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Street 2017. patient centered communication .pdf


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Title: The many “Disguises” of patient-centered communication: Problems of conceptualization and measurement
Author: Richard L. Street Jr.

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G Model
PEC 5662 No. of Pages 4

Patient Education and Counseling xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Patient Education and Counseling
journal homepage: www.elsevier.com/locate/pateducou

Patient Education Communication

The many “Disguises” of patient-centered communication: Problems of
conceptualization and measurement
Richard L. Street Jr.a,b,c,*
a

Department of Communication, Texas A&M University, College Station, TX, United States
Department of Medicine, Baylor College of Medicine, Houston, TX, United States
c
Houston VA Center for Innovations in Quality, Effectiveness and Safety, United States
b

A R T I C L E I N F O

Keywords:
Patient-centered communication
Communication measurement
Physician-patient communication

A B S T R A C T

Objective: To critically examine different approaches to the measurement of patient-centered
communication.
Methods: Provides a critique of 7 different measures of patient-centered communication with respect to
differences in their assumptions about what constitutes patient-centeredness and in their approaches to
measurement.
Results: The measures differed significantly with regard to whether the measure captured behavior (what
the interactants did) or judgment (how well the behavior was performed), focused on the individual
clinician or on the interaction as a whole, and on who makes the assessment (participant or observer). A
multidimensional framework for developing patient-centered communication measures is presented
that encompasses the patient’s perspective and participation, the biopsychosocial context of the patient’s
health, the clinician-patient relationship, quality of information-exchange, shared understanding, and
shared, evidence-based decision-making.
Conclusions: The state of measurement of the patient-centered communication construct lacks
coherence, in part because current measures were developed either void of a conceptual framework
or from very different theoretical perspectives.
Practice implications: Assessment of patients’ experiences with quality of communication in medical
encounters should drill down into specific domains of patient-centeredness.
© 2017 Published by Elsevier Ireland Ltd.

1. Introduction
This commentary addresses a deceptively simple question.
What exactly is ‘patient-centered communication’? Patientcentered communication (PCC) would presumably help accomplish the goals of patient-centered care. That statement, however,
is also complicated. As Mead and Bower [1] noted in 2000,
“patient-centeredness has been used to refer to so many different
concepts that its scientific utility may have been compromised” (p.
1102). Similarly, 100 s of PCC and related measures exist in the
literature [2], many of which are not informed by a conceptual
framework or are grounded in a variety of different theoretical
perspectives. Thus, any claim that a particular medical encounter
was or was not patient-centered would depend on which measure
of PCC was used [3,4].

* Correspondence to: Department of Communication, Texas A&M University,
College Station, TX, 77843-4234, United States.
E-mail address: r-street@tamu.edu (R.L. Street).

Patient-centered care has become institutionalized as the ideal
for health care delivery [5]. Yet, the sheer number of different
approaches to measuring PCC limits the capacity of communication science to make coherent contributions regarding the ways
communication processes can achieve the goals of patientcentered care. In this commentary, I critique some existing
measures that are explicitly labeled as measures of PCC. Second,
a conceptualization of PCC is offered with a goal of capturing the
multidimensional nature of what PCC embodies and the features of
clinician-patient communication that should be measured.
2. The many disguises of patient-centered communication
To analyze the properties of different PCC measures, I have
chosen 7 from the following studies: Agha et al. [6], Johnson et al.
[7], Stewart et al. [8], Street et al. [9], Mazor et al. [10], Reeve et al.
[11], and Swenson et al. [12]. Table 1 categorizes each measure
with respect to examples of constituent items, its ontological
assumptions, whether PCC is considered an attribute of an
individual or interaction, who makes the assessment (e.g., observer

http://dx.doi.org/10.1016/j.pec.2017.05.008
0738-3991/© 2017 Published by Elsevier Ireland Ltd.

Please cite this article in press as: R.L. Street, The many “Disguises” of patient-centered communication: Problems of conceptualization and
measurement, Patient Educ Couns (2017), http://dx.doi.org/10.1016/j.pec.2017.05.008

G Model
PEC 5662 No. of Pages 4

2

R.L. Street / Patient Education and Counseling xxx (2017) xxx–xxx

Table 1
Attributes of measures labeled patient-centered communication.
PCC
measure

Example items/categories

Ontological assumptions

Judgment
Focus on
individual or or
interaction? behavior?

Reporter as
participant or
observer?

Stewart
et al.
[8]

Degree to which physician:
(a) explored the patient’s disease and illness
experience
(b) tried to understand the whole person
(c) tried to find common ground

PCC consists of clinician efforts to understand the
biopsychosocial context of the patient’s health and achieve
shared understanding

Individual
(clinician)

Behavior

Both

Johnson
et al.
[7]

Ratio of total amount of socio-emotional talk and PCC consists of proportionally more psychosocial talk and
questions asked by patients divided by all the
questions by patients and less biomedical talk
biomedical elements of talk

Interaction

Behavior

Observer

Agha
et al.
[6]

Ratio of total number of provider utterances to
total number of patient utterances

Interaction

Behavior

Observer

Mazor
et al.
[10]

“I felt listened to”
PCC consists of patient perceptions of degree to which key
“I got the information I needed, when I needed it.” communication outcomes were achieved (information
“I felt comfortable asking questions and voicing exchange, managing uncertainty, etc).
my concerns”

Interaction

Judgment

Patient

Reeve
et al.
[11]

“How often do your doctors and other health
professionals have open and honest
communication with you?”
“How much do your doctors and other health
professionals give you information and resources
to help you make decisions?”
“How well do your doctors and other health
professionals talk with you about how to cope
with any fears, stress, and other feelings?”

Judgment

Patient

Street
et al.
[9]

“The doctor fully discussed with the patient what PCC consists of perceptions of the quality of the clinician’s
was causing the patient's problem”
informational, relational, and partnering communication
“The doctor asked for the patient's thoughts about
his/her health”
“The doctor seemed to care about the patient's
feelings”

Individual
(clinician)

Judgment

Patient or
Observer

Swenson
et al.

“The doctor suggested a good plan for helping the PCC consists of an observer judgments about a clinician’s
patient”
informational, relational, and partnering communication
“The doctor was interested in the patient as a
person”
“The doctor gave the patient a chance to say what
was on his/her mind”

Individual
(clinician)

Judgment

Observer

PCC consists of more patient talk relative to clinician talk

PCC consists of patient perceptions of quality of clinician
Individual
communication with respect to information-giving, decision- (clinician)
making, building relationships, managing uncertainty, and
responding to emotions

or participant), whether the measure assesses judgment (e.g., an
evaluation) or behavior, and whether PCC is measured as process
or outcome.
The most striking feature of the data is Table 1 is how different
the measures are from one another. Three measures (Stewart,
Street, and Swenson) assume PCC is manifest in a clinician’s
communicative performance with no role for the patient. The other
4 treat PCC as either interaction process (Agha, Johnson) or
outcome (Mazor, Reeve). Some measures assume PCC is determined by an observer coding types and duration of patient and
clinician communication behaviors (Agha, Johnson), other measures assume PCC is manifest solely in patient perceptions (Mazor,
Reeve), and the remaining measures use scales that can be
completed by either observers or participants (Stewart, Street,
Swenson). The Swenson and Street measures assume the quality of
the clinician’s information-giving about medical concerns is an
important component of PCC whereas the Johnson measure treats
biomedical information-giving as detracting from PCC. Finally, the
Agha measure considers PCC as simply a ratio of how much the
patient talks relative to the clinician whereas the Reeve and Mazor
measures assume PCC is manifest across multiple communication
functions (information exchange, managing uncertainty, fostering
relationships). Obviously, the state of measurement of PCC
seriously lacks conceptual and epistemological coherence.

In the absence of consensus on how best to measure PCC, a
starting point for thinking about PCC measurement would be to
establish some common conceptual ground from which measures
of PCC could be developed and refined.
3. Conceptualizing patient-centered communication
3.1. Key assumptions
In order to provide some conceptual coherence to the construct
of PCC, some fundamental, metatheoretical decisions need to be
made about its nature. First, should PCC be conceptualized as
something an individual communicator does or did, or is it
something the interactants jointly achieved? Although a review of
measures is beyond the scope of this paper, it is safe to say that
existing measures are highly clinician-centric in that they focus
almost exclusively on the clinician’s communicative performance
[2]. While clinicians certainly play an essential role in achieving the
goals of patient-centered care, success also depends on the
communication of the patient (and family, when appropriate). For
example, if PCC embraces the idea that medical decision-making
should involve the patient and that medical decisions should be
consistent with patients’ values and preferences, then patients
must take an active role by expressing their beliefs and

Please cite this article in press as: R.L. Street, The many “Disguises” of patient-centered communication: Problems of conceptualization and
measurement, Patient Educ Couns (2017), http://dx.doi.org/10.1016/j.pec.2017.05.008

G Model
PEC 5662 No. of Pages 4

R.L. Street / Patient Education and Counseling xxx (2017) xxx–xxx

participating in decision-making. The patient’s communicative
participation must be a sine qua non of PCC assessment. Thus, PCC
should be conceptualized as a characteristic of the interaction, not as
an attribute of an individual’s communication.
Second, should measures of PCC focus on behavior (i.e., what the
interactants did) or judgment (i.e., how the communication was
interpreted or evaluated)? This is an important distinction because
a measure focused on behavior, such as a patient’s communicative
activity when discussing treatment (e.g., asking questions, stating
preferences, expressing concerns), may have little relationship to a
patient’s perception of his or her participation in deciding
treatment. For example, patients often report they are more
involved in decision-making than is indicated by behavioral coding
schemes [13].
To further complicate the matter, if PCC manifests as judgment,
then whose perception is privileged? Is it the coder who makes a
judgment based on a priori criteria (e.g., the 5 As to patientcentered counseling [14]), or is it the patient who is reporting on
their experience [10]? Choosing one or the other is controversial.
To privilege patient experience (e.g., patient self-report) will raise
objections from those pointing to cognitive biases, limitations of
recall, and ignorance (e.g., patients may not ‘know’ the requirements for PCC) influencing patient judgments. Privileging behavioral measures will meet objections from those pointing out that
there is rarely a one-to-one correspondence between behavior and
meaning. I think it is reasonable to assume there is value in
measures completed by participants or observers, focusing on
behavior or judgment, as long as researchers have a convincing
rationale underlying their choice of measures [15]. In the absence
of a gold standard, patient experience must be a necessary (although
not necessarily sufficient) component of PCC measurement. PCC can be
measured as behavior or judgment, by participants or observers, with
a recognition of assumptions and limitations embraced by choice of
measurement.
Finally, is PCC process or outcome? The literature on
communication competence embraces the idea that competence
consists of both process (communicating competently) and
outcome (competent communication) [16]. It is reasonable, if
not appropriate, to assume that PCC can be measured as process and/
or outcome.
3.2. The multidimensionality of patient-centered communication
Rather than take a narrow position on what is and is not PCC, I
propose an ecumenical conception that broadly embraces its
multidimensional nature. Adapted largely from models offered by
Mead & Bower [1] and Epstein & Street [17], the conceptualization
focuses on the goals of PCC that must be accomplished jointly by
clinicians, patients and, when appropriate, families. Specifically,
PCC:
Reveals the patient’s perspective (beliefs, preferences, concerns,
needs)
Explores the biopsychosocial context of the patient’s health and
well-being
Creates or reinforces trust and mutual respect in the clinicianpatient relationship
Includes explanations of disease and treatment options in ways
the patient understands
Has patients actively participating in the conversation and
decision-making process
Creates shared understanding of the problem and courses of
action
Produces decisions that are based on the evidence, consistent
with patient’s values, and feasible to implement

3

The advantage of such a broad conceptualization of PCC is twofold. First, these dimensions are likely not controversial in that
most researchers, health care providers, patients, and families
would agree these are ‘good’ outcomes resulting from clinicianpatient conversations. Second, while existing measures of PCC
have limitations, they to varying degrees tap into these domains of
PCC. For example, the Agha and Johnson measures in Table 1 take
into account patient participation relative to the clinician, thus
tapping into behaviors that represent patient involvement. This
participation may reveal the patient’s perspective and the
psychosocial context of the patient’s health. However, these two
measures leave out other important domains of PCC. While the
Swenson, Stewart, and Street measures ignore the patient’s role in
the encounter, they do broadly tap into features of the clinician’s
communication that promote more patient-centered interactions.
The Reeve and Mazor measures capture most dimensions of PCC,
take into account the patient’s experience, and focus on outcomes
of the interactions. However, they do not identify actions that
contributed to those perceptions.

4. Conclusions
The state of measurement of the patient-centered communication construct lacks coherence, in part because current measures
were developed either void of a conceptual framework or from
very different theoretical perspectives. As a variable subject to
measurement, PCC represents so many different things that it lacks
utility in the absence of more explicit specification of what aspects
of patient-centeredness are being assessed. This is not to say that
the measures described in Table 1 are not tapping into perceptions
and behaviors that are important to a better understanding of
communication process and outcomes in medical encounters.
Rather, consumers of research on patient-centered communication
would be better off if researchers would choose labels more
descriptively linked to what aspect of patient-centeredness was
being assessed (e.g., proportion of time the patient is talking [6],
physician exploration of the psychosocial context of the patient’s
health [8], patient-centered communication outcomes [10]). The
conceptual framework proposed here hopefully points to various
domains of communication that can be considered ‘patientcentered’.

5. Practice implications
The analysis also has implications for clinical practice,
particularly in the assessment of quality of patients’ experiences
communicating with health care providers. First, the assessment of
communication quality should not just focus on what health care
providers did as communicators. It should also focus on whether
key communication goals were accomplished. From a quality
perspective, encouraging patient participation in decision-making
is good; having a patient actually participating is better [18].
Second, the multidimensionality of PCC suggests communication
quality assessments may be better informed by drilling down into
specific aspects of the communication experience (e.g., decisionmaking process, information exchange, fostering relationships). By
so doing, it may be easier to identify problematic aspects of
communication in need of intervention (e.g., clarity of postsurgery discharge self-care) more than a general assessment
tapping into patient satisfaction.

Please cite this article in press as: R.L. Street, The many “Disguises” of patient-centered communication: Problems of conceptualization and
measurement, Patient Educ Couns (2017), http://dx.doi.org/10.1016/j.pec.2017.05.008

G Model
PEC 5662 No. of Pages 4

4

R.L. Street / Patient Education and Counseling xxx (2017) xxx–xxx

Acknowledgment
Richard Street also is supported by the Houston VA Center for
Innovations in Quality, Effectiveness and Safety (CIN 13-413).
References
[1] N. Mead, P. Bower, Patient-centredness: a conceptual framework and review of
the empirical literature, Soc. Sci. Med. 51 (2000) 1087–1110.
[2] L. McCormack, K. Treiman, M. Olmstead, D. Rupert, S. Thacker, R.L. Street Jr.,
Advancing Measurement of Patient-Centered Communication in Cancer Care,
Agency for Healthcare Research and Quality, Rockville, MD, 2011 AHRQ
Publication No.12-EH-EF.
[3] N. Mead, P. Bower, Measuring patient-centredness: a comparison of three
observation-based instruments, Patient Educ. Couns. 39 (2000) 71–80.
[4] R.N. Rimal, Analyzing the physician-patient interaction: an overview of six
methods and future research directions, Health Commun. 13 (2001) 89–99.
[5] Institute of Medicine (U.S.), Crossing the Quality Chasm: A New Health System
for the 21st Century, National Academy Press, Washington, D.C, 2001.
[6] Z. Agha, D.L. Roter, R.M. Schapira, An evaluation of patient-physician
communication style during telemedicine consultations, J. Med. Internet
Res. 11 (2009) e36.
[7] R.L. Johnson, D. Roter, N.R. Powe, L.A. Cooper, Patient race/ethnicity and quality
of patient-physician communication during medical visits, Am. J. Public Health
94 (2004) 2084–2090.
[8] M. Stewart, J.B. Brown, A. Donner, I.R. McWhinney, J. Oates, W.W. Weston, The
impact of patient-centered care on outcomes, J. Fam. Pract. 49 (2000) 796–
804.

[9] R.L. Street Jr., H. Gordon, P. Haidet, Physicians' communication and perceptions
of patients: is it how they look, how they talk, or is it just the doctor? Soc. Sci.
Med. 65 (2007) 586–598.
[10] K.M. Mazor, R.L. Street Jr., V.M. Sue, A.E. Williams, B.A. Rabin, N.K. Arora,
Assessing patients' experiences with communication across the cancer care
continuum, Patient Educ. Couns. 99 (2016) 1343–1348.
[11] B.B. Reeve, D.M. Thissen, C.M. Bann, N. Mack, K. Treiman, H.K. Sanoff, et al.,
Psychometric evaluation and design of patient-centered communication
measures for cancer care settings, Patient Educ. Couns. (2017).
[12] S.L. Swenson, S. Buell, P. Zettler, M. White, D.C. Ruston, B. Lo, Patient-centered
communication: do patients really prefer it? J. Gen. Intern. Med. 19 (2004)
1069–1079.
[13] G.W. Saba, S.T. Wong, D. Schillinger, A. Fernandez, C.P. Somkin, C.C. Wilson,
Shared decision making and the experience of partnership in primary care,
Ann. Fam. Med. 4 (2006) 54–62.
[14] R.E. Glasgow, S. Emont, D.C. Miller, Assessing delivery of the five ‘As' for
patient-centered counseling, Health Promot. Int. 21 (2006) 245–255.
[15] R.L. Street Jr., K.M. Mazor, Clinician-patient communication measures: drilling
down into assumptions, approaches, and analyses, Patient Educ. Couns. (2017).
[16] J.O. Greene, A cognitive approach to human communication: an action
assembly theory, Commun. Mon 51 (1984) 289–306.
[17] R.M. Epstein, R.L. Street Jr., Patient-Centered Communication in Cancer Care:
Promoting Healing and Reducing Suffering, National Cancer Institute,
Bethesda, MD, 2007 NIH Publication No. 07-6225.
[18] R.L. Street Jr., K.M. Mazor, N.K. Arora, Assessing patient-centered
communication in cancer care: measures for surveillance of
communication outcomes, J. Oncol. Pract. 12 (2016) 1198–1202.

Please cite this article in press as: R.L. Street, The many “Disguises” of patient-centered communication: Problems of conceptualization and
measurement, Patient Educ Couns (2017), http://dx.doi.org/10.1016/j.pec.2017.05.008


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