JGIM

ORIGINAL ARTICLES

Blackwell Publishing, Ltd.

Patient-centered Communication

Swenson et al., Patient-centered Communication

Do Patients Really Prefer It?

Sara L. Swenson, MD, Stephanie Buell, BA, Patti Zettler, BA, Martha White, BS,
Delaney C. Ruston, MD, Bernard Lo, MD

OBJECTIVE: To investigate patient preferences for a patientcentered or a biomedical communication style.

DESIGN: Randomized study.
SETTING: Urgent care and ambulatory medicine clinics in an
academic medical center.
PARTICIPANTS: We recruited 250 English-speaking adult
patients, excluding patients whose medical illnesses prevented
evaluation of the study intervention.
INTERVENTION: Participants watched one of three videotaped
scenarios of simulated patient-physician discussions of complementary and alternative medicine (CAM). Each participant
watched two versions of the scenario (biomedical vs. patientcentered communication style) and completed written and oral
questionnaires to assess outcome measurements.
MEASUREMENTS AND MAIN RESULTS: Main outcome measures were 1) preferences for a patient-centered versus a
biomedical communication style; and 2) predictors of communication style preference. Participants who preferred the
patient-centered style (69%; 95% confidence interval [CI], 63
to 75) tended to be younger (82% [51/62] for age < 30; 68%
[100/148] for ages 3059; 55% [21/38] for age > 59; P < .03),
more educated (76% [54/71] for postcollege education; 73%
[94/128] for some college; 49% [23/47] for high school only;
P = .003), use CAM (75% [140/188] vs. 55% [33/60] for nonusers; P = .006), and have a patient-centered physician (88%
[74/84] vs. 30% [16/54] for those with a biomedical physician;
P < .0001). On multivariate analysis, factors independently
associated with preferring the patient-centered style included
younger age, use of herbal CAM, having a patient-centered
physician, and rating a doctors interest in you as a person
as very important.

Received from the Program in Medical Ethics (SLS, SB, PZ, MW,
DCR, BL) and Division of General Internal Medicine (SLS, BL),
University of California, San Francisco, Calif; and Department
of Medicine (DCR), University of Washington, Seattle, Wash.
Presented in part at the 25th annual meeting of the Society
of General Internal Medicine in Atlanta, Ga, May 2, 2002.
Address correspondence and requests for reprints to Dr.
Swenson: University of California, San Francisco, Box 0320, 400
Parnassus Avenue, San Francisco, CA 94143-0320 (e-mail:
swenson@medicine.ucsf.edu).

CONCLUSIONS: Given that a significant proportion of patients

prefer a biomedical communication style, practicing physicians
and medical educators should strive for flexible approaches to
physician-patient communication.
KEY WORDS: patient-centered care; physician-patient relations; knowledge, attitudes, practice; comparative study;
patient satisfaction.
J GEN INTERN MED 2004;19:10691079.

edical educators and researchers advocate a

patient-centered approach to the medical interview
in which physicians ascertain and incorporate patients
3
expectations, feelings, and illness beliefs. Some studies
have found associations between patient-centered commu4 7
7,8
nication and patient satisfaction, treatment adherence,
2,7,9 11
medical outcomes,
and decreased rates of malpractice
12
claims. Furthermore, clinician failure to elicit and discuss
patient expectations in the medical visit predicts dissatis13 15
faction with the visit and persistence of symptoms.
However, evidence for the impact of patient-centered
1619
communication on medical outcomes is mixed
; in wellconducted trials, interventions to enhance patient-centered
communication among physicians failed to improve patient
20
21
medical outcomes and satisfaction. Moreover, little empirical evidence exists about what physician communication styles patients in the United States prefer and whether
22
these preferences vary according to patient characteristics.
Such information could enhance our understanding of how
communication style affects outcomes, help physicians
tailor their communication to individual patient preferences and, ultimately, improve patient satisfaction and
health outcomes.
We conducted a randomized study of patient preferences for a patient-centered versus a biomedical physician
communication style in which the physician is directive
and focuses primarily on biomedical issues. We used
videotapes of simulated office visits in which a patient
broaches the use of complementary and alternative medicine (CAM) with her physician. Our primary study objective
was to compare patient preferences for a patient-centered
versus a biomedical communication style as depicted on
the videotapes. Secondary objectives were to identify
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Swenson et al., Patient-centered Communication

predictors of preferring a given communication style and

to determine whether physician communication style predicts patient disclosure of CAM use.

Videotape Scenarios
I
Unnecessary
Cost

II
Uncertain
Efficacy

III
Potential
Harm

Patient

Older white
woman

Middle-aged
white man

Middle-aged
white woman

Doctor

Older white
man

Middle-aged
black man

Middle-aged
white woman

Actors

METHODS
Study Participants and Recruitment
We recruited 250 patients attending urgent care (231)
or general internal medicine clinics (19) at an academic
medical center during September 2001 to May 2002.
Eligible patients were English-speaking adults age 18 or
older. Based on assessment by the clinic triage nurse, who
was not involved in the study, we excluded patients whose
medical conditions would preclude watching or evaluating
the videotapes (due to significant acute illness, dementia,
and unstable psychotic disorders).
To recruit a representative sample on each study day,
the study administrator (SB) approached the first eligible
patient for recruitment. If that patient declined to participate or if the study administrator found the patient ineligible due to limited English proficiency or dementia, she
approached the next eligible patient. After preliminary data
analysis revealed a paucity of geriatric patients, we altered
recruitment to enrich our sample for elderly participants.
To recruit the latter 100 participants, the study administrator initially screened only patients age 65 and older for
eligibility. If no patients over 65 were waiting, she recruited
the next eligible patient of any age. To minimize selection
bias, the study administrator recruited participants during
different days of the week and times of day. All participants
gave informed consent. Participants who completed the
study were reimbursed with a $20 grocery gift card. The
institutional review board at the University of California,
San Francisco approved the study.

Study Instruments and Measurements

Videotapes. The study videotapes depicted common
scenarios in which patients broach their use of CAM. We
2326
chose CAM use because it occurs frequently
and is a
sensitive topic that often goes unaddressed in the clinical
24,27
encounter.
Although several authors have documented
28 35
benefits of discussing CAM use with patients
and rec36 40
ommended that physicians do so,
it is not known how
patients prefer physicians to discuss CAM.
To evaluate patient preferences across a spectrum of
risk-benefit situations, we developed three videotape
scenarios: (I) Unnecessary Cost, (II) Uncertain Efficacy,
and (III) Potential Harm (see Box). We chose these scenarios based on focus group discussions with physician
experts regarding situations involving patient CAM use
that occurred commonly in their clinical practice. The Unnecessary Cost scenario depicted a patient taking an
expensive, individually formulated vitamin preparation
that offered no clear benefit over a regular multivitamin. In
Uncertain Efficacy, the patient was attempting to lower

his blood pressure by using an herbal supplement with

uncertain risks and benefits. In both of these scenarios,
the patient brings in the dietary supplement and asks the
doctor for her opinion regarding its use. The Potential Harm
scenario showed a patient taking an ephedra-containing
weight loss supplement that increased her previously controlled hypertension to dangerous levels. In this scenario,
the doctor detects the patients use of the supplement by
asking if she is doing anything new that might explain
her elevated blood pressure. We also varied scenarios with
respect to patient and physician gender-ethnicity concordance (Box).
For each scenario, we developed 2 distinct versions for
a total of 6 tapes. One version depicted a more biomedically
focused communication style (A); the second, a patientcentered style (B).41,42 To create the scripts for the biomedical versions, we interviewed a convenience sample of
15 experienced primary care physicians, 5 of whom had a
special interest in CAM, regarding their typical responses
to patient questions about CAM. For the patient-centered
versions, a working group of experts in doctor-patient communication helped to develop the scripts. Each patientcentered version included those elements that have been
evaluated empirically or mentioned in the literature on
patient-centered communication: 1) developing an understanding of the patient as a person; 2) conveying empathy;
and 3) finding common ground regarding treatment and
goals of care.3,16,17,41,43
Within each CAM use scenario, the videotapes differed
only with respect to the doctors communication style. Each
version was identical in terms of patient history and clinical
presentation. In both versions, the doctor offered the same
bottom-line recommendation about the CAM supplement
and presented similar information regarding its risks
or uncertainties. Each utilized the same professional
actors who employed similar body language, tone of voice,
and conversational pace. Mean videotape lengths were 2:43
minutes. For each pair, the patient-centered version was
longer (mean 16 seconds; range 2 to 28 seconds), and the
patient spoke for a greater percentage of the time (47% vs.
38% on average). We showed all three versions of the videos
to 10 attending and resident physicians in general internal
medicine, to assess the videos face validity. (Samples of the
study videotapes can be viewed at http://dgim.ucsf.edu/
swenson/compaltvideos.html).

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Predictor Variables. We developed a 20-item questionnaire

to assess participants demographic and clinical characteristics, CAM use, and satisfaction with their current
physician. Using validated questions from prior studies
of patient satisfaction (see Appendix A available online at
8,44
www.jgim.org),
we also developed a 7-item scale to assess
participant opinions regarding their interactions with
physicians. This Important Aspects of Doctoring scale
had a Cronbachs of 0.70.
Outcome Measurements. Our primary outcome was participants preference for the patient-centered or biomedical
communication style as assessed by the following question:
Thinking back to the videotapes you just watched, which
of the doctors did you prefer? We assessed participants
perceptions about their own physicians communication
style by asking: Which of the two doctors in the videotapes
had a style that was most like your own regular doctors
style? To gain a more nuanced understanding of participants preferences, we developed an 11-item Physician
Assessment Questionnaire (see Appendix B available online
at http://www.jgim.org). Likert scale items were adapted
from validated patient satisfaction scales to assess three
dimensions of care: global satisfaction, patient centeredness,
and other characteristics.8,44 The patient-centeredness
dimension included items on developing an understanding
of the patient as a person, conveying empathy, and finding
41,43
common ground
that we hypothesized would differ for
the biomedical and patient-centered versions of the video8
tape. Six additional items measured global satisfaction
and other physician characteristics that had no a priori
reason to differ between tape versions. For the qualitative
interviews, we asked: 1) Thinking back to the videotapes
you just watched, which doctor did you prefer and why?
and 2) What was the biggest difference between the two
doctors in the videotapes?
Instrument Development. Two investigators (SLS, SB)
pilot tested early versions of the study instruments and
interview questions among 20 health care professionals,
healthy volunteers, and elderly patients for clarity, flow,
and ease of completion. Based on pilot data, we eliminated
and revised several questions and reworded most negatively phrased questions to achieve satisfactory patient
comprehension.

Randomization and Study Procedures

Prior to the study day, one investigator (SLS) randomized consecutive participants to view a specific videotape
scenario (I, II, or III) with either the biomedical (A) or the
patient-centered (B) version first. Randomization was
carried out in blocks of 12 participants. The study administrator remained blinded to scenario and tape order until
after each subject had undergone recruitment and agreed
to participate, at which time participants viewed the preassigned videotape scenario and tape order. After watching

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the first videotape, participants completed the Physician

Assessment Questionnaire. Next, they watched the second
tape and completed an identical questionnaire for the
second doctor. They then answered questions regarding
which doctor they preferred and which doctors style best
resembled that of their own primary doctor. They also
completed the demographic questionnaire, including the
Important Aspects of Doctoring scale. Finally, participants
underwent qualitative interviews, which were audiotaped
and transcribed verbatim for analysis. The study administrator used standardized prompts to encourage participants to elaborate or clarify answers.

Data Analysis
Sample Size Calculations. Our primary outcome was preferences for a patient-centered versus a biomedical
communication style in the videotaped doctor-patient discussions (two-tailed comparison). We thought that an effect
size of 20% would be clinically meaningful (e.g., 40% of
patients preferring the biomedical and 60% preferring the
patient-centered doctor). To detect predictors of communication style preference, we set at 0.05 (two-sided) and
power at 0.80 and estimated a 10% dropout rate to yield
45
a total sample size of 230.
General. We utilized SPSS (versions 6 and 11; SPSS Inc.,
Chicago, Ill) for all quantitative data analysis. Data were
double entered, cross-checked, and cleaned. Due to clustering of responses, we collapsed Likert scale data from the
Important Aspects of Doctoring scale into dichotomous
variables (irrelevant, not important, somewhat important
vs. important, extremely important). We rescaled responses
so that higher scores represented higher levels of importance or agreement. We performed bivariate analysis to test
our primary outcome variable with the following independent variables: participant gender, age, ethnicity, education,
income, presence of chronic illness or disability, prescription
medication use, number of daily medications, and selfperceived health status and control over health. We also
investigated age (Scenario I) and ethnicity and gender
concordance (Scenarios I, II, III, and all scenarios). We used
Pearson 2 analysis or Fishers exact tests (two-tailed),
where appropriate, and Wilcoxon signed-rank tests for
nonnormally distributed variables. For testing hypotheses
related to proportion differences, we performed a two-sided
difference of proportions test using a normal probability
distribution, adjusting for overlapping populations. Unless
otherwise stipulated, statistical significance was set a priori
at P < .05.
Multivariate Analysis. For the multivariate model, we selected
substantive variables originally posited to answer the
primary hypothesis and secondary variables significant at
the 0.05 level on bivariate analyses. We used a stepwise
block procedure to enter variables into the logistic regression
model, entering first variables that are beyond physicians

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control and last, tape order. Variables included gender,

ethnicity, education, age, and presence of disability or
chronic illness (block 1); participant use of herbal medicine,
communication style of the participants own physician, and
two items on the Important Aspects of Doctoring scale
(physician open-mindedness and interest in the patient as
a person) (block 2); and tape order and gender concordance
(block 3). For participant use of CAM, we chose use of
herbal medicine because it yielded a better fitting model
than did overall CAM use. We used the Hosmer-Lemeshow
goodness-of-fit deciles of risk test for determining the
appropriateness of the logistic regression model because
many predictor variables were categorical and our sample
46
size was less than 400.
Qualitative Analysis. A detailed description of the qualitative findings will be published separately; we briefly summarize our methods here. We used the method of constant
comparisons to develop a preliminary coding scheme. Two
of the study investigators (SLS, PZ) independently coded
all responses. The research team (SLS, PZ, BL) then
analyzed and discussed coding discrepancies and revised
and refined the coding scheme. The final scheme consisted
of 34 coding items and 12 themes.

RESULTS
Participant Characteristics
We approached a total of 418 patients for study
participation. Forty-eight were excluded due to cognitive
impairment or an inability to speak English, and 120
declined to participate, for a response rate of 68% (250/
370). Our sample was gender balanced, ethnically diverse,
and relatively young, healthy, and well educated (Table 1).
Our sample resembled the overall patient population in the
urgent care clinic with respect to gender and age (data
available from authors on request). As expected from an
urgent care population, slightly over half had a regular
physician. Among participants with regular physicians,
71% reported being extremely or very satisfied with
them. Sixty-one percent rated their own physician as having
a style similar to that of the patient-centered doctor in the
videotape. Three fourths of participants (189/249) reported
using CAM within the past year. The most commonly
used forms included dietary supplements (41%; 103/249),
massage (38%; 95/249), relaxation or meditation (38%;
93/248), and herbal therapies (36%; 89/250).

Preferred Physician Communication Style

Most participants preferred the videotape doctor who
exhibited a patient-centered communication style (69%;
95% confidence interval [CI], 63 to 75). This preference was
similar across the three videotape scenarios (I: 67% vs. 33%,
z = 0.02, P = .99; II: 74% vs. 26%, z = 0.04, P = .97; III:
67% vs. 33%, z = 0.02, P = .98). We therefore grouped tapes

Table 1. Participant Characteristics

Characteristic
Demographics
Female
Ethnicity
White or European American
Black or African American
Asian or Asian American
Hispanic
Median age, y (range)
Education
High school graduate or less
Some college/college graduate
Postcollege education
Yearly income, $
<20,000
20,000 to 39,999
40,000 to 59,999
60,000+
Health and health care characteristics
Chronic medical problem or disability
Daily prescription medicine
Mean number of prescription medicines
(range)
Self-rated health status excellent or very
good
Current regular MD
Own MD style*
Biomedical
Patient-centered
Satisfaction with own MD
(extremely or very)*
CAM usage
Any CAM use
Use of supplements, herbs, or folk
remedies

Disclosure of CAM use to MD

No. (%)

138 (55)
133
40
37
17
39

(59)
(18)
(16)
(8)
(18 to 85)

47 (19)
128 (52)
72 (29)
57
55
43
87

(24)
(23)
(18)
(36)

69 (28)
117 (47)
3.4 (1 to 25)
118 (48)
139 (56)
54 (39)
84 (61)
99 (71)

189 (76)
137 (55)
33 (50)

* In subset of participants with a regular MD (N = 139).

In subset of participants with a regular MD who use supplements,

herbs, or folk remedies (N = 70).
CAM, complementary and alternative medicine.

from all scenarios into either biomedical or patient-centered

versions for subsequent analyses.

Bivariate Predictors of Preferred Communication

Style
Demographic and Clinical Predictors. Although most
participants favored the patient-centered style, certain
subgroups were less likely to prefer it (Table 2). Older
participants, participants with less formal education, and
nonusers of CAM were significantly less likely than their
counterparts to prefer the patient-centered doctor. Gender
discordance was also associated with a tendency to prefer
the biomedical doctor only for the female physician
(Scenario III). No other demographic or clinical predictors
were associated with communication preference, including
ethnicity and age concordance. Two Important Aspects of
Doctoring items were significant predictors of preferring

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Table 2. Bivariable Predictors of Preferred Physician Interviewing Style (N = 250)

Demographic Characteristic (N )
Level of education
</= 12th grade (47)
</= College grad (128)
> College grad (71)
Age, y
18 to 29 (62)
30 to 59 (148)
60+ (38)
Gender concordance*
Female MD-female patient (49)
Female MD-male patient (36)
MD is open-minded
< Important (1 to 3) (11)
> Important (4 to 5) (238)
MD interest in patient as person
< Important (1 to 3) (39)
> Important (4 to 5) (210)
Use of CAM
Yes (188)
No (60)
Use of herbal medicine
Yes (89)
No (160)

Own MD style
Biomedical MD (54)
Patient-centered MD (84)
Last video seen
Patient-centered MD (125)
Biomedical MD (124)

No. (%) Preferring

Biomedical
Interviewing Style

No. (%) Preferring

Patient-centered
Interviewing Style

P Value

CHI-2

24 (51)
34 (27)
17 (24)

23 (49)
94 (73)
54 (76)

.003

11.8

11 (18)
48 (32)
17 (45)

51 (82)
100 (68)
21 (55)

.013

8.63

11 (22)
17 (47)

38 (78)
19 (53)

.02

5.77

8 (73)
68 (29)

3 (27)
170 (71)

.004

9.67

21 (54)
55 (26)

18 (46)
155 (74)

.001

48 (26)
27 (45)

140 (75)
33 (55)

.006

12 (14)
64 (40)

77 (87)
96 (60)

<.0001

19.0

38 (70)
10 (12)

16 (30)
74 (88)

<.0001

49.5

25 (20)
51 (41)

100 (80)
73 (59)

<.0001

13.1

11.9

8.17

* Subset of participants (N = 85) who viewed Tape Pair I.

Subset of participants (N = 138) who had a current regular physician.

CAM, complementary and alternative medicine.

a patient-centered doctor: the doctors interest in you as a

person and the doctor is open-minded (Table 2).

Multivariate Predictors of Preferred

Communication Style

Previous Health Care Experiences. Participants were more

likely to prefer the videotaped doctor whose style was the
same as their own physicians (Table 2). Among participants who were completely satisfied with their physician,
this effect was more pronounced; 91% (32/35) of participants who were satisfied with their own biomedical physician preferred the biomedical doctor in the videotape and
92% (59/64) of those who were satisfied with their own
patient-centered physician preferred the patient-centered
doctor.

Multivariate analysis revealed four significant predictors of participant preference for the patient-centered
communication style when the effects of tape order were
controlled (Table 3). These were having a patient-centered
physician, rating the doctors interest in you as a person
as more important, and using herbal medicine in the past
year. In contrast, older participants were less likely to prefer
a patient-centered approach. The goodness-of-fit (HL-GOF)
test for the final multivariate model was 0.42.

Tape Order. Participants were more likely to prefer the

second communication style they viewed. Among those
who viewed the patient-centered tape second, 80% (100/
125) preferred the patient-centered doctor, whereas only
59% (73/124) of those who viewed the biomedical tape
2
second preferred the patient-centered doctor ( = 13.1;
P = .001). This recency effect was seen with all three CAM
scenarios.

Likert Scale Ratings of Physician Communication

Skills
Data from the Physician Assessment Questionnaire
showed that participants rated the patient-centered doctors more positively, especially with respect to dimensions
of patient-centered communication (e.g., suggesting a
good plan for helping the patient; Table 4). Conversely, differences between patient-centered and biomedical versions

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Table 3. Multivariate Predictors of Preference for a Patient-centered Interviewing Style*

Independent Variable

Odds Ratio

Age, y
18 to 29
30 to 59
60+
Interest in patient as person: more important vs. less important
Use of herbal medicine: yes vs. no
Own MD style (patient-centered vs. biomedical)
Last video seen (patient-centered vs. biomedical)

Reference group
0.23
0.19
4.32
5.58
15.9
5.13

95%
Confidence
Interval

(0.09
(0.06
(1.70
(2.17
(6.80
(2.27

to
to
to
to
to
to

P Value

0.63)
0.64)
11.0)
14.4)
37.3)
11.6)

.004
.008
.002
<.0001
<.0001
<.0001

* Other covariates were gender, ethnicity, education, and presence of a disability or chronic illness (block 1); one item on the Important Physician
Characteristics scale (physician open-mindedness) (block 2); and gender concordance (block 3).

were smaller for those dimensions that were not specific

to patient-centered techniques and were not statistically
significant for two of these (decisiveness and knowing the
risks and benefits of CAM).

Qualitative Data
What Participants Liked About Physician Communication
Style. Participants who preferred the patient-centered
doctor cited being interested in the patient as a person,
devising a good plan for the patient, and listening more
to the patient. As one participant remarked, the [patientcentered] doctor treated the patient more as a person,
listening to what her goals wereand trying to work out a
plan that would work much more humane. A second noted
that the patient-centered doctor heard the same information as the [biomedical] doctor, but seemed more openminded about why she was doing what she was doing,

andwas more sort of taking into consideration her

feelings.
In contrast, those who preferred the biomedical doctor
found her direct, straightforward, or decisive style more
appealing. One participant preferred the biomedical doctor
because she wanted action, like right now.... She gave it her
best shot right away. Another remarked: I think the doctor
should take more of a leadership role, and I think the [biomedical] doctor did. Still another appreciated this doctors
willingness to take a stand; for example: He wasnt all question, he was to the point. He answered the question like he
knew what he was talking about. I didnt have any doubt.
Seeing Both Sides. Participants who watched the same
videotape scenario discerned key features of the communication styles yet evaluated those styles differently. For
example, a participant who preferred the biomedical doctor
noted that he was dealing more with the facts and the

Table 4. Mean Likert Scale Responses to Biomedical Versus Patient-centered Videotapes*

Item No.

1
2
3
4
5
6
7
8
9
10
11

Dimensions of Care Items

Patient-centered characteristics
The doctor suggested a good plan for helping the patient.
The doctor seemed open-minded.
The doctor was interested in the patient as a person.
The doctor gave the patient a chance to say what was on his or her mind.
The doctor gave the patient his/her full attention.
Other characteristics
The doctor took the patients problems seriously.
The doctor communicated in simple, clear language.
The doctor seemed to know about the risks and benefits of alternative medicine.
The doctor seemed decisive.
Global measurements

This is a doctor I would trust.

I would recommend this doctor to my friends.

Biomedical
SD)
Mean (

Patient-centered
SD)
Mean (

3.5
3.3
2.4
2.4
2.1

(1.7)
(1.6)
(1.3)
(1.2)
(1.1)

2.1
2.5
1.9
1.7
1.6

(1.2)
(1.4)
(1.0)
(0.9)
(0.8)

2.3
2.2
2.8
2.8

(1.3)
(1.0)
(1.5)
(1.5)

1.7
1.9
2.7
2.9

(0.9)
(0.9)
(1.2)
(1.5)

2.7 (1.5)
2.2 (1.1)

2.1 (1.3)
1.7 (0.9)

* In the Physician Assessment Questionnaire, respondents were asked to rate their level of agreement or disagreement with the following
statements regarding the videotapes. Question 11 utilized a 5-point Likert scale ranging from (1) definitely yes to (5) definitely not. All remaining
questions utilized a 7-point Likert scale ranging from (1) very strongly agree to (7) very strongly disagree. Due to multiple comparisons, the
level of statistical significance was set at P < .001.

P < .0001.

P > .01.

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[patient-centered doctor] was dealing more withtrying to

make the patient feel listened to, sympathized with. The
facts are what are useful to me. After viewing the same
tape pair, another participant had similar observations but
preferred the patient-centered doctors approach: In terms
of attitude, the [patient-centered] one was better. But in
terms of getting information quickly, the [biomedical]
doctor was better.
Relationship with Own Physician Style. Some participants
sought out their preferred communication style in their
physicians. For example, one noted, I like to choose my
doctors on how personable they are and if its somebody
Im comfortable with. And if Im not, I just look for another
doctor.... [The patient-centered doctor] is more how my
doctor is here. And that is what I look for. Others disliked
a videotaped doctors style that departed from their past
experiences. For example, one individual who preferred the
biomedical doctor noted that the patient-centered doctor
didnt use any words that were typical words that a doctor
would useI felt [he] was being a phony.

CAM Disclosure
Over half of participants (55%; 137/250) reported using
CAM therapies with potential side effects or drug-drug
interactions (e.g., supplements, herbal medicine, and folk
remedies). Among participants with regular physicians who
had used such potentially harmful CAM, 50% (33/66) had
told their own physician about their use of it. Participants
who thought that their current physician had a biomedical
approach were equally likely to have disclosed their CAM
use (50%; 13/26) as those who thought their physician was
patient centered (50%; 20/40).

DISCUSSION
1

Medical educators, researchers, and consensus

3
panels recommend teaching and practicing patientcentered communication. However, our study represents
the first randomized study of communication style preferences among U.S. patients. We found that 31% of subjects
preferred a more traditional, directive communication style.
Certain patients were more likely to prefer the patientcentered style, including those who characterized their own
physician as patient centered, valued physician interest in
the patient as a person, and were younger than 65.

Comparison to Existing Literature: Communication

Preferences and Predictors
Other studies have also found that most participants
47
prefer a patient-centered style, that patients prefer the
22
perceived decision-making style of their own physician,
16,19,22,48,49
and that older patients prefer a more directive style.
Similar to our findings, Schmittdiel et al. observed an association between gender concordance and patient prefer-

50

ences for a female but not a male doctor. However, unlike

19
other studies, we did not find that male gender, lower
16,19,48,49
19,22
levels of education,
lower socioeconomic class,
19,49
or more severe levels of illness
were associated with preferring the more directive, biomedical style.
Although patient communication preferences in our study
did not vary across different CAM scenarios, other studies have
51
found preference variation across clinical scenarios.
McKinstry found that UK patients were more likely to prefer
a directive style when evaluating doctor-patient interactions
about a physical problem but preferred either style equally
for interactions involving depression or smoking cessa22
tion. A randomized trial of a directive or sharing physician style among British patients found higher satisfaction
rates with a directive style when visits involved physical
problems and equivalent rates when visits were longer or
52
involved counseling, or chronic or psychological illnesses.

Implications
Our finding that almost a third of patients prefer a nonpatient-centered approach may help to explain the mixed
impact of patient-centered communication on satisfaction
and medical outcomes. Patient communication preferences
may act as a key intermediary between physician communication style and patient outcomes. Several studies
suggest that patient perceptions of patient centeredness
or patient-physician congruence of interviewing styles are
19
better predictors of trust, visit satisfaction, and medical
17
outcomes than is actual physician patient centeredness.
Given this diversity of patient communication preferences, it makes sense to try to match patient preferences
with the physicians actual style. Such matching respects
patient autonomy and might enhance patient satisfaction
16,53
with and trust in their medical providers.
However, 29%
of patients do not experience their preferred physician
communication style with respect to decision making, with
greater mismatch among patients of low socioeconomic status
(E. Murray, MD, et al., unpublished data, September 2004).
Better congruence might be attained in several ways.
First, as our qualitative data suggest, some degree of
patient-driven matching occurs when patients choose their
53
primary care physicians. However, patient-driven matching has drawbacks. Frequently changing providers is inefficient. Moreover, socioeconomically disadvantaged or less
empowered patients may not be able to seek out their phys50
icians of choice.
Second, physicians might modify their communication
style to match patient preferences. Physicians often use a
more directive, or paternalistic style with older, less
educated, and sicker patients and a more patient-centered
style with younger, better educated, and more socioeco5457
nomically advantaged patients.
However, it is not clear
whether these variations are physician responses to individual patient preferences or demographic characteristics.
Because physicians often inaccurately predict patient
58
expectations, even those who consciously modify their

1076

Swenson et al., Patient-centered Communication

communication may fail to match individuals preferences.

Furthermore, physicians demonstrate only limited flexibility with respect to communication style, with over 50%
adopting a single communication style during the majority
42
of their clinical encounters.
Third, health care organizations might match patients
and physicians on the basis of communication preferences.
One randomized trial gave intervention patients provider
demographic characteristics, training, and decision-making
orientation and had them choose their primary care provider.
Although intervention patients reported greater satisfaction and were more likely to have retained their providers
at 1 year, the independent contribution of giving infor53
mation on decision-making orientation was nonsignificant.
Any approach to matching patient-physician communication styles would require an accurate, efficient way of
identifying patient communication preferences. In our study,
even the strongest predictor of communication preference,
the participants own physicians style, misclassified many
patients. Other studies also suggest that inferring patient
preferences from demographic or clinical features would
22,49,51
result in substantial misclassification.
Alternatively,
physicians could elicit patient preferences by directly
asking patients. Some of our study questions appear promising for this purpose but require validation.
In addition to these practical challenges, there are
ethical concerns about matching patients to physicians on
the basis of preferred communication style. First, patient
preferences for a biomedical style may be uninformed. Older
and less educated patients are less likely to experience
patient-centered communication 5457 and thus may be
unfamiliar with it. Our qualitative findings suggest that
such patients may perceive it as foreign to the physicians
role. Second, more patients might prefer a patient-centered
style if they were exposed to good exemplars of it. In several
studies, patients who initially expressed little interest in
participating in decision making were more satisfied when
they experienced more participation than they initially
desired and when they felt that their doctor facilitated
such participation.59,60 Finally, studies report that patientcentered communication is associated with superior
adherence to medical recommendations, visit satisfaction,
8,11,61,62
symptom resolution, and emotional well-being.
Thus,
encouraging patient-centered communication may promote
patients best interests. Hence, for patients who prefer a
biomedical physician, there may be a tension between
respecting their preferences and enhancing their best
interests. Physicians should generally respect informed
patient choices about their medical care. However, doctors
also have obligations to ascertain whether potentially
harmful patient choices are truly informed and to try to
help patients become better informed.63

Implications Regarding CAM Disclosure

Patient centeredness is believed to enhance open
6466
communication and information disclosure.
However,

JGIM

we found that participants whose regular physician used

a patient-centered style were no more likely to disclose their
CAM use than those whose regular physician was not
patient centered. Empirical studies of sensitive topics,
such as HIV risk behaviors and alcohol use, have found
that direct, relatively close-ended questions actually enhance
6769
accurate disclosure.
Our findings provide some empirical support for asking patients routinely and directly about
3638
their use of CAM.

Limitations
Our study had several important limitations. Patient
responses to simulated videotape scenarios may not reflect
their communication preferences during actual physician
visits. Although no studies have directly compared patient
preferences assessed by ratings of videotapes to those in
actual patient-physician interactions, several lines of
evidence support the validity of videotape methodology
for evaluating patient preferences. First, data from our
22,51
study and two others that used videotape methodology
resemble preference differences observed in nonvideotape
16,48,49
studies.
Also, one study found that patients who
received their preferred treatment after evaluating videotape presentations of treatment alternatives had superior
therapeutic outcomes to those who received their non70
preferred treatment,
suggesting that videotape-based
choices may have predictive validity with respect to clinical
outcomes. Finally, our videotape design has several potential methodologic strengths. It avoids the positively skewed
satisfaction scores that occur when patients rate their
4,71,72
own physician
and standardizes communication styles
and controls for other physician and visit characteristics.
The preference of most patients for the patient-centered
doctor may reflect responses to aspects of the videotaped
doctors other than communication style, such as tone or
mannerism. For example, because the patient-centered
versions were slightly longer than the biomedical ones,
patients may have perceived the latter as more time
efficient or the former as spending more time with
patients. We did minimize differences in videotape length
and standardized the patient-centered and biomedical
versions of each scenario with respect to the doctors
recommendation about CAM use. Alternatively, given our
samples high rates of CAM use, our finding that a majority
preferred the patient-centered doctor could have arisen if
participants perceived the biomedical doctor as being more
critical of CAM. However, in multivariable analysis, regarding the videotaped doctor as open-minded was not a
predictor of the respondents preference for a videotaped
physician.
Finally, simultaneously varying several factors (patient
and doctor gender, ethnicity, age) in each CAM scenario
could have led to spurious findings regarding preferences
for a given communication style. The association of gender
concordance with communication style preference on
bivariate analysis supports this possibility, and our sample

JGIM

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Volume 19, November 2004

size and study design limited our power to detect other

similar interactions. However, gender concordance was not
a significant predictor on multivariate analysis of communication style, and neither age nor ethnicity concordance
were significantly associated with communication style on
bivariate analysis. In addition, a majority of participants
preferred the patient-centered doctor across all three CAM
scenarios with varying gender, ethnicity, and age pairings
of the videotaped actors. Moreover, both the qualitative
data and the Likert scale ratings of physician communication (Table 4) suggest that participants discerned and
made choices based on distinct elements of the doctors
communication style. The Likert scale ratings, which participants completed immediately after viewing each videotape, also validate that participants responded at least in
part to patient-centered communication skills.
Participants in our study were more likely to prefer the
most recently viewed videotape. Other studies, including one
videotape study,73 have reported a similar recency effect.75,76
Because our participants were randomized to view different
tape orders (biomedical first vs. patient-centered first), our
study design controlled for this effect with respect to our
main outcome of preferred physician communication style.
Moreover, our finding that four other variables remained
significant predictors of communication preference after
controlling for tape order in the multivariate analysis
suggests that a recency effect could account only partially
for participants communication preferences.
Our findings may not generalize to other clinical
settings, patient populations, or clinical problems. First,
discussions regarding CAM use may not be typical of other
physician-patient interactions. However, CAM use may
involve value conflicts or issues of behavioral change and,
hence, may resemble other interactions that physicians
find challenging and for which they need skillful communication. Second, our relatively young, healthy urgent
care population from an academic medical center may not
be representative of many general internal medicine practices.7678 However, given that young, healthy patients are
more likely to prefer a patient-centered approach, our
finding that a significant proportion of our sample preferred a biomedical approach would likely be borne out in
populations that include more older patients.
Finally, asking participants to choose between a patientcentered and biomedical doctor precludes a more nuanced
understanding of which elements of each physician communication style patients prefer and how this varies during
different portions of the clinical encounter or in specific
clinical contexts. For example, patients who ordinarily prefer a patient-centered communication style might want a
more directive approach if they needed emergency surgical
care. Furthermore, patients may have different communication preferences for interactions with their primary
care providers than for those with physician subspecialists.
Ultimately, skillful communication may entail knowing how
to elicit and adapt to patient preferences over time and in
different clinical contexts.

Conclusion
In conclusion, our empirical findings challenge unexamined assumptions regarding the desirability of patientcentered communication and raise ethical and practical
questions for clinicians, educators, and medical researchers
about matching patients and physicians on the basis
of communication style. For patients who prefer a biomedical communication style, clinicians currently face a
dilemma. Given that patient-centered communication has
been linked to improved outcomes even among patients
who do not initially prefer it, clinicians may choose to
explain the benefits of a patient-centered approach and
encourage all patients to adopt it.7982 However, some
patients who prefer a more directive, biomedical style may
view this approach as paternalistic or incompetent. Further
research is needed to elucidate which elements of patientcentered and biomedical communication patients want in
a specific clinical situation or portion of the interview.
Clarifying these issues will enable clinicians to adopt a
nuanced, flexible approach to the medical interview that
both respects informed patient preferences regarding communication and promotes better patient outcomes.

This work was supported by the Robert Wood Johnson Foundation

Initiative on Strengthening the Patient-Provider Relationship.
The authors gratefully acknowledge the contributions of
Jesse Canchola, MS for his assistance with our data analysis and
Elizabeth Murray, MRCGP, PhD for her valuable comments
and suggestions. We also wish to thank Ralph Gonzales, MD and
Jason Satterfield, PhD for their critical reviews of the manuscript,
Paul Nadler for invaluable assistance with study execution, and
the editors and anonymous reviewers at JGIM for their insightful
contributions.

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