1 Introduction

Health and illness considerations shape social interaction processes and relationships in significant ways. Illness considerations can shift expectations for relationships, and for interconnected roles and responsibilities. In the provider-patient interaction, the language of “relationship-centered” healthcare implies a relational focus. However, because treating the presenting illness concern is the primary reason for the interaction, the relational focus inherently remains a secondary consideration behind treating the presenting illness concern. Furthermore, the connection between communication processes and outcomes (i.e. treating illness) remains a core distinction between healthcare interactions and other social interactions. Additionally, in close relationships, illness increases vulnerability, and changes the ways roles are negotiated. For example, in romantic relationships, friendships, and families, illness can frame the interaction and shift fundamental assumptions about social interaction in ways social actors do not necessarily expect or anticipate, thus increasing their uncertainty.

This chapter examines implications for social interaction processes in health contexts. First, we begin with a description of relationship-centered healthcare and the underlying assumptions of recognizing the provider-patient interaction as a relationship, but a distinct type of relationship with an inherent focus in accurate diagnosis and negotiating next steps in treatment. An inherently important and defining aspect of the healthcare interaction is the potential to shape bottom-line impact. By “bottom-line impact” we mean outcomes of relevance to people in their everyday lives and to health care providers. Thus, the second section of this chapter adduces evidence for communication processes as predictors of outcomes including satisfaction, adherence, quality of life/health consequences, and medical malpractice. Next, we define and describe the theoretical attributes that shape the ways social interaction processes function in particular ways in illness contexts. Finally, we examine the interconnections between other close relationships and illustrate theoretical and applied implications of the ways health and illness considerations shape social roles and relationships. Overall, the chapter helps explain how and why social interaction processes in health contexts differ from other interpersonal processes.

2 Relationship-centered healthcare and the underlying assumptions

Many of the principles of the physician-patient relationship are analogous to those of personal relationships. In choosing a physician, individuals seek someone with whom they are compatible in beliefs and values, who can best satisfy their medical, emotional, and physical needs, and who shares in decision-making. Like personal relationships, some relationships with physicians succeed over the long term, but others flounder, continue with low commitment or satisfaction, or break off. In medicine, the concept of relationship-centered care is based on a philosophy of shared power and mutual interaction between health providers (usually physicians) and patients as central to the delivery of healthcare (Beach et al. 2006). Relationship-centered care recognizes that clinician-patient relationships are central to diagnosis and healthcare delivery and stresses partnership, attention to relational processes, shared decision-making, and self-awareness (Suchman 2006). The underpinnings of relationship-centered care focus on the moment-to-moment relational processes, the value of difference and diversity, and the importance of authentic and responsive participation (Suchman 2006). The principles of relationship-centered care include recognizing the personhood of the participants, acknowledging that affect and emotion are important components of these relationships, considering healthcare relationships within the context of reciprocal influence, and placing moral value on the formation and maintenance of genuine relationships in healthcare (Beach et al. 2006).

Relationship-centered healthcare developed historically alongside the biopsychosocial model of healthcare, where the diagnosis and treatment of illness includes the patient’s subjective experience as inherently important. This purview stands in contrast to the biomedical model that historically dominated medical education and mainstream medical practice. The core assumption of the biopsy-chosocial model is that responding to patients’ suffering requires giving patients a sense of being truly understood in their psychological and social dimensions in addition to a biological explanation for symptoms (Engel 1977). Thus, physicians are active participants in the unfolding of interactions and relationships with patients rather than being detached gatherers of biomedical information. Similarly, Michael Balint’s use of the term “patient-centered medicine” includes the need to respond to the patient as a whole person with unique human attributes in considering diagnosis (Balint 1969). Later, patient-centered care was defined to include both physicians’ and patients’ agendas, finding and exploring common ground, and integrating both the disease and illness experience (Brown et al. 1986; Stewart 2001).

The shift to “relationship-centered” language (often still called “patient-centered”) came from a Pew-Fetzer task force on advancing psychosocial health education in addition to biomedical education (Pew-Fetzer 1994). “Relationship-centered” care emerged as a third conceptualization for healthcare processes, with language intended to capture the ways the social role and privileges of the healer seemed to be founded on meaningful relationships more broadly than technically appropriate transactions (Beach et al. 2006). Research and practice continue to examine ways to accurately address biomedical diagnosis while fully exploring patients’ concerns and expectations, and recognizing the human element of the health professional. Ongoing research continues to address the interaction as co-created by provider and patient, such that physicians come to appreciate the patient’s narrative through negotiated dialogue that requires lack of judgment and demonstrating empathy that allows for solidarity with the patient and respect for his/her humanity (Borrell-Carrio, Suchman & Epstein 2004).

Care, trust, and openness serve as the foundations for relationship-centered care. Relationship-centered care promotes the physician’s ability to play a role in relational dynamics, including finding common ground (Frankel, Eddins-Folensbee, and Inui 2011). Concrete operationalization of relationship-centered care in medical education and practice continue to unfold. A recent proposal from some of the leaders in the relationship-centered care network proposes mindful practice, integration of reflection in the formation practice from novice to expert, and communication skills training as core foundations for teaching relationship-centered care (Frankel, Eddins-Folensbee, and Inui 2011). Research suggests that physicians’ professional development of self-awareness is crucial to responding empathetically to patients and to fully recognizing what patients bring to the interaction (Duggan et al. 2009; Krasner et al. 2009). Methods for integrating physician and patient perspectives and measuring the dyadic influence of both participants in relationship-centered care also continue to unfold (Kenny et al. 2010).

Similarly, organizations concerned with the structure of the healthcare delivery system and the connections between healthcare delivery and population-based outcomes have also contributed to the conceptualization and analysis of “patient-centered” healthcare. The Institute of Medicine (IOM) defines patient-centered care as: Health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care (IOM 2001). The IOM includes patient-centered care as one of six domains of healthcare quality and calls for a fundamental change in the system of care to address the chasm between the kind of care patients receive and the care patients seek.

Overall theoretical descriptions of patient-centered and relationship-centered care suggest underpinnings of considerable consensus, but the resulting practice attributes and patient services are less clear. Research continues to address the organizational attributes inherent in providing such access to care, engaging patients in their care, sharing in decision making, transferring information across healthcare providers, integrating specialist care, and allowing ongoing patient feedback to providers (Davis, Schoenbaum, and Audet 2005). Developing organizational structures for patient/relationship-centeredness only begins to address the inherent disconnect between theoretical explanations for social interaction processes in healthcare and other interpersonal processes. Attention to the relational aspects of the interaction may predict length of the relationship with the physician, as well as other important indicators of outcomes of the interaction (as reviewed in the next section). Compatibility in beliefs and values, and satisfaction with medical, emotional, and physical needs may serve as a pathway to better health and longer-term commitment. However, understanding the relational focus but missing the need to address presenting medical concerns would negate the most fundamental assumption of the healthcare interaction – that the relationship is inherently grounded in a need to accurately diagnose and treat some presenting symptom(s).

3 Communication processes and interaction outcomes

Social interaction processes in health contexts are inherently connected with treating illness and other outcomes, and the focus on interaction consequences remains a core distinction between healthcare interactions and other social interactions. Communication behaviors in provider-patient interactions in particular are associated such consequences as satisfaction, adherence, quality of life/health outcomes, and medical malpractice. Linking provider/patient communication with health outcomes is a cornerstone of health communication and medical research. We provide an overview of the research evidence for communication predictors of health outcomes and then describe theoretical attributes that contribute to explaining the processes of communication in health contexts.

Research on outcomes addresses elements that occur during the interaction (e.g., co-participation, patient assertiveness or self-advocacy, and provider expressions of empathy), as well as outcomes immediately after the interaction (e.g., satisfaction and health knowledge), and more distal outcomes (e.g. adherence to treatment, self-efficacy, and symptom reduction) (Beckman, Kaplan, and Frankel 1989). The most frequently studied outcome in the interpersonal health communication literature is patient satisfaction, which is relatively easy to examine and measure, and requires very little from the individuals asked to make a judgment (Duggan and Thompson 2011). Although satisfaction may not be the most significant health communication outcome, research indicates that satisfaction ultimately impacts additional consequences.

4 Theoretical attributes of illness contexts

Examining theoretical attributes of the health context allows for continued development of frameworks for explaining the interconnections between social interaction processes and health consequences. First, confronting physical symptoms such as vomiting, mobility issues, and a multitude of other symptoms makes competent communication more difficult. Moreover, illness brings to the surface a multitude of constructs that (re)frame perceptions of what is important in relationships and in coping with longer-term possibilities of death or disability. Thus, the next section of this chapter describes theoretical attributes (and usually combinations of these theoretical attributes) that shape social interaction processes in healthcare contexts.

Illness diagnosis can increase anxiety for patients and for families and friends of patients, with potentially heightened, and often unanticipated, anxiety of dealing with longevity/mortality resulting from serious illness. The general impact of anxiety in interpersonal communication is evident in such theories as Gudykunst’s (2005) Anxiety/Uncertainty Management theory, but the anxiety that one feels when facing serious illness or confronting death exceeds the scope of what research addresses in explaining uncertainty due to cultural differences (Ulrey and Amason 2001). The health research on anxiety clearly indicates such an impact about long-term prognosis (Chan 2011; Fröjd et al. 2007) as well as anxiety about diagnostic procedures (de Bie et al. 2011). Communication behaviors can buffer or exacerbate anxiety. For instance, Mello et al. (2012, in press) found that although discussions about emotional support with doctors increased cancer patients’ level of anxiety, patients also ultimately reported that engagement with the physician decreased the level at which the symptoms interfered with daily activities. Further research on cancer patients indicates that perceived personal risk and response efficacy are associated with cancer information seeking both directly and through the mediation of anxiety, whereas optimistic comparative risk perceptions are associated with less anxiety (Zhao and Cai 2009). Research by Morse and colleagues (2009) indicates a consistent association between anxiety and communicative behaviors across two studies (one experimental and one self-report) using different operationalizations of the measures, but they note that religiosity can have a buffering effect on anxiety.

Another defining attribute of much interpersonal communication in healthcare is the sense of urgency that often accompanies healthcare delivery (Curtis, Tzannes, and Rudge 2011; Murak 2004). Little “everyday”, if we can characterize any communication as “everyday”, interpersonal communication is consistently associated with the urgency that can characterize interpersonal health communication. When a patient is coding, which is a term indicating that a patient may be dying (“code blue” is the full term), there is little time to be polite. Instead, one must demand, yell, or command in ways that might not be tolerated in most everyday interactions. Although such brusqueness is not unique to health care, health care is one of the few contexts in which death or severe disability is a potential consequence of polite communication. Physicians become socialized to behave brusquely and abruptly, and these patterns continue in subsequent interactions that might not actually be as urgent. Within less urgent interactions, the provider is frequently instructing a patient about a treatment regimen, ultimately telling patients what to do and expecting them to follow these instructions. Expecting such adherence should require sophisticated persuasive strategies, although in actuality it is rare that the persuasive attempts are well thought-out. Most care providers are not sophisticated persuaders (Wouda and van de Wiel 2012). It is likely that the habit of telling patients what to do becomes a pattern and impacts subsequent communication that ideally should be more participative or collaborative (Duggan and Thompson 2011).

Similar concerns can be raised regarding the status differences that characterize much communication during health care delivery (Bao, Fox, and Escarce 2007). While much communication is affected by status differences, we would argue that the status differences are more frequent and more pronounced by education differences, medical jargon, and the social status of physicians. The status differences pose notable consequences for (lack of) shared participation in interaction, and for verbal and nonverbal indicators of dominance and conversational control (Ommen et al. 2011). Unlike some interpersonal contexts, most health care communication is inherently structured according to control patterns (Thompson et al. 2011). The health care provider is typically “in control” of the interaction; patients or family members have to struggle to make themselves heard and to participate. Although many providers now allegedly advocate shared control, communication behaviors frequently are not consistent with this ideal (Gwyn and Elwyn 1999). Instead, providers use subtle control behaviors that are difficult for patients to confront and label as directly offensive (Duggan et al. 2011). The dominance/control behaviors themselves then have subsequent consequences, such as decreasing trust, openness, and accuracy of diagnosis (Politi and Legare 2010).

Physician-patient interactions are also likely to be characterized by education differences in a way that is less apparent in most other daily interpersonal interaction apart from those that occur within educational contexts (Bao et al. 2007). The doctor is usually far more educated than is the patient, which again brings about the dominance patterns noted above and a subsequent impact on verbal and non-verbal aspects of communication indicative of dominance (Paasche-Orlow and Roter 2003). These, again, have their own outcomes, including the patient’s story not being fully told. It is apparent in much writing on effective communication in health care that a narrative approach to provider-patient interaction is likely to result in a more adequate understanding on the part of the care provider of the health problem (Charon 2009). A narrative approach allows the patient to tell his or her story.

These status and education differences also interact with gender socialization issues, in that nurses are still more likely to be women and physicians somewhat more likely to be men. Physicians are socialized to interact with patients in certain ways (Haidet et al. 2008; Kasman 2004), and nurses are similarly taught certain ways to interact with doctors (Brandi 2000; Davidhizar, Policinski, and Bowen 1990). Although nursing schools no longer teach nurses to stand when a physician enters the room, it was not that long ago that they did. Traditionally, nurses were taught not to question doctors, and still learn to approach “difficult doctors” (Davidhizar et al. 1990: 12; Brandi 2000) in ways that minimize potential for defensiveness, elicit cooperation, and are strategically timed. All of these strategies are also characteristic of how women are socialized to interact with most men. These gender differences and the differential orientations of gender interact with status differences and education differences, and the notion of intersectionality becomes relevant, as well (Hankivsky et al. 2010). The concept of intersectionality reminds us that systems of discrimination overlap, and that multiple demographic, social location, health status, and quality of life variables interact to create differential effects.

Patients, too, are socialized to interact with care providers, especially doctors, in particular ways (Sousa 2007). This socialization occurs through early interaction as children are accompanied by parents to health visits and come to model parental behavior, through reinforcement patterns, and through mediated models. Media representations of health care delivery settings and health care providers have been the subject of more research than the other avenues of patient socialization and suggest a doctor-as-hero representation of healthcare (Hildén and Honkasalo 2006; Strauman and Goodier 2011).

Increasingly in medicine, there is also high reliance on medical technology. Although most fields are now dominated by information technology, health care is also dominated by very sophisticated, advanced medical technology. This technology can intimidate patients – and even many providers (Police, Foster, and Wong 2010). To better understand this issue, perhaps one should picture how most medical interviews now operate: the provider is staring at the computer and typing in the patient’s responses rather than interacting more directly with the patient with higher levels of eye contact, more direct body orientation, less interpersonal distance, etc. It is not difficult to speculate about the subsequent effects of these communicative patterns, although empirical research on the topic is just beginning to be conducted (Norman, Aikins, and Binka 2011). There is, of course, even more speculation and empirical assessment of the related issue of patients bringing information that has been obtained through the Internet into the provider-patient interaction. There is great variability in provider responses to such web-based contributions (Chiu 2011).

It is probably also obvious to anyone who has ever gone to a doctor that time constraints are another defining attribute of the health care context. Much provider-patient interaction is severely constrained in terms of time, which likely contributes to the observed interruptions by care providers, dominance within the interaction, abruptness, and decreased likelihood of fully listening to patient narratives (Duggan and Thompson 2011; Thompson et al. 2011) despite what we know about the value of narratives in health care (Sharf et al. 2011). Notice how all of this goes against the patient- or relationship-centered approach to medicine that is generally advocated (Duggan and Thompson 2011). Furthermore, medical mistakes (Hannawa 2009), that may also be associated with time constraints, have severe consequences in healthcare delivery.

Inherent in much of the discussion above is the notion of uncertainty. Although uncertainty is obviously relevant to all interpersonal communication (Berger and Calabrese 1975), uncertainty manifests in different ways in health care. One’s key uncertainties about communication in health care go beyond issues of what the other interactant is like or how one should behave and focus instead on oft-times serious concerns (warranted or not) about one’s health, prognosis, diagnosis, etc. Illness-related uncertainty, thus, has been a focus of much health communication research. There are several key theoretical perspectives that are relevant to this discussion: Uncertainty in Illness Theory (Mishel 1990), Problematic Integration Theory (Babrow, 1992), the Theory of Motivated Information Management (Afifi and Morse 2009; Afifi and Weiner 2006), and the Theory of Communication and Uncertainty Management (Brashers, 2001; 2007). Babrow, Kasch, and Ford (1998) argue that uncertainty may result from complex situations, properties of information (such as clarity or completeness), probabilistic thinking, the structure of information (such as how/whether information is integrated with other information), and lay epistemology. These varying forms of uncertainty may result in different management/minimization strategies. For instance, uncertainty as a result of too little information might lead to information seeking, but uncertainty from information overload might lead to an avoidance or selective attention strategy (Babrow and Matthis 2009). Additionally, it should be noted that social support is one interpersonal communication process that may aid in uncertainty management (Goldsmith 2004). Uncertainty management can be collaborative or negotiated. Individuals may have different or conflicting goals that require careful coordination (Brashers, Goldsmith, and Hsieh 2002).

This review of some of the theoretical attributes illustrates the complex interplay between the voice of medicine and the voice of the lifeworld (Mishler 1985). The attributes of the illness context shape interactions in ways that are not completely explained by the biomedical/illness model or by a predominantly relational lens. Instead, interpersonal processes about health and illness are shaped by multiple theoretical attributes that are not inherently unique to the healthcare context, but that shift the development of perceptions, behaviors, and relationships over the course of coping with diagnosis and management of health and illness.

5 Interconnections between illness and social roles and relationships

The provider/patient interaction cannot be fully understood without also recognizing connections to social roles and relationships, and to the larger social systems that comprise the provision of healthcare. Family dynamics can be crucial determinants of what happens in the health care context, and concerned family members may well play a role in the provider/patient interaction, particularly if the patient is seriously ill (Pecchioni and Keeley 2011; Pecchioni, Thompson, and Anderson 2006). Although research has focused on provider/patient interactions, family members provide a disproportionate amount of healthcare over the life span. The inclusion of the family member inherently complicates the healthcare interaction, where family members may experience high fear and anxiety alongside patients. Normative life circumstances, sequences, routines, and social roles are shifted to accommodate the illness (Cohen 1993). When a health crisis affects one family member, others are also impacted, as are family rules and levels of homeostasis (Pecchioni and Keeley 2011). For example, family members watching painful and/ or invasive procedures, noticing the relentless threat of progressive complications, and experiencing ongoing encounters with families suffering similar trauma or even facing death can further increase fear and anxiety for the patient. Uncertainty associated with serious illness can be so stressful for families that it can further exacerbate fear and anxiety. Indeed, the consequences of serious illness are so severe that the death of a child increases likelihood of parental divorce (Pillow, Zautro, and Sandler 1996) and behavior problems among surviving children (Foster et al. 2012).

Ultimately, families and friends may have to confront the possibility of long-term disability, and to confront death and dying issues. Most individuals still die in hospitals rather than at home or in other hospice contexts, despite their wishes to the contrary, and the poorest people are also the most likely to die in a hospital (Smallwood 2010). Many interactions with those who are terminally ill are actually characterized by avoidance of the topic of dying, and even avoidance of those who are dying altogether. Individuals who are dying report difficulty getting family members and friends to participate in such conversations. Instead, family members and friends pose a pretense of normalcy and internalize multiple layers of denial (Goldsmith et al. 2011). Although hospice tries to improve communication at end-of-life and provide a focus on care rather than cure, it also requires that patient and family members allow such an approach.

Furthermore, dealing with an illness changes the disclosure boundaries for communication in close relationships, as disclosing illness may make individuals feel embarrassed, uncomfortable, or exposed (Petronio 2002). An illness crisis can function as a catalyst for shifting privacy rules, and patients and their families may be surprised at what they are willing to disclose or withhold. Family and friends may also function as informal healthcare advocates such that they too consider themselves to be part of the disclosure and healthcare decision-making (Petronio et al. 2004). However, patients may have different expectations for particular friends and family members with regard to who has access to which parts of their private health information. Disclosure about health information poses a communicative dilemma, where the interconnection among multiple social relationships may sacrifice trust and cross boundaries even with mindfulness of ways to extend the healthcare interaction to include friends and family. Patients themselves might not want to know all the details of their illness (Schofield et al. 2003). Additionally, many illness issues are stigmatizing (Smith 2011) in ways that likely further shape uncertainty, anxiety, avoidance, and numerous other negative social interaction processes.

Finally, the experience and expression of emotion is a central component of illness and of coping. Friends and family members may better attend to emotional concerns of illness, but research also suggests that patients rarely overtly express their true concerns. They instead disclose their concerns and expectations through implied “clues,” subtle disclosures including expressions of concern or worry, attempts to understand or explain symptoms, speech clues (i.e. repeating an illness statement), personal narratives, and suggesting unresolved concerns (i.e. seeking a second opinion or implying unresolved care with another provider) (Lang, Floyd, and Beine 2000). Emotions might indicate that something about the illness, about the healthcare, or about the connections with friends or family has been compromised.

6 Conclusion

This chapter has conceptualized the provider-patient relationship as broader than addressing a set of biomedical symptoms and has described theoretical attributes that shape social interaction processes about health and illness. Considering the provider-patient interaction as a broader social relationship inherently connected with family and friends who care about the patient allows for more sophisticated understanding of the ways interaction processes unfold. This relational focus provides a cornerstone for interpreting the experience of illness as inherently relational, and thus a social interaction that involves negotiating decisions in ways that can translate into understanding, trust, and expressivity or, on the contrary, into negativity and disrespect. Theoretical attributes help explain the pathways that connect interaction processes with healthcare providers as they predict better (or worse) health outcomes. Although the core focus of responding to illness concerns remains a primary goal of healthcare interactions, this chapter illustrates the ways the broader theoretical attributes allow for more complete understanding of social interaction processes in healthcare contexts.

These interaction processes take place within a set of organizations that in the end also remind us that medicine is a business. The issues of health, illness, and life-and-death noted in this chapter function within larger organizational structures including providers, funding agencies, and the changing government policies about the connections among patients, physicians and organizations as providers, and funding/insurance agencies. Finally, the time constraints that are related to organizational changes in health care organizations – cutting out jobs, making each individual take on more responsibilities and tasks – also make life more stressful for each health care provider, impacting communication, which then impacts health outcomes and related social interaction processes.

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