Moderators

Moderators of Patient-Clinician Communication

Outcome Relationships

  • A model with two continua, one related to the degree to which the factor is intrinsic and extrinsic to physicians, patients, and their relationship, and the other related to the degree to which the factor is intrinsic.
  • Intrinsic moderators are characteristics of individuals and clinician-patient relationship and they either directly or implicitly tap into affective and cognitive processes.
  • Examples include health literacy, emotional state, knowledge about the illness, goals and self-efficacy.
  • Extrinsic moderators include characteristics of disease, the family, and social environment, cultural values and beliefs, the health care system, and economic factors.
  • The stable-mutable dimension reflects the degree to which the moderator is susceptible to change.
  • Understanding what factors are changeable is critically important because modifiable factors can be targeted for interventions to increase the chances that communication will accomplish desired outcomes.
  • It has been recognized that both social and technical components including external factors like organizational setting, influence the quality of health care.

Four Intrinsic Moderators of Communication and Health Outcomes

  • There are four intrinsic moderators of communication and health outcomes.
  • These modifiable moderators are:
    • Health literacy
    • Social distance
    • Clinician attitudes toward patients
    • Patient preferences for clinician and patient roles in care

Four Intrinsic Moderators of Communication and Health Outcomes

Health Outcomes

  • Health Literacy is a person's capacity to obtain, process, and communicate information about health.
  • It is a modifiable and important moderator of relationships between communication and outcomes because it affects patients' ability to understand clinical and health-related information.
  • Low health literacy may restrict the patient's ability to be an active participant in medical consultations because of limited familiarity with health-related terms, and because of embarrassment due to this limited understanding.
  • Several of the pathways linking communication to improved outcome such as improved patient knowledge and shared understanding, better medical decisions, and enhanced patient agency, may not be achieved for low-literacy patients.

Four Intrinsic Moderators of Communication and Health Outcomes

Health Literacy

  • The communication challenges facing people with low literacy may account for some disparities related to race, access to care, and poorer health outcomes among people with chronic diseases such as diabetes.
  • Health care organizations can address literacy-related barriers by providing patients with culturally appropriate health education that helps them to understand their health issues, encourages patient participation in discussing concerns and beliefs, and provide suggestions for how to talk with their physicians.

Four Intrinsic Moderators of Communication and Health Outcomes

Social Distance

  • Social distance refers to the number and importance of dissimilarities between physicians and patients.
  • Clinician-patient differences in beliefs about health, use of language, and health-related values create the risk of misunderstanding or bias.
    • This can lead to situations in which patients' needs are not understood and false assumptions are made about their needs and capabilities.
  • Perceived social distance is mutable. By showing attentiveness, avoiding interruption, asking about the patient's beliefs and values, and giving clinical information ina way the patient understands, the physician communicates commitment, respect, and an interest in the patient as a person.
    • In turn, when patients share their beliefs, values, and preferences, they are sharing information that provides opportunities for the doctor to understand them better and for both parties to discover common ground.

Four Intrinsic Moderators of Communication and Health Outcomes

Physician Attitudes Toward Patients

  • Differences in race, gender, and class between patients and physicians may have sub-conscious or implicit influences on physicians' attitudes, perceptions, and communications with patients.
  • These perceptions can influence the physicians' communication, such as following up on the concerns of some patients but not others.
  • Under these circumstances, there is a greater burden on patients to communicate effectively.
  • Physicians' negative perceptions of patients can disrupt pathways linking communication to better health because they limit the degree to which physician and patient can achieve shared understanding, make informed decisions, build therapeutic alliances and adequately deal with the patient's emotions and concerns.

Four Intrinsic Moderators of Communication and Health Outcomes

Patient Preferences for Physicians and Patient Roles

  • Patients have expectations for their own roles and their physician roles in the health setting.
  • These include thoughts about what is to be discussed and who has control over decision making.
  • A substantial number of patients fail to achieve their desired level of participation in the decision-making process, which then lowers satisfaction with care, increases post-decision regret, and increases patient anxiety.
  • Patients also vary in their expectations for physician and patient roles and this often has been found to be associated with demographic characteristics.
  • Older and less educated patients are more likely to prefer paternalistic decision-making models, whereas younger and more educated patients desire more active and collaborative roles.
  • Patients preferences for physician and patient roles in the clinical encounter may change from visit to visit, or even over the course of their consultation.
  • Research indicates that patients' perceived roles in the consultation, not their preferred roles, were stronger predictors of evaluations of care.>
  • Patients that report a shared role with their physicians were more satisfied and assessed their physicians' communication more favorably than patients who felt that their actual roles mismatched their previously stated role preference.

Context as an Important Source of Extrinsic Moderators

  • Clinician-patient interactions, like other forms of communication, are "situated" that is, they take place within multiple layers of context, including organizational, political, geographic, and media.
  • Extrinsic moderators are influential on patient-clinician communication.
  • Three particular important aspects of context are:
    • family and social environment
    • the media environment
    • the health care system
  • The patient's social environment, consisting of extended family, friends and coworkers, can affect clinician-patient communication and outcomes in several ways.
  • Family and friends can either reinforce or undermine the decisions reached by physicians and patients and thus affect adherence and health outcomes.
  • Family members' presence in the clinical encounter can either facilitate or hinder interactions and communication which then affects the degree to which key functions of communication are achieved.
  • Media coverage of an health issue can affect patient's beliefs and expectations, particularly when the media reaches a large audience.
  • Aspects of the media, including the Internet, offers resources and social support for several individuals.
  • The physical and procedural features of the health care facility can affect clinician-patient communication.
  • The clinical team can provide care as a "team" effort and provide informational and social support resources to patients through shared electronic resources, including the Internet.
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