Kevin Real and Richard L. Street, Jr.
Doctor-patient communication is a vital component of both patient health and physicians’ professional lives. The quality of doctor-patient relationships can infl uence a number of factors (for reviews, see Roter & Hall, 1993; Stew- art, 1995; Street, 2001; also see Haskard, Williams, & DiMatteo, this volume), including health outcomes (Kaplan, Greenfi eld, & Ware, 1989), patient adher- ence to medical treatment (DiMatteo, 1994), decisions to pursue malprac- tice litigation (Beckman, Markakis, Suchman, & Frankel, 1994; Levinson, Roter, Mullooly, Dull, & Frankel, 1997), pre-and-post-visit trust (Gallagher &
Levinson, 2004), patient satisfaction (Stewart, 1995), and physician satisfac- tion (Gallagher & Levinson, 2004). An overlooked component of this rela- tionship, however, is the organizational context in which these interactions occur. Hence, this chapter examines the question: In what way do health care organizations affect the process and outcomes of communication in medical consultations?
This is a very diffi cult question to answer for two reasons. First, there is no single organizational model of health care fi nancing and delivery, espe- cially with the increasing infl uence of third-party payers and various managed care forms of health care organizations. These exist in many forms, each of which may differentially affect the quality of care provided and the quantity and quality of doctor-patient communication. Second, theoretical models of provider-patient interaction try to explain what happens during the medical consultation in relation to individual and partner-level variables such as age, education, communicative style, relational history, and more. Although this work highlights the importance of communication in the medical encoun- ter, it does little to account for the role of context in physician-patient com- munication. Street (2003) set forth an ecological perspective to propose that doctor-patient communication is situated within and affected by a variety of social contexts, including interpersonal, organizational, media, political, legal, and cultural. Although the interpersonal context is the fundamental one to this interaction, this chapter examines the organizational context surrounding doctor-patient communication.
Indeed, very little attention has been paid to the impact of the organization
on the communication that occurs in these encounters. Although studies have examined physician and patient communication within medical encounters, only recently have researchers investigated how the clinical context infl uences these interactions (Street & Gordon, 2006). The organizational context is complex and can involve several factors that may affect doctor-patient com- munication, including policies for access to doctors, scheduling, how many patients are seen daily, how long MDs have to interact with patients, phy- sician income, support staff for physicians, referral policies, organizational structures, technology, and much more. This chapter focuses on how health organizations are structured and fi nanced and the impact of these features on the doctor-patient relationship. We also discuss how doctors (and to a lesser degree patients) work within and around these constraints during the medical consultation.
To address these issues, we fi rst review the various organizational forms of health care delivery and how these continue to change over time. Second, we discuss how social and environmental changes have acted to reduce the auton- omy of the medical profession and increase the infl uence of organizations. We then explore the impact of these organizational and social changes on specifi c aspects of the physician-patient relationship: confl icting loyalties, trust, and disruption of continuity. Finally, we examine how information and communi- cation technology can mitigate these impacts on doctor-patient communica- tion. Throughout this chapter, we examine the degree to which organizational context (e.g., solo vs. group practice setting; hospital vs. clinic) accounts for variation in doctor-patient communication.
Organizational Contexts of Health Care Delivery
Physicians work in many different organizational contexts, including hospitals, health maintenance organizations (HMO), staff or group model multispecialty clinics, large integrated delivery systems as well as traditional private practice group or solo settings (see Lammers & Barbour, this volume). Each of these contexts likely infl uences how physicians work and how they interact with patients. There are many forms of organized health care delivery but these can primarily be classifi ed into offi ce practices, medium-to-large sized clinics, and hospitals. Offi ce practices include solo, partnership, and small group practice settings. Clinic settings can be comprised of large multispecialty groups, and then within this design are various strategies related in part to fi nancing: the traditional indemnity model, the staff and group model health maintenance organizations (HMOs), and a set of hybrid practices, such as Independent Practice Associations (IPAs), Preferred Provider Organizations (PPOs), and Physician-Hospital Associations (PHAs). These newer hybrids are designs that combine a variety of models of health care delivery and fi nancing, are typically responsive to changes in the health care marketplace, and contain a mix- ture of pre-paid plans, fee-for-service arrangements, and contracts for services.
Doctor-Patient Communication from an Organizational Perspective 67 Hospitals can be non-profi t or for-profi t and many now exist as part of networks or integrated systems of hospitals and other health care contexts (Lammers, Barbour, & Duggan, 2003). The important thing to understand in this whole array of organizational forms is that health care fi nancing is not identical to health care organizational structures.
The most infl uential form of health care fi nancing related to the organi- zational delivery of care in the United States involves third-party payers and what is most commonly known as managed care. In general, managed care refers to a system for delivering medical care that attempts to control costs and improve quality by monitoring how doctors treat illnesses, limiting referrals to specialists, and requiring authorization prior to hospitalization and other specialized treatments (Birenbaum, 1997; Kuttner, 1999). The term managed care is used to describe a variety of different fi nancing and delivery plans, but at its core it describes the control of health care interactions and costs by third-party payers (insurers, employers, government). Although there has been some legitimate concern over the use of managed care terminology for its managerial overtones (Hacker & Marmor, 1999), as well as some who argue that health care has entered a “post managed care” era (Alexander & Lantos, 2006), this form of health care organizing and fi nance is still deeply embedded in the U.S. health care system. Because the focus of this chapter is an organi- zational perspective on doctor-patient communication, we use the term man- aged care despite its limitations. The development of managed care has led to changes in the relationship between health care fi nancing (insurance) and health care organizations. Prior to the onset of managed care, the fi nancing of health care was typically separate from organizational context. As managed care developed, fi nancing became intertwined with health care organization design, structure, and logic.
Although managed care was (and still is) often synonymous with HMOs, any organizational context in which physicians practice can be fi nanced through managed care policies. In some cases, managed care simply refers to a contractual arrangement between employers and/or insurance companies and physician groups. Plans can range from merely requiring third-party payer pre-certifi cation of medical care to controlling and monitoring almost every aspect of the health care context (Wagner, 1997). At one end of the spec- trum are HMOs, which are typically larger group and staff model clinics that provide care for a fi xed amount per person per year, in which the health care organization and the insurer are one and the same. This is often the organi- zational context most associated with the term managed care in the minds of various health publics, including patients. In an HMO, the patients also are known as the insured and they usually come from a defi ned population (e.g., a company’s employees)—and they receive care only from the providers employed by or contracted with the HMO, which assumes the risk involved in treating a population of patients. At the other end of the spectrum is fee- for-service, in which third-party payers pay the bills for physician and health
care organization services. In between are hybrid organizational designs and networks (IPAs, PPOs, PHAs), which are a complex set of contractual arrange- ments designed to link providers with third-party payers. There are no defi ning organizational features for these new arrangements other than the contracts that connect them together and to payers. As such, physicians from solo, small group practices or large groups may belong to any of these vehicles and may even belong to more than one at the same time. These varied organizational contexts likely affect doctor-patient communication in particular ways, yet there is little research that links organizational context and structure to doc- tor-patient communication.
Examining doctor-patient communication within situated contexts can be particularly valuable when examining how physicians respond to organi- zational and institutional situations. Hoff (2003) argued that studying physi- cians in context requires a greater emphasis on particularistic research designs involving qualitative methods “as well as on comparative analysis that gath- ers data across a variety of organizational situations within the same study”
(p. 94). Research that accounts for organizational context could examine the infl uence of specifi c organizational factors on doctor-patient communication.
For example, the amount of time physicians have to talk with patients and the quality of this interaction likely infl uences the pattern of communication across health care organizational contexts (e.g., hospital, HMO, group or solo private practice setting). It may be that physicians who work on salary may have plenty of time to talk to patients. It could also be the case that their employer may require them to see a certain number of patients every hour.
Much of this may depend on the amount of professional autonomy a particular organizational context provides for its physicians.
Increasing Organizational Infl uences on Physicians
The working life of a physician is signifi cantly different in the fi rst decade of the 21st century from what it was like in the middle of the 20th century, when physicians had a great deal of autonomy over their professional work.
Freidson (1970) asserted that physicians maintained professional dominance in that they controlled the conditions of their work through political and legal authority. Starr (1982) argued that medicine was a “sovereign” profession because of the degree of control it had over its own work. This professional autonomy meant that physicians as a group were self-regulating, impervious to judgments from outside groups, free to practice without supervision from higher authorities, and maintained control over who entered the fi eld (Abbott, 1988; Freidson, 1970; Starr, 1982). Physicians as individual practitioners had clinical autonomy and often were unquestioned by nurses, administrators, or even their own colleagues (Abrahamson, 1967). Abbott (1988) noted that, although medicine had been threatened by other occupations, it maintained authority over its body of work.
Doctor-Patient Communication from an Organizational Perspective 69 Those days are over in medicine as signifi cant pressure has risen from numerous sources—insurers, employers, government, other professions, media, and so on—that has led to changes in the relationship between physicians and their patients. These structural and organizational changes may be partially refl ected in the desire of younger physicians who no longer talk about trying to “establish a practice” but instead describe trying to “get a job” (Shortell, Gillies, Anderson, Erickson, & Mitchell, 2000). This also is suggested by the dramatic increase in the number of physician-employees. Many physicians, perhaps as much as 40%–50%, work as salaried employees in many different types of organizations, including for-profi t and non-profi t organizations, uni- versities, and corporations (American Medical Association, 2000). This has led to charges by some that the reward structures of managed care have the potential to create confl icts of interests and lack of trust between physicians and patients when a doctor’s income is linked to clinical decisions (Rodwin, 1993, 1995).
Research into communication and physicians in managed care organiza- tions has been mixed. Lammers and Duggan (2002) reported that doctors involved in managed care contracts experienced reduced satisfaction, espe- cially in regard to clinical autonomy. Real, Branson, and Poole (in press) found that physicians who practiced in private practice settings generally were dis- satisfi ed with the state of affairs of medicine, primarily because of managed care and the perceived interference from third-party payers in clinical and fi nancial matters. In contrast, salaried physicians working in a non-profi t staff model HMO generally were satisfi ed in terms of their day-to-day experiences.
Real surmised that the HMO was unique in that it was physician-led and the doctors believed they had clinical autonomy. Moreover, the HMO physicians in Real’s study fi t what Hoff (2001) argued is the proper lens in which to view physicians; instead of professional dominance, autonomy, and authority, physi- cians can be thought of as “workers” who have individual needs and goals that can sometimes be best met working as employees rather than independent practitioners. Other studies have found similar results: Physicians who work on salary in benevolent organizations feel unencumbered by administrative work and able to focus more on their patients and the practice of medicine (Gross
& Budrys, 1991; Hoff, 2003; Hoff & McCaffrey, 1996). Seen in this light, some physicians may be less interested in the fi nancial, entrepreneurial side of medi- cine and more interested in quality of life issues such as less on-call time, more time with their families, and less focus on the administrative aspects of run- ning a practice.
Changes to physician autonomy in light of increasing organizational infl uence may impact doctor-patient communication in a number of ways, including control over time allotted for visit by the organization, physician attitudes toward communication, and more. In organizations in which patient visit time is limited, doctor-patient communication will be qualitatively dif- ferent than in organizations in which there is less restriction. Shorter exams
tend to limit information exchange and increase controlling communication behaviors by physicians (more directives, interruptions, less tolerance for ques- tions), whereas longer visits allow patients more time to raise their concerns as well as physician responses to these issues (Bensing, Roter, & Hulsman, 2003;
Street, 2003). Physician autonomy can affect communication preferences as well. Those physicians predisposed to engage in partnership-building, empa- thy, and encouragement will do this in contexts in which this is considered part of the organizational culture. On the other hand, in health care organi- zations that reduce physician autonomy over fundamental matters (such as visit length), individual physician predispositions are less salient. Although an individual doctor may want to develop rapport and allow patients time to talk in visits, there may simply not be enough time and resources for this to occur regularly. In these situations, patient attitudes toward doctor-patient commu- nication become especially important, as patients who actively participate and are conversationally involved are more likely to have successful outcomes in their interactions with physicians than those who are less engaged (Street, 2003). Those patients who are more inclined to engage in information-seeking behaviors with physicians—asking questions and being assertive—are more likely to receive the answers they need to make informed health care decisions than other patients. As we summarize our fi ndings thus far, on the one hand, there is increasing fi nancial and organizational infl uence and, on the other, there is decreasing physician autonomy, some of which is voluntary in nature.
This leads us to the following question: What has been the impact of these changes on the doctor-patient relationship?
Impact on Doctor-Patient Relationships
Organizations infl uence doctor-patient relationships in signifi cant ways. For example, in an effort to control costs and quality, many health care organi- zations and third-party payers frequently monitor physician behavior, includ- ing the tests doctors order, any referrals they might make, drugs they may prescribe, the time they spend with patients, and decisions they make that involve the hospitalization of patients. This process, formally known as utiliza- tion review, is designed to rationalize the health care that organizations deliver by ensuring that physicians adhere to their organizational and contractual obligations. This can be accomplished in numerous ways, including preautho- rization, immediate approval (usually over the telephone), and retrospectively, with reimbursement decided upon after the delivery of care (Wynia, Cum- mins, VanGeest, & Wilson, 2000). The organizational context of health care is complex, and doctor-patient relationships also can be affected by a number of other attributes, such as the overall goal of the organization (e.g., for-profi t, non-profi t); size and structure (e.g., solo practice, small group practice, multi- specialty staff model clinic, hospital); the extent to which the organization is independent or part of a national or multinational corporation; organizational
Doctor-Patient Communication from an Organizational Perspective 71 policies; market-based competition; and the number and ratio of physicians and other providers on hand to treat patients. Organizations can guide and constrain the number of tests that physicians order, the time they spend with patients, the number of patients they see in a given day, the options for refer- rals to specialists, and the salary or reimbursement levels. Organizations also can provide technology and staff to support the administrative side of physi- cian work, which can affect doctor-patient communication.
Organizational design and structure are a result of deliberate, conscious choices. Potter and McKinlay (2005) asserted that organizational policies and structures infl uence the quality of doctor-patient relationships in terms of the length of the relationship, the investment the organization is willing to make in patients, and the degree to which care will be ongoing or episodic. For example, acute care hospitals are structured so that attention is focused on the immediate needs of patient treatment—performing emergency surgery, tak- ing X-rays, and post-operative recuperation. Physicians make rounds to check on the status and condition of patients, but rarely engage in lengthy bedside consults. On the other hand, traditional primary care practices are designed to allow physicians enough time and resources to understand each individual patient’s overall (medical, family, and social) history in order to accomplish a number of aspects of patient care: diagnose and treat medical conditions, dispense medical advice, and develop an ongoing relationship with a patient (Potter & McKinlay, 2005). As these examples illustrate, the purpose, struc- ture, history, and policies of medical organizations infl uences the nature of the provider-patient interaction. Doctor-patient communication in hospitals will be limited in most cases, whereas it will be comparatively greater in offi ce- based practices in which physicians and patients have more time and inclina- tion to communicate.
Accordingly, physicians practice medicine within organizations, such as hospitals, emergency rooms, and primary care offi ces that infl uence their relationships with patients. Moreover, external organizations in the form of third-party payers exert infl uence on the doctor-patient relationship. These new developments, falling under the rubric of managed care, have generated concern for the doctor-patient relationship. The rise of third-party payers in American medicine has had a major impact on doctor-patient relationships.
Waitzkin (2001) argued that third-party payers often employ non-clinicians to monitor and challenge physician clinical decisions, determine patient load, and monitor the amount of time spent with individual patients. Furthermore, Potter and McKinlay (2005, p. 469) asserted,
Because personnel from third-party payer organizations make decisions on whether or not they will reimburse a physician for a procedure per- formed or a recommended opinion, or pay for a patient’s prescription (to name a few), these third parties are infl uential in the doctor—patient relationship.