From Volume 42, Issue 2, March 2015 | Pages 185-193
This paper reviews six key communication models and frameworks in healthcare contexts. Comparison suggests key inter-relationships between the different stages of the clinical consultations. Implications are identified for future study in healthcare provider-patient communication.
If one accepts that personal communication is core to the healthcare provider-patient relationship, then the quality of these interactions during routine consultations will have an important impact on outcomes. Provider-patient communication dynamics, however, can be influenced by different issues, such as the content of the encounter and the style of both parties' interactions.1,2,3,4,5 These practical issues, however, cannot be fully explained without a conceptual understanding of existing healthcare communication models or frameworks. This article, therefore, briefly reviews key communication models and frameworks in healthcare developed since 1950, which underpin provider-patient relationships in medical and dental contexts. This examination of the historical development of the existing conceptual models and frameworks may potentially provide directions for future research in healthcare provider-patient communication.
The earliest studies related to healthcare provider-patient relationships date back to the 1950s. To analyse a society as a social system, Parsons6 proposed that people were assumed to enact roles associated with their positions. Interactions between two individuals, such as a physician and a patient, were analysed using his sociological theory of structural-functionalism. Drawing on this theory, the doctor was considered as the one who played the dominant position by virtue of his/her professional knowledge and skills.
Later on, Szasz and Hollender7 reviewed and described the evolution of three basic models of the relative positions of participants in a doctor-patient relationship over time (Table 1). The authors asserted that the first ‘Activity-passivity model’ was historically ‘the oldest conceptual model’ (p586). In this model, the professional took complete control of the relationship and the patient acted only as a passive agent. The second, the ‘Guidance-cooperation model’, was described as the normal medical practice in the middle of the 20th century, where the physician showed the patient what to do and how to cooperate with the plan of care. Finally, they described the third and last stage of evolution, the ‘Mutual participation model’, which they asserted was an ideal method for treating ‘intellectual’ and ‘educational’ (p587) patients. The goal in this model was to establish a partnership wherein the healthcare provider and the patient shared the responsibility for the treatment outcome. While the concept of patient-centred care was not introduced, the importance of patient participation was emphasized.
| Model | Physician's Role | Patient's Role | Clinical Application of Model | Prototype of Model | |
|---|---|---|---|---|---|
| 1 | Activity-passivity | Does something to patient | Recipient (unable to respond or inert) | Anaesthesia, acute trauma, coma, delirium, etc. | Parent-infant |
| 2 | Guidance-cooperation | Tell patient what to do | Cooperator (obeys) | Acute infectious processes, etc. | Parent-child (adolescent) |
| 3 | Mutual participation | Helps patient to help himself | Participant in ‘partnership’ (uses expert help) | Most chronic illnesses, psychoanalysis, etc. | Adult-adult |
Donabedian reviewed and evaluated the quality of the medical process in terms of the level of doctor-patient interaction.8 It was at this time that exploration of the elements of structure, process and outcome started to be formulated into a model. By this approach, a consultation could be seen as a process for providers and patients to interact with each other. Structure was viewed as the input variables of doctors and patients; while outcome could be seen as the overall treatment outcome. Depending on the level of physician-patient interaction, distinct consulting styles could be identified and shown to be recurring across consultations during doctor-patient interactional process. Byrne and Long's9 verbal behavioural study of medical consultations, for example, examined more than 2,500 doctor-patient interviews and found that a doctor-centred pattern was the dominant style in terms of question-answer sequences adopted in medical consultations.
In a review article of doctor-patient communication in medical encounters, Pendleton10 noted that, of the studies published between 1944–1981, the existing research, on the medical consultation process at that time, was framed in terms of social interaction. He asserted that a model for medical consultation was required and suggested a simple ‘input-process-outcome’ model in schematic form that considered communication processes as a reiterative, interacting cycle at the point of encounter. This model indicated that the dynamic of doctor-patient relationships could be influenced by specific factors such as their expectations and social environments. Inui and Carter11 remarked that this generic model fed information and expectations (input variables) into the doctor-patient encounter, which came out the other end as experience outcomes (outcome variables) of the medical care provided in the consultation process. Although Pendleton's model simplified the actual complexities of doctor-patient communication during their encounters, this ‘input-process-outcome’ structure gave a general model for future medical consultations.
Later, Frederikson12,13 tried to integrate previous research and proposed another ‘input-process-outcome’ model (Figure 1). This ‘information-processing model’ was based on exchanging and contributing information between the doctor and the patient during the medical consultation. The model criteria were that both doctors and patients had the responsibility to make the consultation work and the doctor-patient relationship was a mutual information exchange system.
In the 1970s, doctor-patient communication was kept in the theoretical stage rather than integrated into the medical school curriculum. Kurtz,14,15 believing that communication skills could be taught and learned, began to work on a practical communication framework for the consultation process. As a result, an expanded framework for medical consultations (Figure 2) was developed16 to evaluate the level of professional in the medical consultation. This framework delineated the flow of the medical interview tasks in clinical practices. It included five stages with specific objectives to be achieved within a medical interview:
In order to achieve these objectives, an intensive checklist (total 71 items)16 was additionally provided for different stages to assess the content and process of medical interviews. With the framework and checklist, Kurtz and her colleagues believed that the level of communication competence of medical students could be enhanced through this systemic learning process.
Current research studies in healthcare provider-patient communication tend to follow the ‘input-process-outcome’ model as a prototype17,18 and this generic model seems to provide an effective structure for exploring healthcare provider-patient communication in the medical context.
In the dental context, comprehensive conceptual models or frameworks for communicative encounters between dentists and patients are very limited because the research focus is mainly placed on doctor-patient communication. Notwithstanding this fact, Parsons's6 sociological theory of structural-functionalism can also apply to the dental context and, therefore, the interaction between dentist and patient can be analysed in terms of their pre-defined role expectations. Likewise, the same holds for Szasz and Hollender's7 description of the doctor-patient relationship (Table 1), Pendleton's model10 of provider-patient communication, and Frederikson's model12 of information exchange in Figure 1, which can be extrapolated from the medical context to the dental context as well. In addition, the generic ‘input-process-outcome’ model may also apply to the dynamics of dentist-patient relationships in dental consultations.
An early sociolinguistic study related to communication and language in dentistry was published in 1985. Coleman and Burton19 investigated ‘the dentist's control over the patient in terms of the distribution of talk’ (p75) during dental consultations in England. They concluded that the dentist showed a verbal dominance in the dentist-patient relationship and indicated that there was an inequality between the dentist and the patient. Seeking to fill the perceived lack of a general communication model in the dental context, Sondell and Söderfeldt20 applied the generic ‘input-process-outcome’ model in medicine and proposed ‘a model for encounters in dentistry’ (Figure 3). This model suggested that there was room for further dentist-patient relationship development within a framework, which was determined by ‘external factors (for example, laws, regulations) and odontologic tradition’ (p116). Based on the generic ‘input-process-outcome’ model generated in the medical context, three stages could be clearly identified:
The Input Stage indicated that the psychosocial factors of dentists and patients, such as age, gender and their expectations, would influence dental consultations. In addition, a review article21 indicated that environmental factors, such as costs and clinic facilities, might also influence the dentist-patient interaction and these factors were therefore included in this stage as well.
The Process Stage was the actual clinical communication stage. The model indicated that not only the dentist and the patient, but also the clinical staff, contribute in this stage. The clinical staff, such as receptionists, dental hygienists or dental surgery assistants might play roles and interact with patients in the consultation process. Any of them, hence, could contribute to the process and influence the outcomes. Other factors, such as how dentists cared for the patient, how they talked to the patient, and how they treated the patient, would also influence the consultation process and the outcome. However, the authors emphasized that the interaction between dentists and patients was the primary focus because the majority of interactions occurred between these two groups. Therefore, understanding how dentists interact with their patients during the consultation process would possibly enhance the quality of their communication.
The Outcome Stage indicated that outcomes could be the clinical treatment outcome, compliance, patient satisfaction of treatment, and dentist satisfaction of treatment. These possible outcomes could be further divided into immediate, intermediate, or long-term outcomes of the dental consultation. For example, an immediate outcome could be the level of satisfaction of the dentist and the patient immediately after consultations. Intermediate outcomes could be the patient compliance with the dentist's instructions, and long-term outcomes could be the overall improvement of the patient's oral health.
These three stages formed a loop and suggested a sequence of effects within the model. The Input Stage suggested that input variables might affect the consultation process, with the dentist and the patient potentially influencing each other based on their different backgrounds. Similarly, dentist-patient interactions during the Process Stage might affect the results in the Outcome Stage, which might in turn affect the Input Stage, such as expectations, again. This loop-formed model not only indicated that different stages had various influencing factors affecting the target stages, but also proposed that each stage interacted with each other (eg input-process, process-outcome and input-outcome). These inter-relationships between different stages, as a result, formed a complex process and actually enriched the content of a ‘simple’ consultation.
Today, the inclusion of effective communication as a core competency has been widely accepted as one of the domains in medical and dental contexts.22,23,24,25,26,27 Various authority boards, such as, for example, the Accreditation Council for Graduate Medical Education,22 have clearly stated that the ability of graduating doctors to demonstrate effective communication skills is one of the core competencies in their curricula. The Association for Dental Education in Europe has highlighted ‘Communication and Interpersonal Skills’ as one of the key competence domains for the graduating dentist.24 The General Dental Council in the UK has stated the importance of patient communication for the dental team.25 The National Dental Examining Board of Canada has also required ‘a beginning dental practitioner’ to have competence in communicating effectively with patients and health professionals.27
These criteria display a growing recognition that good healthcare provider-patient interactions are essential for a successful healthcare professional (treatment outcomes) where the generic ‘input-process-outcome’ model provide a model to describe routine consultations in the healthcare context. From Sondell and Söderfeldt's model20 in dentistry (Figure 3), we can see that many aspects of the clinical consultation still have room for further investigation, such as the nature of the impact of talk-in-interaction, since spoken communication is the predominant form of provider-patient interaction. In addition, the inter-relationship between the different stages (eg input-process and process-outcome) has not been fully revealed and may be worthy of exploration in the future. After all, the ultimate goal of healthcare research on the provider-patient relationship is to improve the quality and effectiveness of their communication.
Different models and frameworks in healthcare provider-patient communication in both medical and dental contexts and different stages of the generic ‘input-process-outcome’ model have been reviewed. These conceptual models provide the point of ingress for us to understand the interaction between the healthcare provider and the patient. The future focus should be the in-depth exploration of inter-relationships between different stages of consultation from an evidence-based approach in order to enrich the existing communication models.
