to engage in shared
decision-making. However, the literature states that supplemental written information and patient
web portals can help remove these barriers. “Benefits to patient-provider communication from
using secure messaging have also been reported in terms of assisting patients in self-management
of illness and improving health outcomes” (Seljelid et al., 2020, p. 2). The increased utilization
44
of telemedicine has highlighted gaps in legal, ethical, and HCP education. Increasing patient
outcomes and provider job satisfaction through more effective PPC involves considering many
known and unknown areas that impact the provider-patient relationship.
Healthcare Provider Communication and Patient Outcomes
Since PPC is the foundation of the provider-patient relationship, it is crucial to
understand how communication has changed over time. Butalid et al.’s (2013) study of changes
in doctor-patient communication between 1977 and 2008 found that communication has shifted
from psychosocial to task-oriented. This change in communication patterns can be attributed to
time pressures (Chevalier et al., 2020; Moore et al., 2017). “Time pressure for providers is a big
issue quoted by 53% of physicians” (Jolles et al., 2012, p. 6). According to Peregrin (2014), the
average patient visit is eight minutes long, yet other research shows that about 13 to 18 minutes
is the average (Caldwell et al., 2017; Howe et al., 2019; Neprash et al., 2021) with one study by
Lafata et al. (2016) reporting an average of 27 minutes for primary care visits. Regardless, the
HCP must quickly establish rapport as soon as the visit begins. This attempt at establishing
rapport, but also maximizing their time, is usually by asking how they can help, to allow the
patient to feel that they will be heard (Peregrin, 2014). “An analysis of 392 videotaped primary
care office visits, physicians were found to discuss a median of six topics with 15.7 minutes per
visit translating to a median of 5 minutes spent on the major topic of the visit” (Caldwell et al.,
2017, p. 66). These discussions are occurring as the HCP is performing the exam and documents
their findings.
Perhaps one of the most significant shifts in healthcare delivery is the implementation of
electronic medical records (EMR). Paper files have been replaced by computers or tablets in the
examination room, creating a diversion for the HCP (Lafata et al., 2016). The amount of
45
documentation required by the EMR software can potentially add significant administrative time
to the visit, further compounding time pressures felt by HCPs (Lafata et al., 2016; Neprash et al.,
2021). While EMRs guide the HCP through prompts to aid in patient information gathering,
these prompts may do more harm than good. Lafata et al. (2016) found that relying on EMR
prompts rather than engaging in conversation during the patient history portion of the visit can
create missed information-gathering opportunities and result in patients receiving less
preventative health services. EMRs have not only impacted the HCP workflow but also patient
satisfaction. When the HCP reviews or inputs patient information into the EMR, their attention is
diverted from the patient. Breaking eye contact and taking notes can decrease a patient’s feeling
of safety (Parnas & Isobel, 2018). Patients report lower satisfaction when the HCP spends more
time during the visit looking at the computer than the patient (Chan, 2017; Lafata et al., 2016).
HCPs are feeling pressured by time and documentation requirements. Patients can
perceive this pressure in their HCP through their posture, vocal tone, or volume (Parnas &
Isobel, 2018) thus impacting PPC. These perceptions are individual to each patient and are
shaped by education, culture, income, and previous encounters with the healthcare system (Chan,
2017). A patient’s perception of their HCP can influence trust and satisfaction with their provider
and the amount of time they feel was spent in the examination. Patients satisfied with their HCP
may perceive the visit to be 5 minutes longer than the actual length (Howe et al., 2019). While
longer visits are correlated with increased trust and patient satisfaction, HCP bedside manner
may be more important than how long they spend with the patient (Howe et al., 2019; Neprash et
al., 2021).
With the time pressure felt by HCPs and the information needed to be conveyed in that
short amount of time, it is no wonder that patients may feel uncertain about their treatment.
46
“Given the limited time for face-to-face consultations, health care professionals and patients
experience considerable challenges in setting priorities to address clinical concerns” (Das et al.,
2015, Introduction section). While verbal communication is essential, written communication
can enhance information comprehension and recall (Jolles et al., 2012). Patients with chronic
conditions are challenged to communicate effectively with their HCP and understand health
information (Seljelid et al., 2020). Health literacy can be a significant barrier to PPC and
favorable patient outcomes.
Health Literacy and Shared Decision-Making
Health literacy may be why some patients struggle to communicate effectively with their
HCP or understand their treatment. Low health literacy is associated with poor treatment
adherence (Barriere et al., 2019) and increased hospitalizations, morbidity, and mortality rates
(Bo et al., 2014). In a study by Lederer et al. (2015), one-third of chronic kidney patients solely
relied on their HCP for information, but 28% of patients did not understand the information
provided. Another study by Langewitz et al. (2015) found that 87% of patients want to know all
the information about their diagnosis and treatment. Only 9% preferred the HCP to determine
what information was most important to know (Langewitz et al., 2015). Education level, rushed
visits, and medical terminology not translated into a common language contribute to low health
literacy (Bo et al., 2014; Lederer et al., 2015). Jolles et al.’s (2012) study of communication in
hypertension care found that patients with higher socioeconomic status tend to receive more
information from their HCP and have greater involvement in their care. The same study also
found that “47% of patients without a college degree versus 14% with a college degree said that
they had an incomplete understanding of the information” (Jolles et al., 2012, p. 9).
47
Health literacy can be measured by a patient’s ability to engage with their HCP and
understand their diagnosis and treatment protocol (Bo et al., 2014). However, provider-driven
education is limited because it relies on the patient to consume the information rather than
eliciting an exchange of information between the HCP and the patient (Lederer et al., 2015). This
exchange of information, effective PPC, and clarification of treatment protocol can decrease
patient anxiety, increase treatment adherence (Barriere et al., 2019), and influence health
outcomes on both a medical and psychosocial level (Underhill & Kiviniemi, 2012). One size
does not fit all when it comes to PPC (Barnes et al., 2016). PPC can leave patients in the position
of a bystander in their healthcare (Lederer et al., 2015) and increase the probability of treatment
discontinuation due to a lack of information or a patient’s misunderstanding of the treatment
protocol (Barriere et al., 2019). However, when patients are given additional information about
their treatment and thus feel more informed, they are more likely to initiate or continue treatment
(Calderon et al., 2015). When patients are more informed, they can become active participants in
their care through shared decision-making.
Shared Decision-Making
Patients who are involved in making health decisions have better health outcomes, but
they need to have a baseline level of understanding of their medical status to make those
decisions (Barnes et al., 2016). Forty-seven percent of patients do not ask questions because they
lack knowledge of the disease (Lederer et al., 2015). Shared decision-making (SDM) is a
component of a therapeutic alliance (Underhill & Kiviniemi, 2012) that is more than the HCP
presenting options to the patient, requiring a dialogue between the HCP and the patient (Seljelid
et al., 2020). That dialogue establishes trust within the patient, hence allowing them to share their
symptoms, treatment preferences, and expectations, creating positive behavioral, psychosocial,
48
and lifestyle effects in chronic disease patients (Seljelid et al., 2020). As previously mentioned,
some patients struggle with low health literacy, which can impede SDM.
Studies show that the amount of information given to a patient during a visit can exceed
their recall capacity but providing written information can increase recall and comprehension
(Langewitz et al., 2015). Information presented at the beginning and end of the visit is more
clearly recalled than information presented in the middle of the visit (Jolles et al., 2012).
Providing supplemental written information can also increase health literacy, SDM, and
treatment adherence (Jolles et al., 2012; Langewitz et al., 2015). Specifically, the most effective
written information is that which is tailored to the patient’s specific treatment protocol
(Langewitz et al., 2015) and written in the patient’s preferred language (Chan, 2017). Health
literacy and information recall are barriers to SDM. Secure messaging on patient web portals can
bridge the gap and help increase treatment adherence and patient outcomes.
Patient Web Portals
Patient web portals (PWP) allow patients to view summaries of past visits, make an
appointment, request prescription refills, and send secure messages to their HCP. The secure
messaging feature is one meaningful way to bridge the gap in PPC between visits by facilitating
easy communication between patients and HCPs (Caldwell et al., 2017). Nevertheless, it is
underutilized (Chan, 2017). The adoption of PWP has increased rapidly. In the United Kingdom,
in less than two years, between April 2014 and February 2016, patient access to online medical
records increased from 3% to 97% (Neves et al., 2018). PWP is linked to patient empowerment,
improved healthcare delivery, improved outcomes in chronic care patients (Niazkhani et al.,
2020), increased healthcare utilization, treatment adherence, and health literacy (Schillinger et
al., 2017). Patients report higher satisfaction and better continuity of care (Neves et al., 2018)
49
and decreased reports of depression due to increased emotional support (Seljelid et al., 2020).
HCPs report decreased outpatient and urgent care visits (Hogan et al., 2018). Schillinger et al.’s
(2017) study of secure messaging on PWP found that most messages sent by patients through
PWP, 22%, are for prescription refill requests; this is followed by appointment requests (21%),
information clarification (16%), medical guidance (14%), and, finally, paperwork requests
(13%). A similar study by Hogan et al. (2018) revealed that of the 711 messages coded within
their study, 52.5% were sent by the patient and 47.5% by the clinic.
The benefits of PWP and secure messaging are not only for patients. HCPs report a
greater ability to gain a holistic view of a patient, which allows for a more tailored approach to
care that is not possible in the short timeframe of a face-to-face visit (Das et al., 2015; Seljelid et
al., 2020). PWP allows patients to share symptoms, medication use, adverse effects, and other
information between visits allowing the HCP to perform real-time monitoring (Caldwell et al.,
2017). This type of monitoring allows HCPs to provide nontraditional yet clinically valuable care
(Das et al., 2015). Because the information is shared through messaging, patients can take their
time formulating questions (Hogan et al., 2018) and can share information they find challenging
to do in a face-to-face visit (Das et al., 2015). Prompt responses to patient concerns by the HCP
or clinic staff can improve treatment adherence and outcomes (Caldwell et al., 2017). However,
Hogan et al. (2018) found that 25.4% of messages from the clinic appear rushed.
Patient-centered communication is an essential component of relationship building and
can improve patient participation in care, treatment adherence, and outcomes (Hogan et al.,
2018). Secure messaging is a tool, but the same tenets of patient-centered communication used in
face-to-face encounters apply (Alpert et al., 2021) especially given the challenges of the inability
to decipher vocal tone or body language (Hogan et al., 2018). Despite the benefits of PWP, there
50
have been significant barriers to adoption in both patients and HCPs. For patients, the main
barriers are limited access to technology and health literacy (Niazkhani et al., 2020). Lack of
access to the Internet or inability to navigate the portal is a significant barrier for patients,
especially older patients (Caldwell et al., 2017). Schillinger et al. (2017) report low health
literacy, which is linked to poor PPC and treatment adherence, as another significant barrier for
patients.
While the barriers to patient adoption of the PWP are important, the barriers for HCPs are
perhaps more crucial to the efficacy of secure messaging as a means of increasing PPC. HCPs
report that the primary barrier to PWP adoption is workload concerns, followed by patient
privacy, reimbursements, and relationships with patients (Niazkhani et al., 2020). By far,
workload demands are the most pressing concern for HCPs who already feel they are working
within tight time constraints (Caldwell et al., 2017; Das et al., 2015). “The professionals had
difficulties in justifying the use of a work tool that did not give the clinic income because, in the
end, their occupational behavior depends on giving the clinic sufficient earnings” (Das et al.,
2015, Discussion section, Implications). Until workflow and reimbursement barriers are
overcome, full adoption may not be possible, despite the benefits that PWP and secure
messaging have on patient outcomes. Prior to the COVID-19 pandemic forcing shifts in
healthcare delivery, providing care via telemedicine came up against the same workload,
security, and reimbursement issues as interacting with patients through secure messaging.
Telemedicine
Telemedicine is the delivery of care via telephone, or video conferencing software and
has grown in utilization due to the COVID-19 pandemic. Historically there have been concerns
with providing care in this manner, including the ability to do a comprehensive exam, legal,
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privacy, reimbursement, and access issues (Balestra, 2018; Contreras et al., 2020; Gopal et al.,
2021; Nittari et al., 2020; Siew et al., 2016). However, HCPs and patients have found that
telemedicine has merit (Contreras et al., 2020; Tolia et al., 2017). Prior to the COVID-19
pandemic, direct-to-consumer telemedicine services were exposing a gap in healthcare services,
creating a gap in efficacy data between in-person care and telemedicine (Akhtar et al., 2018). It
is estimated that telemedicine saves the patient an estimated $48,000 in time and travel costs
(Blue et al., 2020) and can alleviate overcrowding in emergency departments (Tolia et al., 2017).
“Many visits to the emergency department (ED) are driven by doctors’ offices being closed and
patients’ lacking access to other providers” (Akhtar et al., 2018, p. 790). This lack of access to
other providers due to the HCP’s office being closed or the inability to get an appointment
redirects patients with non-emergent concerns, such as a sore throat, to the ED. Some EDs have
found that utilizing telemedicine in the triage area allows more non-emergent patients to be seen
more quickly, thus increasing throughput time and decreasing overcrowding (Tolia et al., 2017).
Perhaps one of the most significant benefits of telemedicine, which became more
apparent during the height of the COVID-19 pandemic, is the ability to expand services areas,
especially in rural areas, expedite care, and decrease patient volumes at the clinic (Contreras et
al., 2020). The decreased lag time to get care through increased utilization of telemedicine did
not impact patient satisfaction. In fact, one study showed a 95% patient satisfaction rate with
their telemedicine visit (Blue et al., 2020). Patients are not the only beneficiaries of telemedicine.
HCPs find that providing care via telemedicine allows them more time to prepare for the visit,
which may increase patient satisfaction because the patient feels less rushed (Gopal et al., 2021).
Observation is one of the most important tools for providers. Providing care via video
conferencing allows the HCP to have sustained eye contact with the patient, which results in a
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greater ability to read the patient’s facial expressions (Begasse de Dhaem & Bernstein, 2020).
Telemedicine can also afford the HCP a glimpse into the patient’s living environment, which is
not possible in an in-person visit (B. Walker, personal communication, July 24, 2020). From an
organizational perspective, telemedicine is a cost-effective staffing solution for EDs. It allows for
the quick and easy addition of medical staff during periods of high patient volumes (Tolia et al.,
2017).
The benefits to the HCP, patient, and healthcare organization are important, and barriers
exist for all three of these stakeholders. Perhaps the most critical barrier to address is the legal
and ethical considerations of providing care via telemedicine. Before the COVID-19 pandemic,
differing state requirements, especially for advanced practice practitioners such as nurse
practitioners, created confusion and legal concerns in delivering care to patients who may not be
located in the HCP’s state (Balestra, 2018). The limitations, inconsistencies in diagnosis, the
potential for misdiagnosis, and the potential for malpractice claims are also valid legal and
ethical concerns (Nittari et al., 2020; Siew et al., 2016; Tolia et al., 2017). Nittari et al. (2020)
highlight this concern by stating that “the risk of misdiagnosis is greater and the legal statutory
clauses are not standardized or universal” (p. 1). Nittari et al. (2020) further expand upon this
concern by saying that “liability and potential issues such as negligence and malpractice will also
have an impact on telemedicine” (p. 2). It remains to be seen how the rapid adoption of
telemedicine during the COVID-19 pandemic will impact the future use of telemedicine.
Beyond the legal and ethical concerns, operational challenges exist. From the perspective
of care delivery, a telemedicine visit mirrors an in-person visit insofar as there is an interaction
between the HCP and the patient that results in information exchange, diagnosis, and
prescription of treatment (Nittari et al., 2020). However, healthcare organizations and HCPs
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struggle with reimbursement concerns. Access to the Internet and navigating technology is a
barrier for patients, and connectivity issues are a potential barrier for both HCP and patient (Blue
et al., 2020; Contreras et al., 2020). Beyond operational and technical barriers, there are
considerations for the HCP regarding adapting to the telemedicine environment.
Telemedicine may feel like an informal environment for the patient, especially if
connectivity issues occur (Blue et al., 2020). The HCP may need to adjust how they
communicate during a telehealth visit to ensure effective PPC. The HCP may establish rapport
through body language in an in-person visit, such as shaking the patient’s hand. The loss of body
language can hinder trust and relationship building. Therefore, the HCP will need to modify their
approach to account for the lack of sensory or physical contact (Gopal et al., 2021). These
accommodations include being mindful of speech speed and allowing for pauses (Begasse de
Dhaem & Bernstein, 2020). HCPs will also need to accommodate for the lack of nonverbal
shows of patient support at the end of the telehealth visit. Begasse de Dhaem and Bernstein
(2020) point out that “accompanying patients back to the waiting room after a visit shows them
that we will continue to be there for them” (p .2), which is not possible in telemedicine. Training
in the form of continuing medical education and curricula in medical schools is needed to
mitigate any negative implications to PPC resulting from telemedicine (Nittari et al., 2020).
Telemedicine was instrumental in healthcare delivery during the COVID-19 pandemic.
“Statistics show that telemedicine if adopted collectively can bring about greater care for
individuals, cost savings in the long run, and more importantly a more organized and sustained
manner for public health” (Nittari et al., 2020, p. 10). It remains to be seen if telemedicine
utilization rates will endure when the COVID-19 pandemic is no longer a concern. Regardless,
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alleviating legal and ethical concerns and providing effective PPC via telemedicine appears to be
a work in progress within the medical community.
Conceptual Framework
CAT and CLT are the foundations of this research into barriers to effective PPC. CAT
speaks to communication from both HCP and patient perspectives, and CLT focuses more on the
patient’s experience of understanding the information communicated by the provider. Together,
these theories provide a lens through which perceived barriers to effective PPC can be
examined from each party’s perspective through both qualitative and quantitative means.
Howard Giles (1973) developed speech accommodation theory to investigate how people
situationally alter their speech to be accommodating or non-accommodating and the resulting
consequences of those accommodations. Over time speech accommodation theory was refined to
include nonlinguistic or nonverbal accommodations such as head nodding and eye contact
(Momand & Dubrowski, 2020), thus creating CAT. Farzadnia and Giles (2015) define the five
proposed sociolinguistic strategies of CAT as approximation, interpretability, interpersonal
control, discourse management, and emotional expression. These five strategies can be
accommodating or non-accommodating (Chevalier et al., 2020). The “unique feature of CAT is
its position that speakers accommodate (or not) where they believe or expect their interactants to
be linguistically” (Farzadnia & Giles, 2015, p. 18).
CAT focuses on minimizing the social difference in communication between people
based on the assumptions that people change their speech behavior based on the person they are
speaking to, and that communication effectiveness is based upon appropriate accommodations
(Momand & Dubrowski, 2020). The literature highlights how CAT affects PPC precisely
because PPC is an exercise in information exchange and relationship building (Farzadnia &
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Giles, 2015). Accommodation and non-accommodation are the tenets of CAT. Accommodation
is associated with greater feelings of trust and treatment compliance (Jones et al., 2018; Pines et
al., 2021; Soliz & Giles, 2014). Non-accommodation is associated with misunderstanding, and
miscommunication and has the potential for communication breakdown, which can result in
hostility (Pines et al., 2021). Over-accommodation can also occur and is seen as a form of
patronizing or perpetuation of stereotypes (Jones et al., 2018; Soliz & Giles, 2014). There are
two distinct categories of CAT, convergence, and divergence of communication (Momand &
Dubrowski, 2020), which may be used consciously or subconsciously to achieve a desired social
identity or communication goal (Chevalier et al., 2020; Pines et al., 2021; Soliz & Giles, 2014).
Convergence is used to gain approval or affiliation with the other person (Soliz & Giles, 2014)
and is correlated with increased patient satisfaction (Momand & Dubrowski, 2020). Divergence
is seen as a means of emphasizing a person’s distinction of group identity (Soliz & Giles, 2014)
and is associated with less effective communication and poorer outcomes, especially in patients
belonging to minority groups (Jones et al., 2018). CAT focuses on how people communicate.
CLT focuses on the amount of information shared.
CLT focuses on a person’s ability to process and retain new information based on the
presentation of that new information. This psychological theory states that a person has three
types of memory, each with differing abilities to retain information. The sensory memory retains
a duplicate of the information present for a very brief period of time. The information is then
processed through the working memory, which retains that information for a short time. Retained
information then transfers into long-term memory. While sensory and long-term memories have
unlimited capacity, the conduit between the two, the working memory, has limited capacity
(Mayer, 2010). In addition to the three types of memory, there are three types of cognitive loads,
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intrinsic, extraneous, and germane (Kennedy & Parish, 2021). Figure 1 provides an outline of
information based on CLT.
Figure 1
Cognitive Load Theory
Note. Cognitive Load Theory. Adapted from Effective Educational Videos, by C. J. Brame,
2015, https://cft.vanderbilt.edu/guides-sub-pages/effective-educational-videos/., Retrieved
November 5, 2021. Adapted with permission.
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Cognitive load and information overload are terms that are commonly used
interchangeably. “Information overload can be defined as a situation whereby the volume of
information supplied in a given time frame exceeds an individual’s capacity to process
information” (Obamiro & Lee, 2019, p. 550). The literature shows that a person’s ability to
process information affects their ability to make decisions (Singh et al., 2018) and utilize
educational materials. It can also create pressure, confusion, anxiety (Liu & Kuo, 2016), and
avoidance behaviors which are correlated with adverse health outcomes (Obamiro & Lee, 2019).
There is also a strong correlation between health literacy and cognitive load, and learning
depends on cognitive load (Kennedy & Parish, 2021). However, patients lack sufficient health
literacy to manage their health (Obamiro & Lee, 2019) or use educational materials because they
are not created with their health literacy in mind (Liu & Kuo, 2016; Obamiro & Lee, 2019). The
inability to understand the information and the amount of information presented create
information overload (Betts et al., 2018). When studying potential barriers to effective PPC, it is
essential to look at how communication occurs and how much information is relayed at one time.
The conceptual framework for this study begins with a lemniscate or infinity loop,
with the left side of the loop representing the HCP and the right side representing the patient. The
lemniscate itself represents CAT and the continuous follow of communication between the HCP
and the patient. There are three vertical lines towards the middle of the lemniscate. The
first line represents infrastructural barriers. This line is in the HCP section to show that
infrastructural barriers affect the HCP more than the patient. The second line, which bisects the
middle of the lemniscate, represents the effects of media and implicit bias. This line is in the
middle to represent a barrier that affects both the provider and the patient. The final line
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represents cognitive overload and is located in the patient section to show that cognitive barriers
affect the patient more than the provider. See Figure 2.
Figure 2
Conceptual Framework
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Effective PPC focuses on verbal tone, the language used (technical versus layperson), and
active listening. CAT is an appropriate lens for examining healthcare provider-patient
communication because it considers interpersonal communication’s emotional, motivational, and
behavioral aspects. It also emphasizes the speaker’s ability to adjust their communication style,
either consciously or unconsciously, based on the goals of the conversation (Giles, 2008). CLT is
appropriate to examine the problem because the patient’s understanding of their diagnosis and
treatment can directly affect compliance and health outcomes. The amount and types of
information HCPs present to patients during an encounter and the resulting compliance and
outcomes can be examined through CLT.
Summary
Effective communication is the foundation of all relationships. Many factors impact
effective PPC. This literature review only begins to address some of these factors. The first is the
effects of media on PPC. HCPs and patients are exposed to health information through a variety
of media forms. The portrayals seen in medical documentary programming, medical dramas, and
reality television shows can influence patients’ perceptions of healthcare and create unrealistic
expectations. Medical educators have acknowledged this influence to the extent that medical
television programming has been integrated into the curricula. In addition to television
programming, DTCA, CHDs, and online health information have created a new dynamic in PPC.
Patients are exposed to pharmaceutical advertisements on television, online, and in print
materials. CHDs, including wearable devices such as the Apple Watch, and HGTs, provide
health data, which may or may not be accurate. When seeking additional information on a
specific medication, health condition, or results from HGT, some patients may not be able to
discern the efficacy of that information. A strain in PPC can result when a patient requests a
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specific medication they saw an advertisement for, shares the results of an HGT, data from their
CHD, or information found online. When this occurs, patients may look to a PRW to search for a
new HCP based on reviews from other patients.
Implicit bias, conscious or unconscious, can be experienced by both the patient and the
HCP. The literature shows that HCPs may be primed for implicit bias, more specifically gender
bias, due to the lack of diversity in anatomy textbooks. The nature of medicine further
compounds the issue of implicit bias. HCPs are tasked with making multiple decisions per hour.
Because of the high volume of decisions and speed with which many need to be made, HCPs
may use cognitive shortcuts to reduce decision fatigue. It is these cognitive shortcuts that can
foster implicit bias. In addition to the risk of implicit bias in healthcare, there is also the issue of
HCST. HCST can also impact both patients and HCPs. However, the people most at risk for
HCST are older adults, people from marginalized populations, and women, especially women of
color. Dismantling implicit bias and HCST will take conscious effort, but it is possible.
Patients who are more satisfied with their HCP tend to be more engaged in their
healthcare and have more favorable health outcomes. The time spent with the patient in a visit,
attention given, and overall bedside manner are essential contributors to patient satisfaction. The
shift from a focus on psychosocial interactions to a more technical flow of communication has
changed the dynamic of PPC in the past four decades. This shift in focus leaves HCPs feeling
pressured by time and documentation requirements. Patients can sense this by verbal and
nonverbal cues, leaving patients feeling dissatisfied with the encounter. Because HCPs are
pressed for time, they may not be able to present information that acknowledges a patient’s level
of health literacy. Patients with low health literacy cannot effectively engage in SDM, which is
correlated with better health outcomes. Secure messaging through PWPs can help bridge the
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information gap for patients but creates workflow issues for HCPs. However, increased
utilization of telemedicine during the COVID-19 pandemic has shown promising PPC and
patient satisfaction results. It remains to be seen if this trend continues.
The problem of PPC was studied using a combined conceptual framework of CAT and
CLT. CAT addresses how accommodations of communication occur between two people
through vocabulary or speech patterns. These accommodations can create a convergence or
divergence, and adaptation or non-adaptation, of communication. CLT addresses a person’s
ability to process and understand new information. The ability to process and understand new
information is important to acknowledge as it relates to the issues of health literacy and time
pressures during a patient visit. Chapter Three will set forth the methodology used in
investigating the problem of PPC from the HCP’s perspective.
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Chapter Three: Methodology
This chapter outlines the research design and methods used to identify, collect, and
analyze data pertinent to perceived barriers to effective healthcare provider-patient
communication. The chapter begins with the three research questions addressed in the study, an
overview of the study’s design, and the research setting. The positionality of the researcher and
its relationship to the setting and participants will then be discussed. This discussion will be
followed by the study’s methodology, including the data sources, collection procedures, and the
credibility and trustworthiness of the data. Finally, the ethics of the study will be addressed.
Research Questions
This study aimed to explore the perceptions of healthcare providers on barriers to
effective communication with patients. The study answered the following three research
questions.
1. How do online resources, including physician review sites and patient web portals,
influence healthcare provider-patient communication?
2. What role does implicit bias, in both the healthcare provider and patient, have on
healthcare provider-patient communication?
3. What perceived barriers do healthcare providers feel exist that impede effective
communication with patients?
Overview of Design
A qualitative research design with inductive and deductive data analysis was used to
study the problem of healthcare provider-patient communication. Merriam (2016) defines
qualitative research as “a type of research that encompasses a number of philosophical
orientations and approaches” (p. 19). Narrative inquiry was used to gain an understanding of
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healthcare providers’ lived experiences regarding patient communication. Semi-structured
interviews were used to collect narrative qualitative data from healthcare providers, allowing the
researcher to be guided by a list of questions and the flexibility to expand upon the responses
provided (Merriam, 2016). This research design aligns with the purpose of the study because it is
focused on the problem of communication from the HCP’s perspective, based on their lived
experience.
Ten in-depth, 30-minute interviews were conducted to ensure that comprehensive data
was collected. The researcher recorded and transcribed all interviews for review during analysis,
and all interviews followed a consistent format. Any notes taken by the researcher during the
interviews were retained in their original form, and any identifying data was removed. The data
were analyzed and coded for themes both by hand and using NVivo (released in March 2020).
To allow maximum time spent during the interview on data collection pertinent to the study’s
research questions, participant demographic data was obtained through a demographic survey
distributed through Qualtrics, Version March through June 2022 of Qualtrics. Qualtrics and all
other Qualtrics product or service names are registered trademarks or trademarks of Qualtrics,
Provo, UT, USA. https://www.qualtrics.com.
Research Setting
This qualitative research study included currently practicing medical doctors, nurse
practitioners, and a physician assistant in any specialty in the United States. Purposeful sampling
using a snowball sampling approach was employed to allow for flexibility and variety in
participants (Merriam, 2016). Most of the participants in the study worked at large academic
medical centers, with a concentration of participants located in Los Angeles, California, and
Boston, Massachusetts. Table 1 outlines the participant demographic data. Six participants were
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medical doctors, three were nurse practitioners, and one participant was a physician assistant.
Seventy percent of participants have been practicing medicine for 20 or more years. Twenty
percent of participants have been practicing medicine for 11 to 15 years and 10% have been in
practice for 6 to 10 years. Participants practiced in a variety of medical specialties. Table 2
outlines the specialties represented in the research study.
Table 1
Participant Demographic Data
Participants
Type of
medical
credential
Medical
doctor (MD)
Doctor of
osteopathy
(DO)
Physician
assistant (PA)
Nurse
practitioner
(NP)
Other
Total 6 0 1 3 0
Number of
years in
practice
0–5 6–10 11–15 16–19 20 or more
Total 0 1 2 0 7
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Table 2
Participant Medical Specialties
Specialty Number of participants
Anesthesiology 1
Emergency medicine 1
Family or internal medicine 1
Infectious disease 1
Neurology 2
Obstetrics and gynecology 1
Psychiatry 1
Pulmonology 1
Transplant medicine 1
The Researcher
This study explored communication between HCPs and patients as it affects patient
outcomes and provider job satisfaction. The researcher’s dominant identity is a White, able-
bodied, middle-class, university-level educated, native English-speaking person that is insured,
which affords the researcher significant advantages in healthcare provider-patient interactions.
However, despite possessing the language to communicate using medical terminology resulting
from the researcher’s education in biological sciences, health education, and public health, their
subordinate identity as female creates an intersectionality of privilege with an oppressed identity
of being female.
As a person educated in patient care through formal training at the university level and
professional experience and experiences caring for their father and personal interactions, the
researcher has gained substantial wisdom relating to this topic. As a caregiver, the researcher
witnessed the effects of managed care on physician scheduling and time spent with each patient.
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As a female, more specifically mother of twins, the researcher experienced a significant delay in
diagnosing celiac disease due to implicit bias and misattribution of their symptoms.
Considering the topic of communication between HCPs and patients, the researcher most
closely aligns with the philosophical worldview of constructivism. Constructivism explores and
processes the cause, effect, and understanding of human experiences (Creswell & Creswell,
2018). Communication between HCPs and patients is a shared, lived experience, however, each
party holds a different context and meaning to the encounter. Exploring these multiple, socially
constructed realities through qualitative methods informed recommendations to help facilitate
more effective communication resulting in increased patient outcomes and healthcare provider
job satisfaction. This paradigm’s focus on how factors interact, process and meaning, and causal
mechanisms align with the researcher’s positionality and ability to appreciate the HCP’s
perspectives of the interaction.
The researcher’s positionality creates a significant obstacle to the lack of understanding
of what equity looks like for people of color, especially women of color who face multiple
oppressions. The researcher also lacks an understanding of what equity looks like for uninsured,
non-able-bodied, or for whom English is their second language. Using the constructivism
paradigm of inquiry allowed the researcher to understand equity in a meaningful way by
exploring the perspectives of the HCP. Constructivism also allowed the researcher to understand
both the cause and effect of how medical practice scheduling practices and the ways HCPs
communicate with patients impact patient outcomes and job satisfaction.
Data Sources
This study employed a qualitative research design that employed semi-structured
interviews with HCPs who are currently practicing medicine in the United States.
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Method 1
Semi-structured interviews with healthcare providers served as the only method of data
collection. Participants were asked to complete a short, four-question close-ended survey to
gather demographic data only, and all interview questions were open-ended. A qualitative
inquiry was appropriate for this study because it allowed for rich, comprehensive, narrative data
collection.
Participants
Purposeful sampling was used for this method of data collection. This study explores real
and perceived barriers to PPC from the HCP’s perspective. Therefore, purposeful sampling
allowed for data collection from only those individuals who are HCPs, as defined in Chapter
One. Interview participants were healthcare providers practicing in any specialty within the
United States. Including all specialties allowed for the inclusion of a wider diversity in patient
populations and provider experiences.
Ten interviews were conducted. The researcher used a snowball recruitment method,
leveraging their personal and professional network to identify interested participants. All
interested participants were sent an email outlining the study’s purpose, a link to schedule the
interview, and a link to the Qualtrics survey to gather demographic data (See Appendix A for a
copy of the Participant Enrollment Letter and Informed Consent).
Instrumentation
Semi-structured interviews allowed for both consistency and flexibility in the order of
questions asked. This flexibility was essential as more than one topic may be discussed per
interview question (Merriam, 2016). After receiving informed consent, the interview was
recorded and transcribed for data analysis purposes. An interview protocol consisting of six
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primary interview questions with several secondary questions or probes was used. While these
questions were intended to be asked in order, a semi-structured interview protocol was used to
maximize data collection and member checking. The interview questions focused on gathering
data to help answer the study’s research questions. The interview questions also addressed the
aspects of the conceptual framework, including communication accommodation, infrastructural
barriers, effects of media, and cognitive load. The rationale for selecting interviewing was to
establish a narrative and gain an in-depth perspective of real and perceived barriers to effective
PPC.
Several topics were addressed through the interview questions to establish a narrative
qualitative inquiry. The interview began with questions to establish this narrative by asking the
HCP about a typical day in the clinic. Specifically, the length of time they spend at the clinic,
how many patients they see, how long of a break they have between patients, and what they do
on those breaks. The interview then continued to ask questions specific to the effects of media on
PPC. Questions were asked about the participant’s experience with communication
accommodating based on the patient and any experiences with implicit bias. Finally, the
participant was asked to share their thoughts on creating a clinic that fully supports PPC.
Data Collection Procedures
Each interview lasted no more than 30 minutes and was conducted via Zoom. Utilizing
Zoom allowed for easy recording of the session and for the HCP to participate in the interview at
the location of their choice. It also maximized scheduling options for the researcher and
participants. Recording interviews is a best practice to protect data (Merriam, 2016) and allow
later transcription and analysis (Creswell & Creswell, 2018). The researcher conducted the
interviews in a private office space to minimize distractions and allow for a professional setting.
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Before beginning the interview recording, the researcher obtained verbal informed consent from
the participant. Primary demographic data, including the type of medical credential, the number
of years in practice, medical specialty, and current job satisfaction, was obtained through a
demographic survey completed by the participant prior to the interview. The demographic
survey, as outlined in Appendix B, took participants less than 5 minutes to complete. The
demographic data were gathered and analyzed using Qualtrics, Version March through June
2022 of Qualtrics. Copyright © 2020 Qualtrics. Qualtrics and all other Qualtrics product or
service names are registered trademarks or trademarks of Qualtrics, Provo, UT, USA.
https://www.qualtrics.com. The complete interview protocol can be found in Appendix C. All
interview recordings were transcribed for data analysis. The researcher also took notes during the
interview to be used in the data analysis and included them in the final report.
Data Analysis
Data analysis began at the onset of the interview. The researcher documented thoughts,
feelings, concerns, and reflections after each interview. All interview recordings were transcribed
using a freelance transcriptionist. Transcripts were reviewed for any obvious transcription errors
and cross-checked with the recording for any questionable transcription results. The data was
coded and analyzed by hand and by utilizing NVivo (released March 2020) qualitative analysis
software based on a priori and axial codes derived from the conceptual framework. The codes
were analyzed independently and holistically examined to generate themes that will serve as
precursors to the findings.
Validity and Reliability
The researcher is the primary means of data collection in qualitative research (Creswell &
Creswell, 2018); therefore, it is essential to ensure credibility and trustworthiness. The researcher
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utilized reflexivity to acknowledge any biases because of their positionality (Creswell &
Creswell, 2018; Merriam, 2016). Continuous reflection throughout the data collection process
allowed for maximum objectivity and fortify the credibility and validity of the qualitative
findings (Maxwell, 2013). In addition to reflexivity, the credibility and trustworthiness of the
findings were ensured through maximum variation, member checking, peer review, and an audit
trail (Merriam, 2016). Maximum variation was employed during the purposeful sampling to
ensure that there was diversity among participants. Every effort was made to ensure diversity in
gender and race and to gain representation of physicians, physician assistants, and nurse
practitioners in the study. This diversity of medical credentials allowed the researcher to
determine if any themes exist between physicians and advanced practice providers (physician
assistants and nurse practitioners).
Member checking during the interview was used to test the plausibility of the data being
collected. An audit trail was also used to ensure credibility and trustworthiness. Transcripts were
reviewed against interview recordings to ensure that there were no mistakes (Creswell &
Creswell, 2018). Finally, triangulation was used by inductive and deductive approaches to
coding the qualitative data. All interview documentation, including demographic data, interview
recordings, transcripts, and researcher notes taken during interviews, was retained throughout the
course of the study.
Ethics
The researcher complied with the University of Southern California’s Code of Ethics.
Informed consent was gained from providers in advance of the interview. Participants were
reminded throughout the interview that participation was voluntary and that they may decline to
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answer any question or end the interview at any time. All participant data was kept confidential
and scrubbed of any identifying information.
This research study aimed to improve patient outcomes and healthcare provider job
satisfaction by understanding the barriers to effective healthcare provider-patient
communication. Many stakeholders benefit from solving this problem. Patients are the most
obvious beneficiaries of this research through improved overall health. Healthcare providers will
benefit through increased job satisfaction which is directly linked to patient outcomes (van Osch
et al., 2017). Health insurance providers, including Medicare and Medicaid, can benefit from this
study through decreased payouts for care as patient outcomes increase and the need for care
decreases. Health Administrators may be harmed by this research if the barriers uncovered
through this research point to infrastructural issues that, if mitigated, could impact the clinic’s
profitability.
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Chapter Four: Findings
The findings within this study show the commonalities and diversity of the perceptions
and lived experiences of HCPs across several provider types and medical specialties. The
findings represent the perspectives on barriers to healthcare provider-patient communication
from six medical doctors, one physician assistant, and three nurse practitioners representing eight
diverse medical specialties. While there is diversity among the participants, this is only
representative of a small group of HCPs practicing within the United States.
The topics that emerged from the literature review and integrated into the conceptual
framework focused on PPC from the HCP’s perspective, including the effects of media, implicit
bias in healthcare, and infrastructural barriers that impact effective PPC. Through in-depth
interviews, this study’s findings emerged within similar themes of lack of time to effectively
communicate with patients, communication accommodation employed by HCPs, administrative
workload, and implicit bias felt towards providers. In addition to the identified topics uncovered
in the literature review, an unexpected theme of HCP compensation also emerged. According to
the evidence, these are only some of the reasons why PPC remains a challenge in increasing
patient outcomes and provider satisfaction.
The three research questions for this study were designed to achieve a better
understanding of the HCP’s perceptions and lived experience with patient communication, with
the main focus on the effects of media, specifically physician rating websites and secure
messaging, conscious employment of communication accommodation, implicit bias felt both
towards the provider and the patient, and infrastructural barriers. Ten in-depth interviews were
conducted to answer these research questions, which were then transcribed and analyzed. The
interview protocol can be found in Appendix C. The following sections begin with the broad
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findings for each research question. The remainder of each section presents synthesized evidence
followed by a summary of the overall findings for the research question. An overarching
summary of the study’s overall findings will conclude the chapter. Table 3 provides an overview
of the participants.
Table 3
Participant Overview
Participant
pseudonym
Medical
credential
Years in
practice
Medical
specialty
Gender Location
Concierge MD Medical
doctor
11–15 Family or
internal
medicine
Male Los Angeles
Obstetrics MD Medical
doctor
20 or more Obstetrics and
gynecology
Female Boston
Emergency
medicine MD
Medical
doctor
11–15 Emergency
medicine
Male Boston
Psychiatry MD Medical
doctor
20 or more Psychiatry Male Boston
Anesthesiology
MD
Medical
doctor
20 or more Anesthesiology Male Boston
Infectious
disease MD
Medical
doctor
20 or more Infectious
disease
Female Boston
Neurology NP Nurse
practitioner
6–10 Neurology Female Los Angeles
Pulmonology
NP
Nurse
practitioner
20 or more Pulmonology Female North
Carolina
Transplant
medicine NP
Nurse
practitioner
20 or more Transplant
medicine
Female Los Angeles
Neurology PA physician
Assistant
20 or more Neurology Male North
Carolina
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Research Question 1: How Do Online Resources, Including Physician Review Sites and
Patient Web Portals, Influence Healthcare Provider-Patient Communication?
The first research question focused on how media, including online resources such as
PRW and PWP, influence PPC. Participants felt that PRWs are wholly subjective and rate more
than just the patient experience with the HCP but the entire experience. Many participants
reported that they do not even look at their online ratings. Several participants noted that PRW
are another way that healthcare has become less about patient care and more about the business
of medicine. Regarding PWP, participants had mixed feelings about patient access to their online
medical records and the effect this has on PPC. While some felt that patients have the right to
access their medical records and that PWP allows for easy communication between visits, others
felt that PWP creates more harm than good for the patient and the HCP. Patient access to medical
information without context and sometimes before the HCP has reviewed the information inflicts
undue anxiety or panic in patients and increases the administrative burden on HCPs who need to
respond to an influx of messages or calls from upset patients.
Physician Rating Websites
The ability for patients to share experiences online can positively and negatively impact
provider-patient relationships. As Psychiatry MD noted, “I rarely see a patient who hasn’t
Googled me. They may know more about me than I know about them when they come in. I
assume that”. When asked if he looks at his reviews, he said, “Never looked at them. Never
will”. Other participants shared Psychiatry MD’s practice of not looking at their online ratings or
reviews. Overall, participants felt these ratings are subjective and do not accurately reflect the
HCP’s care. These reviews often reflect more on the patient’s overall experience with the clinic
or hospital rather than solely on their encounter with the HCP.
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The frustration with online ratings not accurately reflecting the patient experience with
the HCP was voiced by Neurology PA:
One of the issues that occur with these patient satisfaction sites and the scales is, again
that, subjectivity from the patient themselves. They might have been on time for their
clinic session. They might have been on time for their appointment. They might have had
just a very straightforward concern or an issue; however, they were delayed maybe 30
minutes or so from their clinic appointment time because the patient in front of them was
late or had a very complex situation that needed to be addressed. They don’t understand
that. Quite frankly, they don’t care, and that’s part of the consumerization of medicine
that’s occurred over the past several years and has been heightened and reinforced by
these types of sites that encourage people to give feedback.
While Concierge MD does not look at his online reviews, he was very candid about the damage
they can do to an HCP’s reputation when he said:
The problem with the online reviews. People are mad … I found that I actually feel bad
oftentimes for these other providers because they’re subject to people who – again, they
might not even want to see that provider, but that was the only one who has availability.
And so, they may have a personality issue. Then the provider is on the hook for an online
review for something they can’t even control half the time.
Transplant Medicine NP shared that she does not look at any online feedback because her
institution has its own rating system. However, when she was working at a primary care practice,
she did look at her reviews and said:
I was disappointed because there are lots of things that determine patient experience,
right? I could be rude, but if you’re in and out on time, to you, that’s a good visit. Or I
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could be completely thorough and give you more time than allotted and do things that
have nothing to do with our visit, but your overall health, because that’s what I tend to
do, and I was late, so you give me a bad review. Sometimes, I don’t know, you have to
take them with a grain of salt, you know.
Obstetrics MD concurred with the other participants and expanded the findings to mention how
making medically sound decisions can negatively impact HCP reviews even if they were in the
best interest of the patient when she said:
I will say I think it’s really, it’s almost irresponsible, but it’s here to stay. I think that
there are a lot of patients that will come and demand certain things, and it’s not medically
correct. Antibiotics are a great example, and my specialty sort of has that, and so if you
work really hard to explain to people what the data and evidence and harm is both to
society and to them, first of all, it takes a lot of time, and second of all, a lot of them don’t
buy it because they came to you and they wanted something, and if you don’t give them
that, that’s a loss, and that comes out of really your potential rating on how good is this
doctor.
Pulmonology NP shared how she can see both sides of the issue and how PRW can help patients
when she said:
I think it’s good in a way because I think it gives the patient a voice, which is important.
I’ve talked to patients who I suspect went through something pretty awful from their
perspective, and they didn’t have a voice for that. I might be the first or second person
hearing about it, and I try to listen really carefully when that happens. At the same time,
not everybody has the maturity, I guess, to give that feedback in a thoughtful way. Like,
here’s how my visit could have gone better. Here’s how my experience could have gone
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better. And also, here’s what was good about it. Sometimes it’s just like negative stuff,
and as clinicians, that’s hard for us to hear because we do try, I think to give our patients
the best experience we can. If you only hear negative stuff, I think that contributes to our
burnout in a way because you feel like you did all this work and tried and cared, and then
it’s like it didn’t really make a difference as far as their perception goes.
Ultimately, she feels that the reviews are too subject to represent the care given accurately and
feels that:
[Providers] get enough feedback that they feel is not only negative, but maybe they don’t
feel like they can do anything about it, that might add to the burnout that I think a lot of
people are already experiencing in healthcare right now.
Overall, participants do not find PRW to be useful or an accurate representation of their clinical
work due to the subjective nature of the reviews left by patients. They also feel that they have no
control over the negative aspects of the patient’s experience, for example, parking fees, long
waiting times, scheduling issues, or copays. Therefore, it is felt that these reviews are not as
useful as the more formal feedback mechanisms employed by their institutions.
Patient Web Portals
Reviews from patients on PRW are not the only potential cause of HCP burnout resulting
from the media. Patient access to electronic medical record data and the ability to message their
HCP is another barrier to effective PPC. Participants were divided about patient access to their
medical records. Concierge MD strongly supports patient access to medical records when he
said, “all the medical records belong to the patients.” However, he does feel that the way PWP
“is set up now where people are trying to find access to their information is ridiculous.”
Neurology NP agrees that PWP benefits both patient and HCP, “I think it’s easier actually to
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contact the providers if they need something. It saves time for calling for an appointment. They
can just message the doctors directly.” As an early adopter of inviting patients to message him
directly, Psychiatry MD shared that he appreciates the messaging aspect of the PWP, stating, “I
think it’s great for patients to be able to communicate and use that portal. I’ve been giving
patients my number and text and stuff forever, and they use it really prudently.” Infectious
Disease MD also admitted that the messaging ability through the PWP is a beneficial
communication tool when she said:
I think that, in general, for me, it’s easier to communicate with the patients through the
portal … because you can take care of that while you’re doing other things sometimes.
Whereas blocking out time to make a bunch of phone calls can be a little bit more
onerous in a way. I can answer patient questions at 10 o’clock at night if I need to.
Pulmonology NP shared a positive patient outcome as a result of the patient’s access to their
records on the PWP:
I actually helped discharge a patient who had access, but also, he was very conscious
about it and very involved in his care. He loved that access. He loved that he could –
when he was getting ready to discharge, and a provider came in and said, hey, I’ve got
your medications taken care of, and they’re ready for your discharge, he could look in his
portal thing and say, oh, yeah, it’s all ready. So, he loved that, and he used that to learn
more about what was wrong with him and all of that stuff. That actually made his
education a lot easier for me.
Not all experiences with PWP are positive. Those participants who were not as supportive of
PWP cited the speed with which patients had access to their records following an appointment or
posting laboratory results.
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The lack of context or explanation of a test result in the PWP can cause undue stress on
the patient and the HCP. Psychiatry MD shared an incident when a patient received a result and
could not get in touch with the specialist who ordered the test, so they called him:
I got a Saturday night at 9:45 message from a patient about a GI test that they had had
and got the results that were scary. They couldn’t reach their GI doctor, so they were
calling me. Like, what do I know about those results?
Obstetrics MD shared a common frustration she encounters in her practice regularly regarding
patients not understanding laboratory results:
I think it’s only harder for the doctors and the healthcare providers. The patients always
see it first. There’s no way around it, and none of it makes sense. Half of it doesn’t make
sense when you even went to med school. … It only makes it more because there’s more
calls and contacts. Everyone freaks when they see their pap results because it all sounds
like something’s wrong.
Transplant Medicine NP agreed, stating:
The tests even, because then you get a million questions about things that aren’t relevant
because they don’t have the knowledge to interpret them. Imaging, I’m thinking about
imaging particularly, or even labs sometimes. Like, one test will be one number, and
they’re like through the roof, and I don’t really have time to manage all of that, so that for
that reason if you could just message me, that would be great. The rest of it, I don’t care
for.
Anesthesiology MD illustrated a personal example of the confusion patients have that occurs as a
result of PWP access:
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I think it’s like giving a homeowner a wiring diagram of their house. It doesn’t help. It
confuses them. It probably scares them. It’s a problem. I say that because my wife has
access to her portal. I see what she reads, and she doesn’t read what I get to read as a
doctor. I read my Epic chart, which has everything, and then I read the portal, which has
this sort of glossy overview. It’s not helpful. And I can’t tell you how many surgeons
have told me the patients will look on the portal and say, you’ve got an abnormal finding,
you have cancer, and they’re like, oh my God, and there’s no one to talk to. There is no
one to put it in context, no one to say it’s a superficial cancer; I think we removed it all,
you needn’t worry. All that’s not there. I think most patients cannot and are in no position
to make good sense of what they’re reading because of the context that is completely
absent. I think that patients, in general, don’t have the background knowledge,
framework, experience to properly contextualize a lot of what they’re reading.
While responding to messages from distressed patients is time-consuming, Psychiatry MD
shared one story demonstrating the potential danger of rapid patient access to medical data:
I think the notion that a patient can get a result before the doctor gets it, and then they’re
worried, and the doctor can’t respond quick enough; there was a story you may have
heard about this. Marcela, who was the president of the physician organization, got called
out of surgery because of a patient’s husband read something that got him worried she
was operating on the wrong organ or something and pulled her out of the operating room.
I mean, it was really stupid. There is an example of patient portal jeopardy.
Not all entries in the PWP create such extreme reactions, but participants noted that they are
aware that other HCPs and patients will see their notes. This reality has changed how they enter
their clinical notes. Transplant Medicine NP shared:
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I don’t necessarily like for them to be able to see their notes, my notes, because
sometimes I put specific things in the notes to jog my memory for next time and because
other people, it’s multidisciplinary, so social workers, all these different people see these
patients’ notes, the psychiatrist, everybody, and so I have to be candid about the
interaction, and a lot of our patients have addiction issues, so for that, I don’t
necessarily—because sometimes I put things in verbatim that happen, and they’ll tell me
the truth, but then lie to the social worker, but if they can look at their records, they can
see I wrote down what they told me, and then they feel like they can’t trust me or
something, so I don’t necessarily like for them to be able to access the notes.
Psychiatry MD agreed that knowing that his patients will have access to his notes has changed
how he writes visit summaries. He shared how his notes can affect a patient, especially in a
specialty such as psychiatry, where patients may be more sensitive to the HCP’s wording:
It absolutely changes the notes I write. Completely changes the notes I write because
they’re of limited exactness because I have to use code. Sometimes I used code that
another doctor probably would be able to read through. It always did, but now it’s even
more so. I’ve got a patient who’s extraordinary—he’s very much on the spectrum. I really
like him: enormously self-hypochondriacal and self-critical, an anxious guy. You would
call him early neurotic. If I write stuff about our meeting, it will be bad for him. He’ll
ruminate about it. I might even say complimentary things about how wonderful he is or
his sake. It’s almost therapeutic. He’s going to read it and say, oh, my doc thinks I’m
wonderful. Meanwhile, I know I’m walking on thin ice. The patient meets many
challenges in a very courageous way. Yeah. It’s changed my notes.
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While HCPs have mixed feelings, the findings show that positive and negative feelings
are grounded in concern for the patient’s well-being. Participants who were not as positive about
PWP cited the immediate availability of information to the patient as one of the primary causes
of concern, followed by the increased administrative time generated by patient messages or calls.
Those in favor of PWP feel that it is the patient’s right to their medical records and appreciate the
messaging aspect of the portal.
All participants agree that PRW are highly subjective and do not accurately reflect the
care they provide to their patients. Participants feel that the content on these sites is posted by
people who are very unhappy or very happy with their care nor provide constructive feedback.
While participants agreed that PRW is not useful, they had mixed feelings about PWP. The most
significant concern about PWP is the fact that patients have access to medical reports and
findings, at times, before the HCP has reviewed them. This can lead to patient distress and
increased calls and messages, especially given that there is no context provided to the patient in
the interpretation of this information.
Research Question 2: What Role Does Implicit Bias, in Both the Provider and the Patient,
Have on Healthcare Provider-Patient Communication?
The second research question focused on the role of implicit bias, both toward the
provider and toward the patient on PPC. All participants acknowledged that they feel implicit
bias is an ongoing challenge that they are faced daily. Eight of 10 participants candidly shared
their experiences with implicit bias directed toward the patient. Seven of the 10 participants
shared examples of implicit bias directed towards them by patients. These admissions were
accompanied by visual discomfort and a more tense body language in participants that could be
interpreted as a feeling of embarrassment.
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Concierge MD explained the challenge of implicit bias by stating that:
I think we all are subject to our environment. It’s hard to have a human being who’d been
around other people and not be influenced by other people, other systems, and what
they’ve been around, what they’ve known, what the media shows, whether it’s good or
bad.
Obstetrics MD further reinforced the challenge of implicit bias in saying that:
I think we all have implicit bias. I mean, I think there would be a lot of hubris if you
thought you weren’t subject to implicit bias because I think we all are and we need to
recognize that inherently we are all subject to our own implicit biases just by how we’ve
been raised and our own experiences. Not good or bad, just that’s kind of just the facts.
Regardless, all participants felt that they either felt implicit bias towards a patient, felt implicit
bias from a patient, or both. While they try to remain neutral, it is not always easy, especially
under specific circumstances.
Implicit Bias Towards Patients
Many participants noted that they try to treat all their patients equally because they would
like the same treatment from their patients. Despite embodying this aim, implicit bias remains an
issue. Most agree that they refrain from implicit bias toward a patient’s ethnicity. Concierge MD
said, “just because a White person comes in my room, I don’t think they’re a racist … I try to
suppress all that because I found I don’t want people doing that to me.” Anesthesiology MD
commented that he tries “to treat everyone the same … I don’t care what your name is … I don’t
care how famous you are. You’re getting the same care.” However, Infectious Disease MD noted
an example of implicit bias towards a patient based on their profession. She said, “sometimes I
have to check myself if [the patient] is a physician, really trying to make sure that I’m not
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treating that individual any differently than I would if it were a non-physician.” While many of
the participants claimed to be conscious of their bias, one participant candidly shared her bias as
a young provider and the learning opportunity it provided her. Pulmonology NP shared:
I think I have probably prejudged patients. I know I did this early in my career. I did not
live in the South my whole life, but I have practiced in the South all of my nursing career.
I know that somewhere in my brain, when I would hear a Southern accent, I thought
they’re not going to be as quick as someone without a Southern accent, or they’re not
going to be this, or they’re going to be that. I have since then been culturally been put in
the smackdown chair because it really does not matter what your accent is. I have been
schooled in many things by Southerners, and I have found that they’re just delightful
people. You can be ignorant about anything at any given time no matter who you are. I
probably still have biases, but I think early in my career I just didn’t know what I didn’t
know. It took me a while to figure out how I was judging people and why I did that.
Infectious Disease MD shared a similar bias when she said, “I don’t know if it’s implicit bias per
se or just the hurdle of having to speak through an interpreter … but it’s treating an individual
differently because they don’t speak English.” While she admits that interpreting services have
improved due to the COVID-19 pandemic, she was visibly upset that she felt this way towards
non-English speaking patients.
While the participants endeavored to remain unbiased, certain situations with patients
triggered a strong bias. These biases were triggered by the patient’s actions or interactions with
the patient or their family member. Neurology PA was very open with his experience of implicit
bias towards his patients under particular circumstances when he shared:
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I know that I have a certain bias to certain things. Cigarette smoking is one of them. I find
that because cigarette smoking negatively impacts health outcomes so much, I have a real
hard time with a patient who is a smoker who’s made zero attempts to quit. I’m fine if a
patient is a smoker and they’re interested in quitting. Maybe they’ve tried three times.
That’s great. Let’s keep trying. Let’s now try to figure out what we can do, what services
to hook you into, what’s going to be the best way for you to stop smoking because it’s
going to give you the best health outcomes. So, I’m okay with working with patients who
currently smoke but want to stop smoking. The patients who currently smoke and have
no interest in stopping smoking whatsoever are very, very challenging for me because
I’m trying my level best to impart a positive impact on their health outcomes, and they’re
not bringing anything to the table at all. That already sets up in my mind how I’m
approaching that patient, which is vastly different than a nonsmoker or patient who is
currently smoking and who is interested in stopping.
One can appreciate the challenge of caring for a patient who is not actively engaging in health-
promoting activities that will maximize their treatment, recovery, or overall well-being. The
additional challenge of implicit bias can occur because of a negative interaction with the patient
and their family. Obstetrics MD recounted a time with a patient and her husband by saying:
I remember I had this patient. She’d always come in with her husband, and they were
awful. They were so mean to everyone. They were mean to my staff. They were mean to
me. They were mean about the doctors they had seen in the past. It’s kind of a funny
thing. I think my bias is always like, you see them on the schedule, and you’re sort of
like, oh God, this is going to be a big one, a doozy, and so I think your biases start to play
their tune. The absolute funniest part about that entire patient that I’m thinking about
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right now is she now comes alone. Like, I think there was something about them needing
to define what trust would be, and he had to be there to protect her from whatever I was
going say or do that was going to—I don’t know. So, it was really actually funny. I just
saw her a few weeks ago, and I was like, wow, where’s your husband? She said, oh, he’s
in the waiting room. I thought, oh, my God, he actually even came but didn’t even come
in the room. This was like a first, and I think they finally decided to trust me. But it
definitely starts a bias because it ruffles my feathers a little bit to know that they never
trusted me until now, but I guess maybe I earned it.
This recollection clearly shows how an implicit bias can be situationally fostered and can be
eliminated with a change in the interaction between people and the HCP’s dedication to being
aware of their own biases.
There are times, albeit rare when implicit bias can benefit the patient. These types of
biases could be viewed as favoritism, but they ultimately result in greater patient outcomes and
HCP job satisfaction. Transplant Medicine NP shared her implicit biases toward young female
liver transplant patients positively impact patient outcomes when she said,
I try … to be objective … if you’re young and you need a liver transplant, and you’re a
woman, I mean, that’s just become my specialty. … I’ve had several patients get
pregnant post-transplant … one of my patients, we’re on our fourth baby together.
The findings show that HCPs are aware of implicit biases towards patients and make
efforts to mitigate biases. The example of an implicit bias that was eliminated over time
demonstrates how an aware HCP can rethink biases to change negative biases toward their
patients into positive change. The outlying example of implicit bias that benefits patient
outcomes could be argued as showing favoritism toward a patient. Still, this type of bias
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arguably benefits patient outcomes and HCP job satisfaction. While implicit bias toward a
patient was reported to be uncomfortable for all participants, implicit bias felt by patients was
reported to create significant challenges for PPC.
Implicit Bias Towards Providers
The most common implicit bias felt by patients reported by participants was based on
gender, age, and type of medical credential. While nurse practitioners and physician assistants
are clinically trained and board-certified, a perception remains that the care they provide is not
the same as a medical doctor. These implicit biases are barriers to effective PPC, can create
challenges in patient care, and ultimately negatively impact patient outcomes and HCP job
satisfaction.
For nurse practitioners and physician assistants, implicit bias based on their medical
credentials can leave the HCP constantly, justifying their abilities to practice medicine
effectively. Pulmonology NP shared that she thinks “some patients think because I’m a nurse
that I somehow am less helpful in certain situations than a physician.” Transplant Medicine NP
concurred with Pulmonology NP when she said, “I’ve actually had African-American patients
who didn’t want to see me, but they wanted to see ‘the doctor.’” The fact that patients who
looked like her preferred to see a non-concordant physician was frustrating. She shared that the
physician’s responses to these patients always favor her. The physician’s reply to the patient is:
“[Transplant Medicine NP] is going to do a much better job than I am because I’m going to give
you your 15 minutes, and then I’ve got to go onto the next [patient]”. The support of her
colleague was gratifying but does not always make dealing with this type of implicit bias easy.
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The challenge of implicit bias based on medical credentials is a leading contributor to
advanced practice practitioner burnout, according to Neurology PA. This frustration comes
through when he said:
I have led the last, almost 25 years, with folks saying, oh, so when are you going to be a
doctor? Or when am I going to see the doctor? Or can I see the doctor next? Despite the
fact that I have a license to practice medicine, I’m board-certified, and I’ve been doing it
for over 20 years. There is a misperception there that can occur just because I’m not a
physician provider, even though there are some physicians in my area of work who I
would not entrust with a family member, and it makes no difference as to what their
degree background is or what the letters are after their name.
While implicit bias based on medical credentials is challenging for nurse practitioners and
physician assistants, it is only one form of implicit bias they face. Gender and age biases create
intersectionality for these HCPs, further compounding the issue of implicit bias. Gender and age-
related biases may affect the HCP and the entire healthcare team. Emergency Medicine MD
summarized the breadth and effects of implicit biases toward HCPs when he said:
For example, very common [implicit bias] is like towards gender of physicians,
especially in certain specialties, patients who expect certain genders for taking care of
them, and they have some bias towards other genders. ... I’ve tried to understand that
through a cognitive point of view, that it happens unconsciously. But sometimes, it’s
really more explicit and even becomes a microaggression, and that creates a lot of
frustration among the team.
Anesthesiology MD further supported this sentiment when he shared his experience as a program
director and mentor to medical residents and fellows:
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I’m very familiar with the life of a trainee, the younger person, the female, the not white
female, and the stories I have heard are horrible, and I believe them, which is to say that
it’s not my reality, but I know it’s a reality. I know it’s everywhere. It’s very common. I
know it’s real. … Every now and again, someone will say something like, oh, you’re a
Gen X, or you’re of the senior generation, and I’ll be like, you jerk, don’t say that
because they’re implying some things when they say that.
All five female participants were incredibly candid about their experiences with gender-based
implicit bias. Infectious Disease, MD said she has walked into numerous, predominately male
patient encounters to hear, “Oh, hi, nurse.” Pulmonology NP expanded on the gender-based
implicit bias and the expected role she should play as a female provider when she said:
Sometimes I think they think because I am a woman, I’m helpful in only certain
prescribed situations, like helping them stay clean or changing their dressing, which is
fine, but there’s always that attachment to Florence Nightingale, and I think she’s also
seen as a somewhat maternal figure. … I think because I’m a woman, I’m expected to
behave certain ways, and because I’m a nurse, they really want to attach that maternal
aspect to me.
HCPs make numerous decisions per hour which can lead to implicit bias when diagnosing a
patient. The added stress of implicit bias felt from patients can decrease an HCP’s ability to
communicate and care for that patient effectively. The findings show that HCPs who are nurse
practitioners or physician assistants face implicit bias based on their medical credentials. All
participants reported experiencing personally, or with colleagues, implicit bias based on gender
or age. Female nurse practitioners are the most at risk for multiple biases based on their medical
credentials and gender.
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Implicit bias is a topic that all participants acknowledge is a thorny subject in medicine.
All participants voiced awareness of their biases towards patients and acknowledged that they try
to eliminate these biases but are not always successful. Gender, age, and type of medical
credential biases felt from patients is more challenging barrier for participants, including those
who are not subject to these biases, but witness them in colleagues. The findings clearly show
that implicit bias is a formidable barrier to PPC.
Research Question 3: What Perceived Barriers Do Healthcare Providers Feel Exist That
Impede Effective Communication With Patients?
The final question explored perceived barriers to effective communication. This broad
research question was aimed to uncover common and unique HCP experiences, including but not
limited to communication accommodation with patients, patient health literacy, patient cognitive
overload, infrastructural or organizational barriers, and their thoughts on removing these barriers.
The findings supported two expected themes relating to time and communication. However, one
unexpected barrier related to HCP compensation was revealed.
Participants touched on several different aspects of time that are barriers to effective PPC.
All participants agreed that they were not allotted enough time in each patient encounter. They
feel rushed when meeting with patients and are overwhelmed by their schedules. The amount of
administrative work required both during the patient visit and outside of seeing patients is
staggering. Because of the tight schedule, participants reported working through lunch and after
clinic hours to stay on top of their administrative tasks. HCPs are not compensated for the
additional time spent outside of seeing patients, contributing to job dissatisfaction.
All participants feel that they tailor or accommodate their language based on the patient
they are communicating with. However, most participants agreed that the issue of time might
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hinder their effectiveness in communicating in general, accommodating their communication, or
providing verbal or written communication to help increase a patient’s health literacy or
information recall. Several participants noted that the lack of time creates ineffective
communication, which generates more calls or messages from patients, which increases the
HCP’s administrative time. This vicious cycle contributes to poorer patient outcomes and HCP
provider job dissatisfaction and burnout.
Time
All participants agreed that time is the most significant barrier to effective PPC, with
several subthemes of the time emerging from the data. These subthemes include clinic
scheduling practices, interruptions or distractions, and administrative tasks. Psychiatry MD
succinctly summed up the time issue when he said, “the less time you have, the more gifted you
need to be in communicating.”
Scheduling Practices
All participants commented on the pressures imposed upon them by their schedules. For
two participants, the pressures of working in primary care specialties prompted them to change
to a different practice structure or less patient volume-intense specialty. Concierge MD explained
that his shift from a traditional practice to concierge medicine was:
Because you’re seeing 20 to 30 people a day, you don’t have time—or I didn’t have
time—to really give people that in-person kind of dedicated time that I think people
deserve and what I need to establish relationships. … You can’t change behavior in 15
minutes.
Neurology NP also shared the pressures of working in pediatrics before shifting specialties to
inpatient neurology. She said, “in peds before where I would see like 20 to 30 patients in any
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given day. It was more fast-paced. It’s more like a numbers game just because the physicals and
exams are less stressful, easier to do”. Anesthesiology MD shared that he sees “maybe seven
people in a day. Some of the most busy days I can have up to 20 people”.
Neurology PA, who primarily treats patients with complex diagnoses such as multiple
sclerosis and stroke and who have significant mobility and potential cognitive deficits, described
his schedule by saying:
Patients are scheduled every 30 minutes for routine return visits, but sometimes they
show up late. Rarely do they ever show up early or on time. So, a lot of that is really tight
coordination with the clinic staff to figure out who’s going to be seen when and where…
Then you have essentially from 12:00 to 1:00 blocked off, and it’s a grave misconception
that you’ve got a lunch hour so you can go and have a nice leisurely one-hour lunch
under a tree and decompress and regain your thoughts. That doesn’t happen.
Obstetrics MD said with laughter, “It’s just back-to-back. … My favorite of the Zoom meetings,
like the virtual OBs, are 10-minute appointments back-to-back”. She candidly elaborated when
she further described a typical clinic day:
The day is a complete shitshow. It basically starts at 8:30. Almost undoubtedly, people
are late. There’s a new OB patient that starts at 8:30 with my nurse, and that can take
anywhere from a half an hour to an hour, after which I then I meet the patient and
oftentimes answer a lot of questions even after that, and that then visit is scheduled at a
time that then is sort of mish-mosh in with other patients that are also scheduled, despite
trying to leave some space for that appointment, it never quite works out well. Since we
had COVID and started doing virtual visits, we still offer virtual visits, which is actually
great for a lot of our patients, especially when they have multiple visits in a short span of
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time; it makes it easier for them for work and everything, and that’s great, but it’s a little
tricky because those aren’t really monitored by anyone, and so there can be patients
waiting on a Zoom for me, and whereas in the office, they would know that someone was
aware of them. They may not feel that way when they’re in their house or at work on
Zoom waiting for me to come. Whereas a 5-minute or 10-minute delay isn’t a big deal
when you’re in an office, like on your phone. When you’re on Zoom, you just have no
idea what’s going to happen, so I try to track for that eventuality by really telling people
to be aware that’s going to happen, how successful I am at really aligning expectations,
I’m not sure, but I try. … I have worked for 30 years in this, and 12 years of training to
cipher this stuff, and in a 20-minute or 10-minute phone call, or 10-minute or 20-minute
visit, I’m supposed to educate people in that [time].
Infectious Disease MD described the difference between seeing patients in the clinic versus
inpatient setting:
In the outpatient setting … I will see … anywhere from 4 to 8 patients…I feel like it’s
really always rushed because whether you have a certain amount of time allocated in the
outpatient setting, knowing that you have several patients waiting, or in the inpatient
setting, if you have five consults that day, you know you have to get through each of
those and be able to spend an adequate amount of time with each of them. I think in the
outpatient setting, I usually feel like I have a little bit more time. In infectious disease is
probably one of the fields where we still have, especially for a new patient, they give us
an hour on a new patient, which is huge. … If anything, I feel like I often have a little bit
more time in the outpatient setting than I do in the inpatient setting, where no one’s
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counting my minutes at that point, but you just know that the work is stacking up, so
there’s constant pressure.
Pulmonology NP also mentioned the pressure to see patients currently admitted to the hospital in
an efficient manner:
I can’t see every patient, so I have to focus on like volume, and high-risk patient
populations, so like patients with trachs or patients with chest tubes. What I do is I go to a
list I have of patients in the system who have trach or chest tubes. I go through that list
and see. I do it based also on do they have these devices and where are they with these
devices. If they’re on a nursing unit that doesn’t typically take care of these patients, I
will go there first. That’s how I prioritize it.
Transplant Medicine NP illustrated the long hours spent seeing patients saying, “I see patients
from 8:00 to about 12:00 or 12:30. … I never leave on time. I never leave really before 7:00 or
7:30”.
In addition to the pressure to efficiently utilize time with the patient, three participants
commented on the continuous interruptions or distractions that occur throughout the day. These
interruptions could be from colleagues within the clinic or from other HCPs. Pulmonology NP
shared that she will get a call “because there’s a patient going home with a chest tube or…with a
trach, and they call me to organize that discharge planning because it can get very complex when
they have one of those devices”. Obstetrics MD described the common interruptions that occur
in her practice saying, “there are phone calls and things happening. The nurses are coming to me
and asking me either to fit in, to be seen right away, or to decide how to triage issues or problems
as they’re arising.”
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Neurology PA went into detail about how the many different types of interruptions he
faces each day in the clinic impact his time with patients:
You get paged from the Infusion Center. You get paged from the pharmacy. You get
paged from Radiology. You get paged from other providers. Those are constant
interruptions throughout the clinic sessions. … As soon as you’re out of that room and
you’re visible to other staff, like medical assistants, nursing staff, pharmacy staff, they
don’t understand that you’re not still working with the patient, so they will attack you in
the hallway with Ms. So and So called. Mr. So and So needs this. Hey, can you do this?
Hey, can you just sign this? And a lot has to go with the answer of no, and we’ll just have
to do it later because it’s not far to the patient who’s in the room. It’s also not fair to
myself as a provider because I have a specific train of thought. If I’m trying to decide
between drug A or drug B, or if I’m trying to think about maybe we are going to start off
at this dose or change that dose, oh, wait, did they say that they wanted it to go to the
local pharmacy? I’m still working in that encounter. I’m still working in that clinic visit,
yet that doesn’t dissuade others from seeing you out there and not physically with a
patient, so they’ll bring work to you. A lot of that is sort of interpreting. If something is
mission-critical, certainly you need to address it at that point.
When asked about strategies for creating a schedule that fosters effective PPC, all participants
mentioned that they would have more time with their patients. Besides addressing the concerns
of scheduling, six out of 10 participants felt that changes to clinic personnel would be beneficial.
Participants felt that with additional personnel support, they could spend more time interacting
with patients.
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The findings show that HCPs in all specialties work long hours of compressed schedules.
Changes to scheduling practices and the addition of clinic support staff could benefit HCPs and
patients. Neurology PA summarizes the issue of time and why this problem persists when he
said, “I think the time factor is the biggest modifiable factor that could occur, but unfortunately,
we’re dealing with time constraints and the fact that we’re still in a fee-for-service billing model
which does not incentivize outcomes. It incentivizes volume.” Time spent with the patient is only
one aspect of their work. Each patient visit requires reviewing the medical record before the
visit, completing numerous required fields in the electronic medical record during the visit, and
documenting the visit afterward. Participants said that this administrative time is not always built
into their schedules. While juggling the demands of the schedule and administrative work,
participants noted that interruptions or distractions add additional stress.
Administrative Work
Participants reported that the administrative portion of their day involves dictating notes,
responding to messages on the PWP or email from patients or other HCPs, returning phone
messages, processing prescription refills requests, and reviewing laboratory or radiology reports.
The findings show that administrative tasks are commonly performed during times that could be
considered HCP off-duty time. When asked about ways to remove the barrier of administrative
tasks, only two out of the 10 participants responded, and those responses regarded the
administrative burden of the EMR. Infectious Disease MD said, “fewer requirements for
documentation where the focus is really on what’s documented versus time spent with the
patient.” Psychiatry MD agreed that removing the stress of checking boxes on the EMR so that
HCPs feel that “they aren’t going to get dinged because they didn’t do their medical record and
check every box.”
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The topic of HCP compensation came up with many participants because time spent on
administrative tasks is not included in their compensation and contributes to HCP burnout. The
need for this work to be done late at night or early in the morning impedes an HCP’s work/life
balance and overall well-being. Psychiatry MD illustrated this point by saying: “Now we’re in an
environment where time is money and docs are burning out because, I mean, how much time
does it take to answer of those patient gateway messages?”
Compensation
Participants shared that their compensation does not cover work outside the time spent
during the patient visit. Administrative and other types of work, such as mentoring staff or
trainees or attending educational conferences and sessions, are not always part of an HCP’s
compensation plan. Participants reported that this compensation model does not accurately
reflect their educational or professional standing, nor does it match other professionals of their
caliber in other industries, such as law. Neurology PA explained the current incentive model in
healthcare when he said, “you’re incentivized on the volume, not outcomes; they don’t care.
You’re a salaried employee … if it takes you five additional hours at night to do your work, then
you should do that.”
Emergency Medicine MD illustrated the overarching burden that is contributing to HCP
job dissatisfaction and burnout by saying:
The system would need to build that [administrative tasks] into the workload for the
clinicians and also in the compensation model for the clinicians. The one thing is to say
your responsibility or role is like to have this 30-minute encounter and then everything
after that is on you, whenever you are going to talk to your patient, how much time it’s
going to take, and you’re not going to be compensated by that. You build a system that
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expects that but also considers that as part of clinical work. If you’re exchanging
messages with your patient, you’re doing clinical work the same way you would be doing
if you were to do a synchronous encounter. I think using a synchronous encounter in
person or online to me is everything. Even if you are answering a question via email or
whatever, the follow-up it’s the same thing as talking to the patient in the regular, normal
encounter. I think that’s beneficial. It’s an additional burden if that’s not built into the
system to be part of your job. What’s happened is that part is expected to happen, but
there is no protected time, for example, for the clinician to do that. We have a visit here.
Then the next visit. In between the visits, you’re supposed to answer questions.
Obstetrics MD comments furthered the discussion of compensation when she shared her feelings
of exploitation by her institution, saying:
I think we are not even remotely compensated for the work we do enough, but I think it’s
kind of the [Institution] brand promise, to be undercompensated for what you do, but I
definitely would argue that probably myself and certainly my colleagues aren’t overly
motivated by money, but more by purpose, which I think is probably exploited a little bit
by the [Institution].
Psychiatry MD agreed that patient gratitude, not money, is not his primary motivation, stating
that for him, compensation is more than monetary sharing:
The thing that is most important to me and a particular interest to me, which is a concept
called physician compensation. That is not based on salary. It’s a trick statement. But it’s
the compensation physicians get from receiving the gratitude from patients, and that
gratitude is earned by providing care in a way that’s effective and that they notice and
that they then express back.
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However, he also admitted that he has “enough salary sources that aren’t just from clinical
services, so I’ve got that degree of freedom.” Yet, Psychiatry MD warned that compensation and
HCP personal fulfillment could be an issue for future generations of HCPs when he shared:
If you look at the anticipated shortages in healthcare, upcoming, particularly mental
health care because that’s my business, but not just, given the retirement of people, given
the change in practice even in psychiatry, which is the financial incentives have led to
psychopharmacology being the way to go, which doesn’t pay as much attention to the
stressors for people who have a predisposition to anything manifesting.
The four participants who specifically mentioned compensation as a barrier also acknowledge
that the current compensation model in traditional, not concierge, healthcare makes overcoming
this barrier a challenge. However, two participants shared ideas on creating more significant pay
equity for HCPs. Psychiatry MD shared his thoughts on how compensation may need to change
to attract future generations of HCPs when he said, “if you have … a fee for service model, as
opposed to a salary model, a model that a 5-minute visit is fine, an hour visit is fine, the right
dose is enough time, you’re going to get people who know they’re going to get paid.”
Obstetrics MD furthered the discussion of compensation by sharing examples of the pay
inequities in medicine versus other professions and industries:
Everyone would play by the same rules. Here’s a weird thing. Why do you pay, like you
give your credit card and you pay full price if you don’t show for something, or why
when an attorney is reviewing or speaking to you, or a college student advisor, like why
are they paid by the minute of every time they’re thinking about you? And why would
that be wrong for doctors to do that? Why would that be wrong? That’s my question.
Like, if you’re on the phone with a doctor, telehealth is being covered, and there’s a bill
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to see if it can be extended for a couple more years, but why can’t that be the norm? Like,
you’re working. I just think it’s interesting that people will pay $35 for a manicure but
not a $10 copay.
Clearly, the findings show that compensation is an issue that could contribute to HCP job
satisfaction and, ultimately, patient outcomes. Those participants who voiced their opinion on the
current compensation model in healthcare feel that this creates inequities between themselves
and others in professions at similar educational and work intensity levels. If an HCP feels
overworked and underpaid, this burden could impact their ability to communicate effectively
with patients and colleagues.
Communication
All participants noted that communication is essential for effective provider-patient
relationships, specifically accommodating their communication and language to each patient.
They also agreed that communication accommodation is necessary to meet patients at their
health literacy level and prevent cognitive overload. Many participants also commented on the
communication dynamics between other HCP and clinic staff. When asked about strategies to
remove communication barriers, six of the 10 participants made recommendations based on their
communication experiences with both patients and colleagues.
Communication Accommodation
All 10 participants overwhelmingly agreed that verbal and body language communication
accommodation is needed. The findings show that participants use simplified language when
communicating with their patients to help increase patient understanding and health literacy.
Concierge MD shared that “you’ve got to meet the people where they are…size them up. That’s
the key to communication. Primary care is a communication behavioral change strategy.”
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Psychiatry MD agreed when he said, “Tuning in to where the patient is, their language, their
culture, their history, the particular issues that they bring, their family situation, all of those in the
calculus, the matrix of dealing with a patient, that’s the art of medicine.” To reinforce the
importance of communication accommodation in both verbal and body language, Psychiatry MD
shared that “If I’m stiff, they’re more likely to be stiff.”
Participants also agreed that they employ communication accommodation regardless of
the patient’s health knowledge or literacy. All 10 participants stated that they attempt to initially
speak to patients with little to no health literacy, the same as they would a colleague with
medical training. During the first few minutes of their conversation, they use the patient’s verbal
and body cues to determine their level of understanding. Neurology PA shared that he will often
“ask them what they do for a living. I’ll try to come up with analogies that they might
understand. If … they work in engineering … I’ll try to come up with analogies that are more in
line with what their knowledge set is.”
Communication accommodation and printed encounter summaries are two strategies
HCPs use to increase patient recall. The findings show that communication accommodation is
vital for patient outcomes. Participants felt tailoring their communication is essential in reducing
patient cognitive overload and increasing health literacy.
Health Literacy and Patient Recall
Neurology PA illustrated how he uses communication, both verbal and print, to increase
patient recall and health literacy:
They don’t remember a lot of things that are said during the encounter … if I’m talking
about how the immune system works with the nervous system, which is the vast majority
of my conversations, I’m not diving into what the difference is in a T-cell and a B-cell
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and what those activation systems are and what the downstream issues are with the
immune system and how that affects on a cellular level with the nervous system. They
couldn’t get it. They’ve got no clue. They don’t understand that. Even if the patient is
another provider, even if it’s another healthcare provider, we’re talking about very
complex concepts that, unless they understand that, they’re going to have a hard time
with … once that after-visit summary is printed, I would actually go through that with the
patient again to make sure that they are absolutely clear as to what it is that we’re doing
and address any final questions the patient might have, so going over what is going with
the patient, going over any tests that were ordered, where to get them scheduled if they
need to get them scheduled, or where they need to go if they need to get them done at that
time, if they need to go across the hall to the lab, reviewing the medications that were
prescribed for that visit, where they were going, whether it’s a specialty pharmacy, a
mail-order pharmacy, or a local pharmacy, making sure that that information is correct.
To increase health literacy, Neurology NP shares research articles with her patients because she
feels that “it’s more of a lack of knowledge, or maybe they’re just not aware of it … I think as a
provider, it’s just most important to give them the correct information that they may not have.”
Pulmonology NP shared her strategy to increase health literacy:
[She will] slow things down when I’m talking, and I try to use visual aids as much as
possible. If a patient has a chest tube and they’re going home with one, I will bring a
chest tube that I keep in my office, and I’ll show them this is what’s in your chest.
Strategies to increase patient recall and health literacy are only one facet of the patient visit.
Anesthesiology MD shared how he also uses multiple means of communication to gain the
patient’s trust in them and the entire care team:
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Most of my time interacting with patients is really trying to earn their trust and get them
to realize they’re in good hands and if they have any questions. I try to get to know them
as a person just to make that connection and to make them feel better, so they’re not so
freaked out because most everybody is pretty freaked out when they’re coming to see me
because they’re having an operation. … Most of the patients I see are under significant
stress, and I try to connect with them on that level.
Pulmonology NP also commented on the importance of connecting with the patient. She stressed
how this connection is not only for the patient to trust her but others on the care team when she
said, “I know that I’m not the only person who needs to interact with that patient. … If I’m
working with the primary nurse, I’m trying to give her what she needs.”
Communication accommodation and strategies to help increase a patient’s health literacy
and recall were reported by all 10 participants. As noted throughout the findings, barriers, such
as compressed schedules and administrative burdens, can impede effective communication with
patients, clinic staff, and other HCPs. Some participants acknowledged that when pressed for
time during a patient visit, they may not employ communication accommodation or extend their
conversations with patients to increase that patient’s health literacy.
Removing Barriers to Communication With Patients
All participants felt that communication with patients is critical to favorable patient
outcomes. One participant, Emergency Medicine MD, feels that removing barriers to effective
communication with patients begins with communication training in medical school. He believes
that just as there is a technical process for performing a physical examination with a patient,
there should be a process for communication. Additionally, in his opinion, he thinks
communication needs to be continuously refined. He shared:
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To me, it’s more a product of how we are trained, and there is not enough training in
proper communication with patients. Our training is really focused on the technical part
of medicine. If I think about the structure, not only like a physical structure but like a
system structure, there are really two things. The system would have proper training, and
I mean training not only for students but for all health professionals to continue training
in communication because it’s very complex, and you’ll never be an expert and fully
competent at communication. You always have things to learn.
Anesthesiology MD felt that removing the barrier to effective communication with patients
requires time and someone to listen “to a patient’s concerns and answering all their questions.” If
the time is not taken to listen to the patient and check for understanding, he has experienced
patients who “go home and tell their family, oh, I saw the doctor today, and they said X when
really you said Y.” He surmised that communication is a challenge, beyond the issues of time
and ample support from clinic staff is because:
Communication is remarkably fraught. I don’t think it works well at all, despite the fact
that we’ve been talking to each other since we were age two. People talk every day, all
day, so we think we’re great at it. I think humans are terrible, absolutely terrible, at
communicating. Having been in the healthcare system on the provider side and on the
recipient side, and family members on the recipient side, it takes my breath away how
bad it is.
Clear communication and using multiple means of communication to educate patients and
manage their expectations were mentioned by two participants. Emergency Medicine MD
discussed the issue of information overload that occurs during a patient encounter. Once a patient
has time and space to process the information, they may “Google things. They’re going to have a
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lot of other questions.” He felt that the PWP could facilitate communication between encounters
to help patients and increase communication.
Neurology PA felt that communication is more effective for patients and HCPs if the
patient is clear on whom to contact with questions or concerns, especially in a practice where the
patient interacts with multiple people from the clinic. He explained:
There should be the clear delineation of services from all the different players and clear
lines of communication between the patient and all those different services. … We deal a
lot with specialty medications that require prior authorizations and use of specialty
pharmacies. Those lines of communication have to be very, very clear, and the patient
has to know who it is that they’re asking those questions to. It makes no sense for the
patient not to know who all the different players are in that environment. They’re not
going to be sending messages or calling to ask for the medical assistant if they’ve got a
question about the prior authorization on a medication that they’re waiting for.
Removing the barriers to effective PPC involves communication between the HCP and the
patient and between the HCP and colleagues.
Removing Barriers to Communication With Colleagues
While all participants mentioned that clear communication with clinic staff and other
HCPs is crucial to favorable patient outcomes, three of the 10 participants shared strategies for
removing barriers to communication with colleagues.
Transplant Medicine NP echoed Emergency Medicine MD’s feelings that even though
people have been communicating their entire lives, that does not mean people are great
communicators. She felt this is especially true when conveying messages about patients in the
EMR when the HCP who wrote the note is not readily available to answer questions. In her
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explanation, Transplant Medicine NP mentioned creating a template or exemplar of clear
communication in a patient progress note to remove the communication barrier between HCPs.
She illustrated this when sharing this example:
A provider wrote their progress note on seeing the patient. They were the consult
provider but also really involved in the care. In their note, we often use their notes
because we can’t always get a hold of them in person. It’s difficult ... What were they
expecting to happen today? What did they want to happen? Is what they’re seeing
discordant with what we’re seeing? Because they only see them for about five minutes ...
I always think of peer support. If we could find a provider who knows how to write a
clear note and just duplicate that and standardize it, that would be wonderful because I do
feel like we waste a lot of time and probably make a lot of errors because we don’t
communicate clearly either in our notes or sometimes just verbally, we don’t
communicate clearly.
The challenge of communicating with other HCPs, especially in multidisciplinary settings, was
also mentioned by Infectious Disease MD. When asked about strategies to remove
communication barriers within the practice, she shared that having all the necessary resources
under one roof would be best for HCPs and patients when she said:
Communication with other services ... some of the really well-functioning infectious
disease clinics are those that are embedded in another specialty. For example, we have
one physician who works very closely with the orthopedic surgery services, and then
several of us work over at [Cancer Hospital] as well and are sort of embedded with the
docs at [Cancer Hospital]. I think the communication between services and between
providers is much improved when that happens, whereas if it completely relies on follow-
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up calls or sharing staff notes, things like that, then I think communication can break
down. This would not be needed or doable for every service, but if we were embedded in
services and working side by side with providers, that would, I think, help with
communication a lot.
Neurology PA shared the importance of clear communication within the clinic is vital to his
ability to stay on schedule and provide adequate care to the patient. The key to removing the
communication barrier with colleagues hinges on clear communication between the entire team
at all times. He said for success in the clinic for himself and the patient:
There are no issues with communication when the patient checks in at the front desk, and
the front desk staff is clear around what time their appointments are, what their copays
are, all of that type of stuff, getting them hooked into financial support if they need that,
there is no miscommunication with the MA stuff who are triaging and rooming the
patient with regard to why they’re there, what kind of concerns they have, what their
medications are, doing the medication reconciliation with the patient, that has to be very,
very clear. Those lines of communication have to be very, very clear.
Communication accommodation and clear communication with the patient, clinicians, and
support staff involved in the patient’s care is essential to effective PPC. While people have been
communicating since birth, all participants noted that they could be better, more effective
communicators. Participants felt that removing the communication barrier requires awareness of
their communication skill defects and continuous training to maintain their communication skills.
Summary
The findings in this study show that the most significant barrier to effective PPC is time,
including not enough time scheduled for each patient, condensed schedules leaving little time
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between patients, and the burden of administrative work that is often completed early in the
morning or after a full day of treating patients. Compressed schedules also leave participants
feeling that they do not have enough time to effectively communicate with patients. Participants
agreed that removing the time barrier requires increasing the time for each patient encounter and
adding clinic staff to help support clinicians and patients. Psychiatry MD summarized the issue
of time when he said that time is:
The fundamental cause of the burnout phenomenon. Those schedules which are too
condensed, administrative barriers, and the electronic medical record which actually
physically sometimes takes our back to the patient, the inability to have the time to even
generate empathy which is another of the necessary active ingredient because we’re
distracted by all the other requirements, which could be things in our own life.
The second significant barrier revealed in this study, which was not anticipated at the onset of
data collection, is the issue of compensation. Four of the 10 participants shared that the current
compensation model does not adequately compensate them for work performed outside of the
patient encounter. Given the amount of administrative work and patient follow-up that occurs
outside the examination room, participants feel that they are not paid commensurate with other
people in similar professions of their educational and professional level, such as lawyers.
When embarking on data collection, the emergence of a theme of media influences,
including medical television programming, online health information, HGT, and CHD, was
expected. However, participants did not have any significant comments on these types of media.
Only one participant mentioned online health information, but that comment was in passing and
not significant enough to be considered a theme in the findings.
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When asked about removing the barriers to communication, two themes emerged –
communication with patients and communication with colleagues. Finally, the findings clearly
show that all participants engage in communication accommodation as a strategy to
communicate effectively with patients. In addition to accommodating their speech by using
language that the patient can understand, participants also use printed visit summaries, messages
through the PWP, and visual models. They also provide trusted resources for patients to learn
more about their condition.
Regarding removing the communication barrier with patients, the findings show that
continuing education on effective communication, frameworks for communication similar to the
process for performing a physical examination, and clear communication to the patient on the
available resources and whom to contact for specific needs is essential. Removing the
communication barrier with colleagues requires clear, consistent notes in the EMR, embedding
multidisciplinary teams within a clinic, and ensuring that all clinic staff understand their roles
and can clearly communicate with each other.
All 10 participants agreed that effective communication is key to successful patient
outcomes. The findings show that participants are pressured by time. Participants reported that
removing the time barrier could allow for more effective communication. Participants agreed
that additional communication training and clinic support could also benefit patients and HCPs.
Regardless, without the removal of the significant barrier of time, participants feel that issues
with communication, patient outcomes, and their feelings of burnout will endure.
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Chapter Five: Recommendations
This study explored healthcare providers’ perceptions of barriers to effective
communication with patients. It was important to conduct because a direct correlation exists
between effective PPC, patient trust, treatment compliance, and satisfaction with care. Effective
PPC also increases patient outcomes and HCP job satisfaction. Studying the problem of PPC
from the HCP’s perspective may help influence changes to scheduling practice, human
resources, and communication education both in medical training and beyond. Qualitative
interviews were used to obtain the answers to the research questions. This chapter will begin
with a discussion of the findings, linked back to existing literature and the conceptual
framework. Next, two recommendations for practice will be proposed based on the findings and
literature. The limitations, delimitations, and future research recommendations will then be
presented. Finally, this chapter will close with the study’s conclusions.
Discussion of Findings
This study’s findings align with the conceptual framework created to serve as a guiding
lens for this research. The conceptual framework design was based on CAT and CLT (Mayer,
2010; Farzadnia & Giles, 2015). Each theory supports a better understanding of the
communication dynamic between HCPs and patients. Adding the effects of infrastructural
barriers for HCPs and the effects of the media and implicit bias for both HCPs and patients to the
conceptual framework has given more depth to the understanding of the participants’ perceptions
and perspectives of barriers to effective PPC. Three primary topics emerged from the literature
review: the effects of media and consumer health products, implicit bias, and infrastructure
barriers, including inadequate time allowed for patient visits, patient health literacy, and the
PWP. Across all three of these primary topics, the element of time was prevalent. Two of the
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primary topics emerged during data collection: infrastructural barriers, including time with
patients and time to complete administrative tasks, and implicit bias. The topic of HCP
compensation also emerged during data collection, which was not expected.
When focusing on the HCP’s experience with PPC, all participants felt that while they
make every effort to be clear and effective communicators, their communication skills could be
better. Participants expressed a passion for their profession but feel that time pressures hinder
their abilities to communicate with patients and colleagues and contribute to feelings of job
dissatisfaction and burnout. The findings have addressed this study’s problem of practice by
generating a deeper understanding of the barriers to preventing effective provider-patient
communication.
Healthcare Provider Experience With Media’s Influence on Provider-Patient
Communication
According to the literature, several types of media influence PPC, including medical
television programming, DTCA, consumer health devices, online health information, social
media, and PRW. None of the study participants commented on medical television
programming, DTCA, consumer health devices, or social media as barriers to PPC. Only one
participant commented about online health information but did not feel it influenced their
communication with patients. All participants reflected on the topic of PRW.
All the study participants agreed that they do not find PRW helpful because they are
overly subjective. Most participants stated that they have never even looked at their online
reviews, instead preferring to rely on the more formal surveys and feedback gathered by their
organizations and institutions. There was overwhelming agreement that PRW tend to have
content submitted by patients who were either enthusiastically pleased with their encounter or
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had an extremely negative experience. When posting feedback online, these reviews tend to
focus not solely on the HCP but the entire patient experience, from the parking to their final
conversation at check out. This could include frustration with insurance copays to any delays in
the waiting room, examination room, or reception. The interaction with the HCP could have been
positive, but PRW does not always reflect that particular portion of the visit.
When a review on a PRW does focus on the HCP’s demeanor, skills, or expertise, a
negative review may not accurately reflect the clinical decisions of the HCP. For example, a
patient may leave a poor review for an HCP because they expected to receive a prescription for
antibiotics when such a prescription was not clinically warranted. Therefore, due to the
subjective nature of these websites, study participants stated that they do not look at the ratings
or comments.
While the literature supports PRW as a tool for patients to research providers, the
findings show that these sites are not the most creditable source of information, specifically
regarding an HCP’s clinical expertise. The disagreement between the literature and findings
reveals a gap in credible information for patients on an HCP’s capabilities. It also highlights the
subjective nature of the information or even misinformation available on the internet.
Health Care Provider Experience With Patient Web Portals
There were mixed feelings about PWP, with some participants not in favor, some firmly
in favor, and others feeling that there are clear pros and cons. Regarding patient access to their
medical records and the ability to message their provider through the PWP, most participants felt
that access to medical records is a patient’s right. However, the majority of participants felt that
the additional time spent responding to patient messages adds an extra layer of administrative
burden to the HCP. Those in favor of being able to message patients through the PWP agreed
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that it is time-consuming but appreciate that this type of work can be done without regard to the
time of day, unlike returning patient phone calls.
One of the most significant cons reported by participants was the immediate patient
access to clinical information in the PWP. Participants noted how laboratory, radiological, or
consulting provider notes might be seen by the patient before the HCP has had a chance to
review them. This rapid access to potentially confusing or worrisome information by patients
without medical context can create undue anxiety or panic.
PWP allows patients and HCPs a way to share information between visits regardless of
the time of day. It empowers patients by giving them access to their medical records without
submitting a formal request to the medical practice or hospital. However, because the patient-
facing side of PWP is linked to the HCP-facing side, patients gain access to test results at the
same time as the HCP, thus making the PWP a double-edged sword. It is a benefit to patients and
HCPs, but it can also cause more harm than good when patients receive information that they do
not understand before the HCP can provide context or clarification.
Healthcare Provider Experience With Implicit Bias
The topic of implicit bias elicited the most discussion from the study’s participants.
Participants were very candid in their experiences of implicit bias both towards patients and felt
from patients. Many participants shared how implicit bias toward the patient and felt towards
themselves can affect how they communicate with the patient. While all participants expressed
an effort to remain neutral and unbiased, they acknowledged their humanity, which has been
shaped by their individual life experiences. Gender, age, and medical credential biases were the
three most common reported biases felt toward participants by patients.
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Gender bias towards female HCPs was mentioned by both male and female participants.
This bias included patients referring to female HCPs as nurses despite the HCP being a physician
or advanced practice provider. Perhaps the most significant bias was linked to the HCP’s medical
credentials. Five of the 10 study participants were advanced practice practitioners, with four
nurse practitioners and one physician assistant. All five participants shared that patients
commonly ask when they can see the doctor. Those HCPs who are women of color are already
facing multiple biases in addition to the bias of being an advanced practice provider.
Patients and caregivers entrust HCPs with their health; doing the work of an HCP is
fraught with pressures and responsibilities to make numerous sound medical decisions per hour.
The addition of implicit bias based on gender, age, or medical credential only increases the
pressure felt by those HCPs who are subject to these biases. Given the large number of people
requiring preventative, emergent, and ongoing healthcare, a matrix of clinicians, including
physicians and advanced practice practitioners, is necessary. While removing all three of the
biases uncovered in the findings would be ideal, focusing on the bias of medical credentials is
the most promising. To begin dismantling the bias against advanced practice practitioners,
greater awareness is needed to help educate patients on the diversity of HCPs. As patients begin
to learn and appreciate how different HCPs work together, those providers subject to bias based
on their medical credentials may find that they encounter this bias less over time.
Healthcare Provider Experience With Infrastructural Barriers
Based on this study’s participants, HCPs experience one significant infrastructural barrier
that impedes effective PPC, time. The barrier of time contributes to additional barriers such as
administrative burdens, feelings of burnout, and the unexpected theme of HCP compensation.
Understanding these barriers and how HCPs navigate them is a component of CAT. All
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participants acknowledged employing communication accommodation consciously and
subconsciously when speaking to patients. Participants felt that when they accommodate their
language to the patient, they can communicate more effectively, thus benefitting the patient’s
outcome and health literacy.
Compressed schedules, not enough time with each patient, and a feeling that the
transformation of healthcare into a business has participants feeling burnt out and unappreciated
by their institutions. This feeling is exacerbated by the feelings of compensation discrepancy
between HCPs and other professionals at their level of education and practice, for example,
lawyers. Several participants voiced their frustrations about the number of hours spent outside of
the patient visit reviewing patient charts, dictating clinical notes, interpreting laboratory and
radiology results, and responding to messages from patients and other HCPs, all of which are not
factored into their daily schedule or compensation. One participant worried about a future
shortage of HCPs if changes are not made to how patients are scheduled, HCP compensation, or
both.
The façade of wealth and autonomy as an HCP was shattered in the findings. The long
hours of training transform into highly compressed schedules for salaries that are solely based on
patient volume. Many HCPs do work outside of clinical practice to increase their overall
compensation. Every participant mentioned that a passion for healing or caring for others led
them to a career in medicine. If changes in scheduling practices is not resolved, HCPs will
continue to burnout and patient outcomes will suffer. If the gap in compensation between HCPs
and other professions, such as lawyers, is not resolved, the current shortage of HCPs will persist
and perhaps become critical. While the issues of time and compensation are separate, they are
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interrelated and critical to the problem of effective PPC, patient outcomes, and HCP job
satisfaction.
Recommendations for Practice
While there are many factors to effective PPC, one consistent theme was present in the
findings: time. Given the nature of medicine, time is always of the essence. HCPs need time to
establish rapport, take a complete history, perform a thorough physical exam, and convey their
findings, diagnosis, and treatment. Patients need time to share their concerns and ask questions.
HCPs are allotted a specific length of time for each type of patient visit. The time allotted may
not always be sufficient. Deviations from the schedule by even one or two minutes due to a
patient arriving late or the visit running over create a domino effect that can be difficult or
impossible for the HCP to recover from. Increased implicit bias may be seen when there is
decreased time. For example, suppose an HCP has seen several patients with the same flu-like
symptoms. In that case, they may assume that the current patient exhibiting the same symptoms
also has the flu with little or no physical examination. However, that patient may not have the
flu.
Since medical training inherently fosters cognitive shortcuts leading to implicit bias and
HCPs are constantly pressured for time, implicit biases occur. DTCA, CHD, HGT, and medical
information readily available online create increasing complexities for PPC. HCPs are already
time-constrained, and patients have more resources than ever to help increase their health literacy
and allow them to participate in SDM more actively. Thus, a vicious cycle of inadequate time is
perpetuated. If the time barrier can be resolved, it is possible that PPC can become more
effective, creating increased patient outcomes and HCP provider job satisfaction.
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This section will discuss two potential means of solving the time barrier in effective PPC.
The first is to create a yearly communication continuing medical education (CME) requirement.
The second is creating a learning management system (LMS) integrated into the existing PWP to
increase patient health literacy and SDM.
Recommendation 1: Yearly Communication-Focused Continuing Medical Education
Requirement
Research shows that HCP skills correlate with patient satisfaction, outcomes, and
malpractice claims (Lundberg, 2014). Communication failures between HCPs and their
colleagues and HCPs and patients contribute to medical errors and adverse patient outcomes
(Hewett et al., 2009). “The purpose of continuing professional development/continuing medical
education (CPD/CME) is to promote maintenance and continuous improvement of the
competence and performance of individual medical doctors or healthcare teams in providing
exemplary healthcare for patients” (Regnier et al., 2021, p. 2). CME credits are required to
maintain credentialing and board certifications and are earned through conferences, virtual
seminars, online modules, and other types of training (Ghanem et al., 2018). HCPs tend to
engage in active learning activities versus learning to fulfill a specific requirement (McMahon,
2016), yet traditional CME programs use lecture formats that miss an essential opportunity for
interactive and experiential learning (Austin et al., 2019; Hilty et al., 2018). The findings support
that ongoing communication education is beneficial. Several participants mentioned the need to
support new and tenured providers in communication skills in the examination room and clear
communication through the PWP.
Continuing competency-based medical education (Lochnan et al., 2020), focused on
quality improvement (Sapir et al., 2016), with peer teaching and case-based teaching, are the
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most effective educational strategy (Kanneganti et al., 2020). Creating an annual
communication-focused CME requirement can address communication challenges and increase
HCP skills with patients and colleagues (Lundberg, 2014). McMahon (2016) found that:
Hospitals and health system leaders report that investment in CME has helped them
improve physician performance, patient outcomes, and care coordination; drive and
manage change, including behavioral and cultural change; improve teamwork and
collegiality as well as leadership skills, and reduce burnout and turnover. (p. 1405)
Institutions that tailor their programs to focus on system-wide areas or priorities tend to see more
significant gains in learning, behaviors, and leadership (Hopkins et al., 2018).
Recommendation 2: Learning Management System to Increase Patient Health Literacy
The findings demonstrate that HCPs do not feel they have enough time with a patient to
communicate in a manner that helps foster increased health literacy. Research shows that HCPs
overestimate their patients’ health literacy (Schillinger et al., 2021). Yet, in acute care settings,
27% of patients do not recall being told their diagnosis, and only 61% know their treatment
(Schlindwein et al., 2019). There has been significant debate regarding patient access to their
medical records. The concern is that giving patients access to this information could negatively
impact PPC. Participants in the study echoed this debate in their mixed feelings on patient access
to medical records. The findings show that patient access to medical records, sometimes even
before the HCP has reviewed the information, causes undue anxiety. One participant even shared
how this access caused a delay in surgery. However, research shows that patient web portals
(PWP) do not increase patient requests for appointments with HCPs but increase patient trust and
involvement in care (Schlindwein et al., 2019). However, PWP, primarily text-based, creates an
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accessibility barrier for patients with low health literacy (Baker et al., 2011; Coughlin et al.,
2018).
Balyan et al. (2019) found that:
Analyses of healthcare service utilization rates demonstrated that patients with predicted
limited HL [health literacy] had on average 10 outpatient clinic visits annually, compared
to an average of 8 to 9 among patients with adequate HL. Similar differences were found
for emergency room visits and inpatient hospitalizations. (p. 9)
The PWP has been designed to share quality information and resources (Fernandez et al., 2017).
However, most present this information in a way that fosters increased health literacy. Baker et
al. (2011) explain that “individuals with low health literacy have difficulty reading and
understanding written information and comprehending numerical information and performing
calculations, and they tend to have worse baseline knowledge, short-term memory compared
with individuals with higher health literacy” (p. 74).
The second recommendation aims to foster increased health literacy by developing a
learning management system (LMS) integrated into the electronic medical record system (EMR)
and PWP. The LMS would deliver patient-specific health information in multiple formats,
including audio, video, and written transcripts. Each learning module would also include
supplemental materials, trusted websites, and resources. Studies show that patients with low
health literacy benefit best when information is presented in multimedia, including audio and
visual (Baker et al., 2011; Coughlin et al., 2018). The LMS would automatically grant patients
access to materials pertinent to their health based on the ICD-10 code, prescription log, and any
chronic conditions recorded on their PWP. Utilizing these data sources will benefit all patients,
especially those with chronic conditions who utilize PWP more often (Coughlin et al., 2018).
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The LMS would also have non-condition-related information for all patients, including but not
limited to wellness, nutrition, and exercise topics. The practice or hospital system will have the
option to include content about the institution, how to prepare for your visit, and other important
information. HCPs would have the option to include a short welcome video about themselves to
foster patient comfort and connection before their first visit.
For communication to be effective, both parties need the appropriate skills and
knowledge. Despite possessing the necessary skills, these skills can degrade over time. Creating
a communication-focused CME requirement would ensure that all HCPs increase and maintain
their communication skills not only with patients but also with their colleagues. The goal of the
LMS is to increase patient health literacy by providing personalized, trusted information for
patients based on their health needs. The inclusion of welcome videos by HCPs will allow
patients to create a rapport and begin fostering a relationship with their HCP before the first visit.
Economic Evaluation of Each Recommendation
To demonstrate the costs and benefits of each recommendation, an economic evaluation
was performed. This section will elaborate, in detail, on the costs and benefits of the identified
issues, outline each recommendation, and conclude with a cost and benefit analysis. Table 4
outlines the costs and benefits of identified issues.
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Table 4
Costs and Benefits of Identified Issues
Costs of adverse patient outcomes Benefits of removing barriers
Dissatisfied patients and caregivers Increased patient retention
Increased morbidity and mortality due to
decreased treatment compliance and
increased complications
Decreased patient complications
Increased malpractice claims Decreased malpractice claims
Decreased shared decision-making Healthcare savings due to increased patient
health literacy
Decreased HCP job satisfaction Increased HCP retention
Programmatic Outline of Each Recommendation
Recommendation 1: Yearly Communication-Focused CME Requirement
There are many benefits to creating a yearly communication-focused CME requirement,
including ongoing communication training that may lead to better communication
accommodation, prevention of bad communication habits, and continuous learning on best
practices. Better communication can increase patient satisfaction, treatment compliance,
outcomes, and provider job satisfaction. The potential topics that can be included in this CME
requirement include implicit bias, conflict resolution, active listening, role plays, and healthcare
stereotype (both by the HCP and towards the HCP).
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Recommendation 2: LMS Integrated With the EMR and PWP
The integrated LMS would offer videos and resources that are automatically added to a
patient’s record based on the ICD-10 code, prescribed treatment, and any chronic conditions
noted in the medical record. These videos will be created at a 6
th
-grade education level, will be
recorded in English with subtitle options that can be based on the community’s demographics or
include all languages available through the translation software, and will include transcripts that
can be translated using online translation software. Contracted HCPs would record and review all
the evergreen content. Additionally, each HCP in practices investing in the software can create
an introductory video to establish rapport and help decrease whitecoat anxiety before the first
visit. Templates to plan for your visit, trusted websites with links to additional included on the
site and with each video, and additional content to increase health literacy and patient wellbeing
would be included. Topics included in the supplemental wellness content would focus on healthy
eating, fitness, the benefits of sleep, etc.
The primary benefit of this recommendation would be the ability for patients to review
the information multiple times in a familiar setting and share the information with caregivers and
family, which would decrease calls with questions and increase health literacy, SDM, patient and
caregiver involvement in care, and overall patient outcomes. Additional benefits include
decreased patient visits due to complications because of treatment non-compliance, and
increased outcomes can increase patient and healthcare provider job satisfaction, decreasing
attrition.
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Costs and Benefits of Each Recommendation
All calculations for the cost and benefit analysis of each recommendation are based on
one hospital system, Massachusetts General Brigham (MGB), located in Boston, MA. The
assumptions for these analyses are outlined in Table 5.
Table 5
Assumptions for Cost and Benefits Analyses
Line item Value
Patients served per year
78,000 (Mass General Brigham, n.d.)
HCPs within the hospital system
6,500 (Mass General Brigham, n.d.)
Number of surgeries performed per year
20,000 (Massachusetts General Hospital, n.d.)
CME course creation $15,000 per course hour (Arabadzhiev, 2021)
Doctorate-level Educational Consultant for
CME (40 hours total)
$130,000 per year (http://www.salary.com)
Full-time Administrative Assistant salary
$63,000 (https://www.ziprecruiter.com)
CME yearly accreditation fees
$7,500 (Kinglad, 2017)
Physician retention cost (including
recruitment, sign-on-bonuses, lost billings,
and onboarding costs)
$750,000 (Berg, 2018)
Average physician attrition
21% (https://aappr.org/2021/10/07/physician-
shortage-worsens-nationally-impacted-by-
covid-19/)
Average malpractice claim (average of all
provider types)
$310,000 (Mrkonjic, 2021)
Average number of surgeries performed by
HCP per year
400 (Ritchie Jr et al., 1999)
Patient retention cost
$19,000 (RevSpring, 2019)
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Line item Value
Patient complication reduction 30% of surgeons prevent a complication in
2% of surgeries = 0.6% (T. Sullivan, 2018)
Transcriptionist
$25 per hour (https://www.upwork.com)
Full-time LMS Project Manager
$119,500 (https://www.ziprecruiter.com)
Full-time Software Developer
$108,676 (https://www.glassdoor.com)
Chetu translation software $125 per content hour
(https://www.chetu.com)
120 TB Google Cloud storage $300 per 30TB = $36,000 per year
(https://cloud.google.com/pricing/list)
Indirect costs
15% of direct costs
Increased patient health literacy savings $993,000 per year (UnitedHealth Group,
2020)
Percent decrease in healthcare utilization due
to increased health literacy
15% (UnitedHealth Group, 2020)
Benefits per for CME Percentage reduction in surgical
complications (2%) in the number of
surgeries performed per year (20,000) =
400, multiplied by the percentage of
surgeons who applied knowledge from
CME (30%) = 120, multiplied by the
average malpractice claim ($310,000) =
$37,200,000.00
Benefits per year for full rollout of LMS Physician retention ($750,000) X Physician
attrition (21%) X Number of providers at
MGB (6,500) = $1,023,750.00
Table 6 details the costs and benefits of developing and implementing the yearly
communication-focused CME requirement recommendation. Table 7 breaks down the
development and ongoing implementation costs and benefits of the EMR integrated LMS
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recommendation. Table 8 analyzes the costs and benefits of implementing and utilizing the
integrated LMS at the hospital system level. Finally, Table 9 outlines both recommendations’
comprehensive costs and benefits analysis.
Table 6
Recommendation 1: Yearly Communication-Focused CME Requirement
Category Item Cost per course
per year
Benefits per year
per hospital
system
Monetary value
Program
development
Course creation
(per 4-hour
course at
$15,000 per
hour)
$60,000 Physician
retention
$750,000
Educational
consultant (40
hours of work)
$2,500 Reduction in
malpractice
claims
$310,000
Administrative
costs per year
$63,000 Patient retention $19,000
Accreditation
fees per year
(per course)
$7,500 Decreased
patient
complications
$1,500,000
Total
development
costs
$133,000 Total benefits
per year
$2,579,000
Ongoing costs Administrative
costs per year
$63,000
Accreditation
fees per year
(per course)
$7,500
Total ongoing
costs per year
$70,500
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Table 7
Recommendation 2: EMR Integrated LMS Software Development
Year 0 Item Cost per
year
Year 1 Item Cost per year
Development
resources including
asynchronous and
synchronous
materials (10 hours
of content)
$150,000 Development
resources
including
asynchronous
and
synchronous
materials (60
hours of
content)
$900,000
Transcriptionist (10
hours of content)
$250 Transcriptionist
(60 hours of
content)
$1,500
LMS project
manager
$119,500 LMS project
manager
$119,500
Software developer $108,676 Software
developer
$108,676
Translation software
(10 hours of
content)
$1,250 Translation
software (60
hours of
content)
$7,500
120 TB data storage
$36,000 120 TB data
storage
$36,000
Indirect costs
$62,351.40 Indirect costs $175,976.40
Total
Year 0
cost
$478,027.4
0
Total
Year 1
costs
$1,349,152.40
Year 0
benefits
per year
per
hospital
system
Physician Retention $0 Year 1
benefits
per year
per
hospital
system
Physician
retention
$375,000
127
Software
develop-
ment
only
Reduction in
malpractice claims
$0 Beta
testing
(assume
50%
benefit)
Reduction in
malpractice
claims
$155,000
Patient retention $0 Patient retention
$9,500
Increased health
literacy savings
$0 Increased health
literacy savings
$496,500
Total
Year 0
benefits
$0 Total Year 1
benefits
$661,000
Year 2 Item Cost per
year
Year 3+ Item Cost per year
Development
resources including
asynchronous and
synchronous
materials (30 hours
of content)
$450,000 Ongoing
content
maintenance
assuming 10
hours of new
content per year
$150,000
Transcriptionist (30
hours of content)
$750 Transcriptionist
(10 hours of
content)
$250
LMS project
manager
$119,500 LMS project
manager
$119,500
Software developer $108,676 Software
developer (0.5
FTE)
$54,338
Translation software
(30 hours of
content)
$3,750 Translation
software (10
hours of
content)
$1,250
120 TB data storage
$36,000 120 TB data
storage
$36,000
Indirect costs
$107,801.4
0
Indirect costs $62,351.40
128
Total
Year 2
costs
$826,477.4
0
Total
Year 3+
costs
$478,027.40
Year 2
benefits
per year
per
hospital
system
Physician retention $562,500 Year 3+
benefits
per year
per
hospital
system
Physician
retention
$750,000
Full roll
out
(assume
75%
benefit)
Reduction in
malpractice claims
$232,500 Reduction in
malpractice
claims
$310,000
Patient retention $14,250 Patient retention
$19,000
Increased health
literacy savings
$744,750 Increased health
literacy savings
$993,000
Total
Year 2
benefits
$991,500 Total
Year 3+
benefits
$1,322,000
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Table 8
Recommendation 2: EMR Integrated LMS (Hospital System Utilization)
Item Cost per year per
hospital system
Benefits per year per
hospital system
Monetary value
Subscription (per
year based on
$25,000 for self-
hosted LMS)
$25,000 Physician retention $750,000
LMS access per year
assuming $2 per
year for a hospital
system with
78,000 patients
$156,000 Reduction in
malpractice claims
$310,000
Patient support
(assuming 0.2 FTE
of administrative
support at $63,000
per year)
$12,600 Patient retention $19,000
Increased health
literacy savings
$993,000
Total costs per year $193,600 Total benefits per
year
$1,322,000
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Table 9
Cost-Benefit Analysis for Each Option
Costs per year Benefits per year Percentage of
change
Total
cost/benefit
Recommendation
1: CME
(development)
$133,000 $37,200,000 0.6% $90,200
Recommendation
1: CME
(ongoing)
$70,500 $37,200,000 0.6% $152,700
Recommendation
2: LMS
Year 0
$478,027.40 $0 0% -$478,027.40
Year 1
$1,349,152.40 $661,000 15% -$1,250,002.40
Year 2
$826,477.40 $991,500 15% -$677,752.40
Year 3+
$478,027.40 $1,023,750,000 15% $153,084,472.60
Net present value
$98,578,084.16
Recommendation
2: LMS
(hospital
system costs)
$193,600 $1,322,000 15% $4,700
Discussion of Cost and Benefit Analysis
Each recommendation’s economic evaluation suggests that a yearly communication-
focused CME requirement and an LMS to increase patient health literacy have significant value
and benefit. Each option addresses the problem of PPC from different perspectives and for
different stakeholder groups. The CME option focuses on the HCP, while the LMS focuses on
increasing the patient’s health literacy. The LMS has a more considerable overall benefit of
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$153,084,472.60 at full roll-out in year three and beyond and a net present value of
$98,578,084.16, despite having a total negative cost-benefit in the first three years, as shown in
Table 9. Further support for the LMS comes from the cost-benefit analysis at the hospital system
level. While the total cost-benefit at this level is not nearly as significant of a value, it could be
argued that as HCPs and patients become more aware of the LMS, the total cost-benefit would
increase year over year.
There are advantages and limitations to each option. For the yearly communication-
focused CME, there is a limitation in making this type of CME course required at the
organizational level and gaining HCP buy-in into the value of requiring a specific type of CME
each year. New CME content must be continuously created and submitted for accreditation each
year. This continuous need for new content is both a limitation and an advantage. It is a
limitation in that the project is never complete, and new communication-focused training will
need to be developed and approved by the organization and the Accreditation Council for
Continuing Medical Education. There are also potential administrative challenges of tracking
which communication CME each HCP has already gained credit. The advantages of continuous
content development are that the organization can create pieces of training that focus on the
institution’s needs at that time. The need for consistent new content allows for just-in-time
training versus just-in-case training. As healthcare organizations become more equitable places
that honor the diversity of their patients and practitioners, the yearly communication-focused
CME with the need for continuous content creation could help achieve several institutional goals.
The LMS has the distinct disadvantage of high start-up costs and the time needed before
it can be tested with patients. The developers will need to work closely with other software
developers to allow for integration with the EMR and billing systems. These systems are
132
proprietary and would require collaboration with the software developers at those organizations.
Non-disclosure agreements will most likely need to be drafted and signed by all parties. There
could be implications of conforming with Health Insurance Portability and Accountability Act
(HIPAA) laws. The final consideration is the maintenance of the LMS. The software will need
continuously upgraded based on the EMR and billing system interface. New content will need to
be updated or added regularly. The advantages of the LMS, beyond the benefits already outlined
earlier, are the ability to add new content continuously. The addition of content is a limitation
because of the investment in continuous upkeep and an advantage because it allows the LMS to
provide the most up-to-date information for patients. As more hospital systems subscribe to the
service, the maintenance costs could be recouped over time.
The literature and data collection concludes that time is the most significant barrier to
effective PPC. The ability to focus on the HCP and the patient could have multiple effects on
eliminating barriers to PPC over time. Given each option’s massive monetary benefit value, it is
recommended to implement both options, as they both have significant cost-benefit values for
the institution and focus on separate stakeholder groups. The investment in each option can be
justified by the overall benefits realized.
Limitations and Delimitations
Several limitations, or influences beyond the researcher’s control, exist in qualitative
research (Merriam, 2016). The most critical limitation is the researcher’s presence; participants
may filter their responses (Creswell & Creswell, 2018). Maximum variation, member checking,
and triangulation can mitigate some of these limitations, but not all aspects of qualitative
research can be controlled (Merriam, 2016). For example, the honesty and candidness of
participants are out of the researcher’s control. Researcher bias is another potential limitation.
133
Despite using reflexivity, it is impossible to eliminate potential biases completely. Finally, the
duration of the study is another critical limitation to acknowledge. The number of participants
may not capture data representing all real and perceived barriers to healthcare provider-patient
communication. One significant limitation of the study was the number of participants and the
interview length. All participants in the study were practicing HCPs; thus, recruiting enough
providers to gather sufficient data was a challenge, even when limiting the interview to thirty
minutes. The need to use the time efficiently necessitated creating an interview protocol that did
not probe deeply into any of the areas of focus.
Delimitations are those aspects of the study that are within the researcher’s control
through the research design (Maxwell, 2013). While the study was designed based on
convenience and access to the sample, the design was crafted to test and analyze the theories
described within the conceptual framework. Using interviews allowed for a targeted and
purposeful inquiry that resulted in data-rich information (Creswell & Creswell, 2018; Maxwell,
2013; Merriam, 2016). Although the study was bound to 10 interviews and only represented the
perceptions of the participants, it provided new knowledge and a basis for future expanded
studies.
Recommendations for Future Research
This section discusses four recommendations for future research based on this study’s
findings and conceptual framework. The recommendations for future research have been
generated based on the limitations and delimitations of this study. The primary concern includes
the limited sample size.
The first recommendation is to replicate this study using a larger sample size. The larger
sample size would allow for a deeper understanding of HCP experiences with PPC. The larger
134
sample size could also include other HCPs, such as dentists, certified midwives, and physical
therapists. It would also allow for data analysis across HCP types and a deeper analysis of the
perceived barriers by specific HCP types. Provider-specific data analysis would allow for a
greater understanding of the unique challenges faced, if any, by advanced practice practitioners
(physician assistants and nurse practitioners) versus physicians. This data could not only
corroborate the findings of this study but also uncover new themes or barriers, especially if the
larger sample size included additional HCP types.
The second recommendation is to replicate this study in one institution or organization.
This study employed a convenience sample. It would be interesting to learn if the same findings
are gathered when focusing on a cohort of HCPs. By replicating this study design at one
institution or organization, the stakeholders could learn the barriers to effective PPC specific to
their clinicians. Replicating this study in one institution or organization would also allow for
changes, such as the recommendation of a yearly communication CME requirement, updated
scheduling practices, or compensation models to be implemented and assessed.
The third recommendation is to replicate this study with HCPs in private practice. All
participants in this study worked for large institutions, including one participant who practices
concierge medicine. It would be interesting to learn if HCPs in private practice face the same
challenges as their counterparts in large hospitals and physician organizations. These findings
could help determine new or refined recommendations to help create an environment that fosters
more effective PPC.
The final recommendation for future research is to complete a series of multiple
quantitative studies. The quantitative studies component could measure areas of the research that
were not thoroughly investigated through the qualitative study, such as feelings about the media,
135
including HGT and CHD, the internet, and television, HCP feelings of job satisfaction, level of
burnout, and opinions on HCP compensation. Combining the results of the current study findings
or adding them to a replicated study with larger sample sizes or a study at one institution would
create a deeper understanding of the problem of barriers to effective PPC. It would also generate
data linking the perceived barriers to HCP job satisfaction and felt levels of burnout. This
information could be crucial in garnering stakeholder support for implementing changes that
foster more effective PPC.
In summary, there are several ways that this study can inform future research. The four
proposed recommendations are based on the study’s findings, limitations, and delimitations.
These recommendations offer a way to expand and deepen the study that can be used to effect
change within the healthcare system that supports effective communication between HCPs and
patients. These changes would ultimately benefit patients, HCPs, and the healthcare system.
Conclusion
This study focused on the healthcare provider and patient communication problem
affecting patient outcomes and job satisfaction. The research questions have been answered
through a qualitative study including physicians, nurse practitioners, and a physician assistant.
The findings can be leveraged to inform organizational changes and for future research. Overall,
the findings show that time is the most significant barrier to effective communication. In addition
to time, the findings show that implicit bias is a challenge, especially for female and advanced
practice practitioners. The topic of provider compensation was uncovered in the research and is a
concern as it relates to both the barrier of time and the future recruitment of HCPs. Changes are
necessary to foster more effective PPC to avoid catastrophic provider shortages, especially
during regional, national, and global health emergencies like the COVID-19 pandemic.
136
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Appendix A: Participant Enrollment Letter and Informed Consent
Dear [Participant],
Thank you for agreeing to participate in my study on Barriers to Effective Healthcare
Provider-Patient Communication. The purpose of this study is to gain insight into real and
perceived barriers to effective healthcare provider-patient communication from the perspective
of the healthcare provider. Your participation in this study is entirely voluntary.
The interview will be conducted via Zoom, should last no more than one hour, and be
recorded to facilitate data collection. Everything discussed during the interview will be treated as
strictly confidential. You may skip questions or end the interview at any time. All findings for
the study will be reported in the aggregate. When an actual quote is reported in the study, it will
be anonymous and identified in the form of “Provider”. No names or clinic affiliations will ever
be associated with the findings. Additionally, the transcripts will only be reviewed by myself,
and the Zoom recording files will be deleted when the study is completed.
Next steps:
1. Sign the Informed Consent document [Link to DocuSign]
2. Schedule your interview time using this link: [Link to Calendly]
3. Complete the Demographic Survey [Link to Qualtrics]
Sincerely,
Tinamarie A. Terrasi
164
Appendix B: Demographic Questions for Interview Protocol
Question Response options
1. How many years have you been practicing
medicine?
0–5 years; 6–10 years; 11–15 years; 16–19 years;
20 or more years
2. What type of medical credential do you
hold? (Choose one)
Medical Doctor; Osteopathic Doctor; Physician
Assistant; Nurse Practitioner
3. In what is specialty do you practice? Family Medicine; Internal Medicine; Pediatrics;
Anesthesiology; Dermatology; Head and Neck
Surgery; Neurology; Neurosurgery; Obstetrics
and Gynecology; Ophthalmology;
Orthopedics; Pathology; Psychiatry; Radiation
Oncology; Radiology; Surgery; Other
4. Please rate your current job satisfaction on
a scale from 1 to 10, with 1 being very
unsatisfied and 10 being extremely
satisfied.
Likert Scale 0–10
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Appendix C: Interview Protocol
Introduction to the interview:
Thank you for taking the time to meet with me. I feel fortunate to interview you. I have
planned this interview to last no longer than one hour. During this time, we have several
questions that I would like to cover. To facilitate data collection, I would like to record our
conversation today. Do I have your permission to record this session? All information provided
will be confidential and scrubbed for any identifying information in the final data analysis. Your
participation is voluntary, and you may stop at any time if you feel uncomfortable. Thank you for
agreeing to participate.
You have been invited to speak with me today because you have been identified as
someone who has a great deal to share about healthcare provider-patient communication. This
research project focuses on healthcare provider-patient communication as this relationship
directly correlates with patient outcomes and healthcare provider job satisfaction. More
specifically, I am interested in uncovering perceived barriers to effective communication from
the healthcare provider’s perspective. The information gathered from these sessions will be
evaluated to find common and divergent themes between healthcare providers to make
recommendations.
Everything we discuss will be treated as strictly confidential. All findings for the study
will be reported in the aggregate. When I report an actual quote in the study, it will be
anonymous and identified in the form of “Provider”. No names or clinic affiliations will ever be
associated with the findings. Additionally, the transcripts will only be reviewed by myself, and
the Zoom recording files will be deleted when the study is completed.
166
If you have questions about your rights while taking part in this study, or you have
concerns or suggestions and want to talk to someone other than me about the study, please call
(323) 442-0114 or email irb@usc.edu. You can reference IRB # UP-21-01115.
Do you have any questions about the purpose of the study before we begin?
Begin recording and again ask the participant again for informed consent and permission to
record.
Interview Protocol
I would like to begin the interview by thanking you for completing the demographic survey
before our time together.
To begin, I would like to learn more about your typical day-to-day experience in the clinic.
1. Can you share with me in as much detail as possible a typical day in the clinic from
start to finish? We can begin with what time you arrive on a typical day.
• How much time do you typically have between patients?
• When do you take breaks in the day?
• What do you do on your breaks?
Next, I would like to hear your thoughts on the effects of media on provider-patient
communication.
2. How you feel online rating sites such as Healthgrades and Yelp?
• What influence, if any, do these sites have on your patient loads?
• What effect do you feel the comments on these sites have on provider-patient
communication?
167
• What about other forms of media such as pharmaceutical advertising, medical
television programming, online health information, or consumer health
devices?
3. Have you experienced colleagues accommodating their communication style or
terminology used based on the patient?
• What accommodations, if any, do you make with patients?
• How have you experienced patients accommodating their communication with
you?
4. What are your thoughts on patient portals?
• What types of interactions do you typically have with patients through the
portal?
• In what ways have patient portals impacted your workload?
• How or in what ways do you use the patient portal?
Now I would like to explore your views on implicit bias. For this study implicit bias is defined as
5. Have you experienced implicit bias with a patient?
• If you have experienced bias towards a patient, what factors contributed to
that bias when reflecting on that experience?
• If you have experienced bias from a patient, how did that feel?
Finally, I would like to gain some insight into your views on clinic structure.
6. If you could create a clinic that fully supported communication, what would that look
like?
• How many patients would each provider see per day?
• How much time would be dedicated per patient?
168
• What types of support staff would be present?
• What resources would you like to see that are not provided?
Conclusion to the interview:
Thank you so much for sharing your insights with me. I appreciate your time and
willingness to share. Your openness and honesty about provider-patient communication will be
beneficial to the study. If I have any follow-up questions, can I contact you by email? And if you
have any additional thoughts, please email me. Again, thank you for participating in my study.
169
Appendix D: Additional Findings
Table D1
Removing Scheduling Barriers
Participant
pseudonym
Response
Concierge MD You can’t communicate in 15 minutes. … [My patients are usually]
scheduled in one to two-hour blocks … we don’t schedule people for
anything less than 30 minutes.
Obstetrics MD I’d have an hour per patient.
Emergency
Medicine MD
A structure that has communication as a protected time. You’re expected
to have this encounter of 30 minutes and expected to have this amount
of time for communication that is built into the system. You don’t leave
it to the clinician to decide how much time I’m going to spend on the
examination, how much time I’m going to spend on medical charting,
how much time I’m going to spend on communication. You have
training, and you build that as part of it. You take care of the patient, and
now you have communication, whatever you need to communicate, but
then having training on how to communicate because if you only have
the space and the time and people don’t know how to communicate, it
also doesn’t work. The same as people who know how to communicate
well but they don’t have the time and the structure to do that.
Anesthesiology
MD
My clinic or my sphere would be with ample time and individuals on my
side, the ones I have some control over, to understand that you need to
check that the patient heard what you wanted to say. Check with them.
Close loop it. Whether it’s reiterate back or hear back from them, it’s
critical. Because otherwise, they’re going to go home and tell their
family, oh I saw the doctor today, and they said X when really you said
Y, and so it goes.
Infectious
Disease MD
More time … I think one thing we do really well with our patients who are
living with HIV is we have a very team-based approach where they’re
brought in by the medical assistant, seen by me, and then seen by one of
our social workers as well, sometimes before or after, but really making
sure—and there are always things that are uncovered with the social
worker that are not uncovered by me, so really having that opportunity
to meet with the social worker, discuss with the social worker what the
issues were there, and loop back with the individual, probably in the
same visit just to make sure all issues are addressed before they go.
170
Neurology NP I don’t really know the number of patients that is ideal but obviously not
overbooking, and I think allowing the providers to have some kind of
time slot in between the morning and the afternoon to either catch up
with their messages so that they’re not behind or do other things. I know
at [Institution] they give the doctors maybe a 20-minute time slot after
maybe a lot of office visits. If they are backed up, it gives them time to
catch up. I think just having adequate time to see the patients, not
overbooking, being able to catch up on your messages, and all your
other results would be ideal.
Pulmonology NP The discharge time is a vulnerable time, and admission, but discharge, and
that is such a rushed process, it is unbelievable … I would say that I feel
like if the discharge plan is not going the way we anticipated it to, then
the primary nurse, or the case manager, or the social worker should be
able to hold a time out and say, no, this is not going to work today. We
still have to do this, this, and this for this patient to go home safely.
Transplant
Medicine NP
I would have at least 30 minutes with every patient.
Neurology PA In an ideal world, we would give them more time. So, instead of the 30-
minute return visit, it would be 40 minutes, at least, for a return visit so
that we could address all of their concerns and have that really be
interdisciplinary. So, if they needed 10 minutes with the social worker,
they should get 10 minutes with the social worker. If they needed more
time to do X, Y, and Z, they should be able to get that.
171
Table D2
Suggested Personnel Changes
Participant
pseudonym
Response
Concierge MD You’ve got to have people to go into healthcare that want to communicate.
Obstetrics MD I think more medical assistants would be helpful and nurses would be
useful, but really the medical assistants because the flow through is
always where I get backed up, like getting patients into rooms. By the
time they’re done interviewing them, there could be another room that’s
cleaned and another person being walked to the room.
Infectious
Disease MD
We would need more stability, is the honest answer. We have—and I think
a lot of the specialty clinics are going through this right now is a lot of
turnover. Like almost weekly, we’ve got someone who’s leaving. We
used to have long-term nurses that ran everything, but now it’s all
medical assistants that are just great; many of them are really great; they
just don’t stay for very long. So, consistency would be helpful.
Consistency in who answers patient calls.
Neurology NP For outpatient, we would definitely have an LPN or an RN to obviously
bring in the patient, check them in, check them out, have them follow up
if there is any follow-up that needs to be done as well, like front office
staff. I assume some kind of coordinator.
Transplant
Medicine NP
I would have my nurse in the room with me. I would have more social
workers. We have them on site. But everybody’s depressed and anxious,
right … I have a nutritionist already, and I have a social worker, but it’s
one for all of them, so I would need more of that. We have the telemed
translator … and I hate that. I would prefer to have someone in the room
with me and not use that.
Neurology PA You have to have lots of different providers there. You have to have Mas
[medical assistants]. You have to have nurses. You have to have the
front desk staff. You have to have clinical pharmacists. You have to
have the providers. You have to have—it would be great to have, and in
a specialty area, you really should have—social workers and access care
managers. All in the same environment and all working to top of scope.
That’s incredibly important. If you have that, and everybody is working
together, and the patient understands who everybody is, and there are
clear lines of communication, then that patient knows where to go to get
resources. And on the other side, the team knows who’s responsible for
providing the patient those resources.
172
Table D3
Administrative Work
Participant
pseudonym
Response
Psychiatry MD At the end of the day, I try to get home, and I say to my wife, okay, I’m
coming. And then I say, well, I better check my email. And it’s like an
hour and a half later because all day long I’ve been working on this, and
now I have all the email that’s been piling up that I haven’t been able to
read. We’ve got email, we’ve got patient messages, we got telephone
[messages].
Infectious
Disease MD
Depending on if it’s a new patient or a new consult on an old patient,
essentially, I would go through their chart. If it’s someone I know well, I
just go through the last visit and the to-do list of what I know we’ll need
to get done, whether it is lab draws or prescription renewals, things like
that, for the visit. If it’s a new patient, it’s often trying to go through
their chart in advance. Sometimes they’ll have a bunch of documents. If
they’re coming for a second opinion, it could be some outpatient
records; it could be the notes from a doc in the hospital, just trying to get
a better sense of what the main question is so I have a sense of why
they’re coming to see me before I go in. … On the inpatient setting,
there is always, almost always, I would say the patient is seen by the
fellow, or if we have a rotating resident, first, so they will go through
and take the full history, and they will go through the chart, and then
they will present that back to me, so I go in with a much fuller picture of
a history being taken and presented to me on the inpatient setting than I
do in the outpatient setting where I do it all myself.
Pulmonology NP Sometimes I’ll work through lunch. It’s like, I’ll catch up on emails while
I’m eating. I’ll make a list of the stuff I have to do for the next day. If I
need to chat with someone, I’ll call them up and chat with them to
coordinate something. Sometimes I do just focus on eating. Sometimes I
have to eat during a meeting, like a WebEx meeting or something like
that. I would say it’s pretty rare that I am able to just sit down and focus
on food when I take a break to eat.
Transplant
Medicine NP
I have all kind of educational meetings where our fellows present research
papers or the attendings present topics, or the pathologists present
topics. I also have all of these meetings about where my patients are in
the transplant spectrum, like are they ready to be listed? Are they
already listed? Are they listed for transplant, but this has now been
found, and I need to work that up? Then I have an onslaught of test
results to review, do my notes, participate in these conferences about the
173
Participant
pseudonym
Response
patients, and participate in conferences with our supervisors about the
workflow and how we can be more efficient.
Neurology PA [I get] into the office, at least a half an hour before clinic starts, to check
the EHR [electronic health record] to see not only what the schedule is
like for the day but to see if there is any outstanding issues that need to
be addressed immediately, so patient advice requests that come in or
provider requests that come in, urgent consultations, feedback from
consultations, any type of labs that are critical that need to be addressed
as soon as possible, any scans, MRI scans, CT scans that need to be
addressed immediately, and then if there are any prescription refill
requests or patient advice requests that need to be addressed
immediately before going into clinic. So, that’s probably a good 30 to 40
minutes prior to even walking into the clinic itself. … You try to get as
much stuff done within the exam room as you possibly can with the
patient in front of you, so that includes some charting in the room itself.
… Then coming back out into the hallway where the workstations are so
you can enter in any orders that need to be ordered, any labs, scans,
putting in any requests for prescriptions that need to be filled for the
patient, verifying where those need to go. … You sort of carve out a
little bit of time to make sure that you’re caught up with your dictations.
Ideally, those encounters are closed the same day. We have a rule that
really those encounters should be closed within 48 hours of the
encounter, which means dictating it out, making sure that all of your
information is there, correctly coding for the encounter, and then closing
it out in the system so that it can go off to billing. ... End of day,
finishing up notes, checking on labs, seeing if anyone else needs
anything.
174
Table D4
Communication Accommodation
Participant
pseudonym
Response
Obstetrics MD Inherently I think we always do that in any communication, so I would
almost hope you meet someone where they are because I guess it would
be an area of comfort for them. One of the things I think is that
sometimes people aren’t listening to you, and that can be very
frustrating, so it only sort of works, I think, if you modify.
Also, any recommendations I make, I feel like, sometimes, I try to say this
more like none of my recommendations matter. It only matters if it rings
true for them and it’s something they’re going to follow. If that isn’t
really where we’re at, then we need to re-look at it and decide what will
work.
Emergency
Medicine MD
I would say that the variety of patients in terms of like age, social,
economic status, type of diseases, type of conditions, even different
cultures changed the way we communicate. Absolutely.
The patients, in my experience, they really have a different expectation and
also different communication styles with different team members …
Nurse, physician, like administrative personnel.
Psychiatry MD If I’m seeing, as I do, like a world-famous neuroscientist, I can approach it
in a certain way. Sometimes you want to give them a clue that you’re
not stupid, so you drop in a big vocab word or something. On the other
hand, if I’m seeing somebody who’s got a high school education and I
think that word in, that’s going to change the vibe of it. Yeah. That’s the
magic of it.
Anesthesiology
MD
Absolutely. Instantly. You immediately find out, are they quiet, reserved,
do you they not want to talk to me? I am not going to chat them up if
they don’t want to talk to me. I’ll lay it down and just get the nuts and
bolts, then. If they’re super nervous, we’ll work through that.
Absolutely. Absolutely accommodate, adjusting for those who are at
different places when they come to visit, and they do come with—there
are the talkers, the non-talkers, there is the nervous, the stoic, etc., etc. I
absolutely do accommodate to that. I morph.
It just depends on where they’re coming from and what I think they can
understand. Are they fluent with what I’m saying? If they show any
signs at all of not getting it, if they misinterpret something right away, I
know I need to slow it down, I need to reduce the sentence length, I
need to stop and ask for questions, and so on. You need to, absolutely.
It’s a very active, dynamic thing.
175
Participant
pseudonym
Response
As I can automate and do the medical side of things pretty efficiently
and pretty intuitively, that frees up cognitive bandwidth for me to pay
attention to body language, body cues, tone of voice, all that kind of
stuff. When you’re a learner, a resident, or a junior physician, you’re so
worried about delivering great healthcare that you’re not thinking about
the patient.
I think over the course of time, I’ve taken the opportunity to use my
attention to pay attention to a patient’s cognitive state, emotional state
because I can, and junior people can’t do that because they’re just too –
I mean, learners. They’re worried. They’re nervous. They’re scared.
They don’t know what they’re doing. They are in no position to attend
to the subtleties of communication.
Infectious
Disease MD
I think what I do is try not to speak in jargon and try not to speak too
science-y. I will give them data and try to explain things as well as I can
but try not to—yeah, try to keep the language more appropriate for a
layperson. Appropriate, I guess, is subjective, but yeah, more
appropriate for a layperson.
Neurology NP We get patients who are familiar with healthcare. They know the
terminology. They know the processes, the imaging, why we’re
requiring. Other patients that don’t know or sometimes I have a
language barrier for my patients, so they’re more like Chinese
population. In that regard, you do have to simplify it in a way that they
can understand, give them a very detailed care plan, and then, of course,
using the interpreter to help with the communication. I always do allow
them to ask any questions that they have. I’ve also noticed speaking
with the family, getting them involved in the patient’s care is really
effective as well. But definitely do have to cater to their level for them
to understand. If you’re throwing out medical terms to someone that
doesn’t even know, they’re like, did I have a stroke? Yes, or no? Yes,
you did, and this is what we’re going to do in terms of explaining it to
them.
I feel like it’s pretty easy to do, and so when I first go into the room, I can
kind of assess how much they know. If they’ve had a stroke in the past,
then it’s easier to explain to them because they know the process and
medications that are required. If it’s a first-time, newly diagnosed
patient that just had a stroke, I carve out more time for them because
they have a lot of questions. Why did I get it? For what reason? So, in
terms of explaining the pathophysiology of everything, we have to really
make it super basic for them.
I think in terms of simplifying it for them, I think if they understand why
they need to take it, why they need to modify their risk factors, I think
they’ll be more compliant. I had a patient with atherosclerotic disease;
176
Participant
pseudonym
Response
we can’t tell them atherosclerotic because they have no idea, so we tell
them if your cholesterol is high, there is plaque that forms in your
arteries, which will interrupt blood flow, things like that. This is why
you need the medication, so the clot doesn’t form. For the most part,
patients are pretty compliant, but for whatever reason, we get a few
patients that either forget to take their medication, they don’t want to
take their medication, and they just have a different – I had a patient
who only wanted homeopathic, so he was taking all of these
supplements and vitamins which was actually worsening her condition
because she was taking something that was working against a blood
thinner, so she got a stroke then. I think patient education is really, really
critical in terms of a neuro perspective. And for kids, obviously, if
they’re old enough, we tell them in a way they can understand, but more
so to inform the parents in terms of babies and things like that. Patient
education is very, very critical.
Pulmonology NP I definitely simplify the language. I try to avoid any kind of medical
jargon. I watch them carefully to make sure they’re understanding. I’m
sure, though, that I’ve talked to patients and families before, and they’ve
nodded their heads like they’re understanding, and I didn’t work hard
enough to verify that they actually understood. I don’t always have them
repeat it back to me in their own words, which is what you’re supposed
to do, so I kind of just take the nodding as they understand, and I move
on because I feel like, sometimes we’re all in a hurry. When they’re
nodding, and they look like they’re listening, it makes you feel good.
Sometimes I feel like if they don’t understand, we don’t always want to
know that because we’re in such a hurry. Yeah. I definitely will slow
things down. I try to slow things down when I’m talking, and I try to use
visual aids as much as I can. If a patient has a chest tube and they’re
going home with one, I will bring a chest tube that I keep in my office,
and I’ll show them this is what’s in your chest. This is what it does. I
probably change my speech in other ways that I don’t even realize; that
if someone were recording me while I was interacting with a patient,
they would be like, oh, you’re a little bit different there.
Transplant
Medicine NP
I will say that sometimes my style with African-American patients is
different than a Caucasian patient or a Latino patient. Yes, I would say I
tailor my style. It depends on who it is. But for the most part, I’m the
same with everybody, which is good and bad, right, because if you don’t
know me, but that’s my practice style. Some people are different, but
I’m a straight shooter, and I need for you to be straight with me if I’m
going to take care of you. I set that expectation early on. I’ll go to the
bad with you, but you’ve got to be honest, and you’ve got to at least try.
177
Participant
pseudonym
Response
Neurology PA Part of that is an active dialogue with the patient to sort of get an
understanding of where they are because it’s important for me to meet
them where they are.
Trying to figure out where the patient is and tailoring my conversations,
and my descriptions to where they are will be important for them to
retain it.
Abstract (if available)
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Asset Metadata
Creator
Terrasi, Tinamarie Ann
(author)
Core Title
Healthcare provider-patient communication: exploring barriers to effective communication to increase patient outcomes and provider job satisfaction
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Organizational Change and Leadership (On Line)
Publication Date
11/21/2022
Defense Date
10/11/2022
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
cognitive load theory,communication accommodation theory,doctor,healthcare communication,implicit bias in healthcare,media in healthcare,nurse practitioner,OAI-PMH Harvest,patient outcomes,physician,physician assistant
Format
theses
(aat)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Spann, Rufus Tony (
committee chair
), Adibe, Bryant A. (
committee member
), Kim, Esther C. (
committee member
)
Creator Email
taberger@usc.edu,tinamarieterrasi@gmail.com
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-oUC112485549
Unique identifier
UC112485549
Identifier
etd-TerrasiTin-11326.pdf (filename)
Legacy Identifier
etd-TerrasiTin-11326
Document Type
Dissertation
Format
theses (aat)
Rights
Terrasi, Tinamarie Ann
Internet Media Type
application/pdf
Type
texts
Source
20221121-usctheses-batch-992
(batch),
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Repository Email
cisadmin@lib.usc.edu
Tags
cognitive load theory
communication accommodation theory
healthcare communication
implicit bias in healthcare
media in healthcare
nurse practitioner
patient outcomes
physician
physician assistant