"

------------------------chapter------~----------------

7
Cornrnunication Research
and the Dodor-Patient Relationship

[ohn E. Carr, Ph.D.'" and Peter E. Maxim, M. D., Ph.D. t

Communication and Conceptual Structure

II has long bcen recogníz cd that the doctor-patient r clationship plays ¡¡
crucial role in contributing lo thc ulrimate success of t hc me dica l
int ervention process. Research findings Irorn the behavioral scicnccs ovcr
the last several dccades havc now confirmed scientifically what has hcen
liltle more than a belief since Ihe dawn of healing, that is, that thc efficacy
of a therapcutic procedure is a function of two primary variables: (1) the
ability of the ther apist to establish a condilion of trust and influ encc ovcr
the patient and (2) the skill of the therapist to utiliz e within Ihat conte~t ;111
array of appropriate therapeutic techniques (Strupp and Bcrgin. 1969).
Me dical educatiqn has traditionally focusecJ tlpon the lauer, providing the
physician/surgeon-Io-be with a bread armame ntnr iurn of t r eatrn e nt
techniques, procedures, and ope rations, lcaving the former lo sornchow be
acquircd through 'the more informal tcaching procedu rcs of the clinieal
training situation, In recent years, medical cducators hove come to
rccogniz e the importance of pr oviding for thc educalion of prosp ectivc
physicians in '(he establishment and Iacilitat ion of tho doclor-palient
relationship, and have turned to their colleagues in the social and
behavioral sciences lo contribute to this irnportant aspect of medical
educalion.
Our imrnediatc iask becornes one of iclentifying t h e crirical íaciors t ha t
define the so-called doctor-patient r elationship. Atlempls al ddinilion
based upon the itemization of the traits and character istics of ideal dactors

"Protcssor and AClin¡; Chairman, Dcpartrncnt u( Ps)'chi.lry a nd Heh avioral Scicncc s.

Universiry 01 W,shinglon School 01 Medicine, Scnule. W.1Shinl\ton.
t Associale Prolessor, Dcpartrn ent 01 Psychialry and Behavioral Scicnccs, Univcrsity o(
Washingion School of Medicine, Scaulc, Washinglon,
 /1 , .
134 I.E. Carr and P.E. Maxirn Cornmunication Rcscnrch and the Doctor-Patlent Rclationship lJ~

and ideal paticnts has generally proven to be noncontribulory. The t~e c0n:'municati?n process between doclor and palient. Throughout our
doctor=potient relationship, as the terrn implies, is not a static or evcn an discussion we will encountcr a recurring therne, namely, Ihal succcssful
additive phenomenon. Whil~ it is lempting lo thin k of it in ihese tcrrns. cornmu nicafinn is largely dependent upon the degrce lo which the
orre cannot identify the ideal physician ¿1I1Y more than one can identify the comrnunicants share a common conceptualization of the world about
ideal patient. Wh~t must quickly be apj-rcciated is that we rnust look at them. In lile fin¡¡J seclion we shall return to this important point and
variables lhnt are intcr aclional in nature. explore its implications in greater detail, Our review \ViII begin with a
To estnblish influence a nd credibility with thc paticnt, lhe therapist is consideration oí the physiological bases for langllage, which distinguishes
dependen! upon operntionally dcfinablc condilions such as interpersonal humans from other specics.
warrnth, positive regard, and accurale ernpathy (Truax and Mitehell, 1971).
While thc conditions of inlerpersonal wannth and positive regard are
attitudinal eondilions, the definition of aceurate empathy is clearly unique
Verbal Communication
in that it involvcs a cornrnunicative process, that is, (1) the ability of Ihe
th crap ist lo undcrstnnd ill Ihe pnlicllt's OWII conccpts the 'paticnt's under- Among hurnans, language is lhe prilllilry form oí cornmunicat+on and as
slanding of his or her conditions (2) lhe 'nbilily of the therapist to such plays an cssential role in Ihe establishment and milil11el1i1nce of soci.ll
comrnunicate bcck lo lhe pal ient in tlic pnticiü's OHIII conceuts the fael t hat he ínstitulions. The capacity of syrnbolic reprcsentation a n d Ihe sophistication
or she undcrstnnds thc patient's condition, and (3) ~hnt the 'patient of gram~ar ,allows the human lo lransrnit an alrnost infinile varicty of
recogniz cs and acknowle dgcs Ihat the thcrapist understands. What is con:mu,nlcatlons. Languagc becomes lhe basis not only for the conccp-
involvcd hcre, thcrefore, is thc capacity of the lherapist to vicw the tualiz atinn of human experience, but also the shilring of it in lhe Iorrn oí
poticnt's eondition from th e patient's conceptual frarncwo rk, to pul hirn- or knowledge with one anothcr. Thus lill1gUólgC becornes a vchiclc of
herself in the patient's sho es and to look al the world through the paticnt's exchar,lge ilmong humans, wilh a high degree of polential Ior impilcling on
eycs. Equally importan! is'lhe nbility of the therapist to cornmunicate lo the behavior, not onl)' at the societal and inslitutional levcls, out also ilt lhe
paticnt l hat in Iact he or she. lhe therapist, is able to accomplish this. indivi~ual Ievcl, lt is importnnt lo distinguish I¡¡nguage, which is lhe
As can be sccn, this is not sirnply communicalion in the sense of a behavl.oral c?mponent of vocal communication. In this rcspe ct, I.mguilge is
mcchnnica! exchangc of informalion, bul a focusing UpOI1 the cognitive a rnanifestation of the social norrn, a representative part of the culture,
and conceptual bases of the cornmunicetion process. lndced, even a ~hereas s~eaking is an individual act t hat takcs on signifiCilllce only
moclest undcrstnnding of thc natur e of communication as it oecurs insofar as 1I conforma ordoes not co níorm lo lhe social prncticcs o( Ihe
bctwccn the patie nt and the physician r e quires fa'rhiliarily with a cornplcx language cornmunity (Wilson, 1975).
arrrry of variables considcred by the physician in lraining. ' Linguists distinguish betwe en "surfnce" Slruclure, which rcfers lo Ihe
In this chapter, w e s ha ll rcvicw these factors arid lhe role thcy play and phonological rcprescntation of Ihe word units, and "base" or "dccp"
nucrnpt lo show how each relates to the other in' the cornmunication struclure, the more complex sernant ic intcrprelation Ihal derives frorn lhe
process. In lhe course of our discussion, we shall first consider the topic of words combined. Another way of c1escribing Ibis distinclion is "how' il
verbal cOll111lunicalion, ils physiological basis i.lnd developmenl, and the r eads" (surface slructure) versus "whal it mcans" (deep structure). There
contriblllion of lingllislic schol¡¡rs to our understanding of the eommuni- appears to exisl within most language syslcms iI limiled nurnber of (orlllal
cation process. Il is importanl to note lhM the development of language pri~ciples by which words are comoined to crente various meanil1gs.
itself involves an interdependent reliltionship between philosophical, Chlldren learn very quickly the "c1eep struclure" uf il langlJilge wilhin .lheir
psychological, ancl sociocultural determinants. Next we shi111 consider ~wn culture, although the process by which lhese princ.iples ilre ilcq\lircd
nonvero¡¡j eOll1municillion or paralanguage, the definilional and methodo- 15 no! yet fuUy understood, lhe distinclion bel \Veen su rfilce a nd elecp
logical problems inherent in sludying lhis phenomenon, i1nd lhe sub- s~ruclt~rc, however, underlies lhe imporlilncc of semanties ;me! Iilnguilge
slanlive findings of scholars in lhe field, We shall then consider the analysls. Here we see the linguistic basis for Ihe eommon observation thil!
complex interrelalion between roles and the eommunication proeess, wilh what words S¡¡y or lo wllnt they rder indivielually is' no! necessarily the
special illtention to lhe impact of role expecliltions on the cornrnunicillions same as ~hal they mei1n cornbined wilh other words. For eXilmplc, Ihe
belween doctor and palient, Following this, we shall consider a special melilphorrcal. u,se of the worel pn;" suggests the lype of problern this poses
problem of Ihe doelor-palient relationship, treatment compliance, and will for the physlcliln. The cornplaint "n pain in the heart" Illar suggest iln
show holV the very n¡¡ture of lhe problem can be lr<lced to factors wilhin ¡¡ttack (Jf angini1 when in lldui1lity Ihe p::llienl is c1eseribing gricf.
 •.••• ·
.' r
.: '/.16.
l.E, Carr and P.E. Maxirn
Communication Research and the Doctor-Patient Rclationshíp 137

Despite their differences, languages possess certain universal properties

Ihal leave sorne lheorists lo hypothesize a bíological capacity for language. peculiarly or distinctively English, [apanese. and so on. in gram-
mar.
The evidence for this hypothesis i; lirnited, but quite persuasive,
4. Stage four is characterized by the clear emergence of complex
Lenneberg (1967) cited five reasons vvhy biological propensiries in the
human for language could be r easonably assurned: transEormations.

l. There is evidence of analomical and physiological specializalion in

the speech rnechanisrn and brain center that controls speech. Language and Conceptual Structure
2. There is evidence of a regular schedule of dcveloprnent in all
lt has been hypothesiz ed (Whorf, 1941; Sapir, 1929) tha! how <In
children, regardless of cultural vari.rtions.
individual experiences the world is shapcd in part by the structurc of the
3. There is evidence Ihal langl.lage developrnent generally continúes
language one speaks:
despite handicaps resulting frorn disabilities or neglect.
4. By cont rast, Ihere appears lo be a failure of nonhurnan Iorrns to Are our own concepts of time, space, and mal ter given in substantially lhc
develop even t h e rnost prlmirive forms of language. . same íorrn by experience to all mcn, or are they in part conditioncd by rhe
5. There exist language universals in phonology, syntax, and sernan- structure of particular languages? (Whorf. 1956, p. 138)
tics.
While it is gene rally agreed that laoguage and pcrception are intc rrclatcd,
Given this innate biological capacity, what, then, motivates the child lo ther e nas be en considerable controversy as to the precise nalure of lhis
learn increasingly complex Iorrns of language? lt has' be en suggesled thal relationship. As a result, there are essentially three versions of the
Ihe child's ne ed for diffcrentiating belween and expressing a growing Whorfian hypothesis: (1) that the slructure oí language dircctly influences
variety of conceptual representations of life events provides the primary thought, (2) thal Ihe structure of language does not neccssarily influence
motivalion. Reinforcemenl provlded by increased capacity for successful thought but do es influence perceplion, and (3) Ihat thc st ructur e o(
interpe rsonal communicalion se erns lo playa major supporlive role in this language does not necessarily influencc thought or pcr cept ion but docs
language acquisition scherna. influcnce m ernbry. Al present, the evide nce appears to best support the
II has been shown thal, developmenlally, the speech of children exposed third versión. that is, that the structure of language has lcss lo do with the
to diííer cnt condilions of learning in different language systerns (e.g.. conceptual representation of experiential events per se but more, rather.
Russian, )apanese, and English) display identical grammatical features. with the inEormation storage arvd retrieval process in cognition. Although
I\ccording lo Bellugt (1965), this course of language developmenl appears surprising, the implicalions of these rescarch findings are no lcss
lo follow a general schema with four identifiable stages: significan!. The impacl of culture, via language, does not so much influence
how an individual p erceives or thinks about whal is happening lo hirn but,
1. An inilial stage comprised almost exclusively of deep structure
~.: rather, how he l~ter recalls it. This gives us sorne indication of the rcasons
sentences such as "se e truck," "daddy gene." Subsequent language
for the cultural richness of myths and legends as conlrasted with official
development involves the addition of transformalions, for exarnple,
reports and eyewilness observations of events. Now, considcr the
changing an affinnative sentence into a negative senlence, which, al
irnplications: Culture and language structure will impact more significantly
this early stage, is accomplished by adding no or nol to the affirmative on what a patie'nt remembers of past medical history than it will on
staternent.
immediale observations of symptomatology.
2. Asecond stage in which Ihere is an increase in the number of
So Iar, we have seen that the unique communicative capacity of lhe
negative morphemes.
human involves (1) anatomical and physiological specialization of Ihe
3. A third stage, essentially the same as stage 2, but with grearer
speech mechanism, permitling br oadcast of a wide range of cornrnuni-
diversity of negative rnorphernes plus a number of special cases. This cative sounds, and (2) the capacity, in parí biologically bascd, oE
stage seems lo represent the upper limit to which non transforma- organizing this finite range of sounds into a systcm of almost infinite
lional grammar can be extended. There are few of the de ep structure meaning potential on the basis of a Iew universal encoding rules. What
sentences se en in stage 1 and more advance d Iorrns of transforma- remains to be described is the third componenl in this systern. (3) the
tional s!atements (e.g., "1 did not hear the noise" versus "no hear cognitive capacity for conceptualizing and organizing lhe refcrcntial basis
noise"). The language begins lo assurne characteristics tha! are for these life experienccs.
 138 j.E, CMr and P.é. Maxim Cornrnunication Rescarch and thc Doctor-Palient Reliltion~hip 139

Concept Formation obscured over the course of time. Whichevcr the case, latter-day explana-
tions may invoke rnyths. religious beliefs, or simply cultural precedenl-
In l his cont cxt we sh<JII define conccp! as the cognitive basis Ior assigning a
"beca use il has always been done that way."
catcgory label, which in Iurn refcrs lo a number of specific instances or
lt is not difficu1t to see that cultures may similarly produce idtosyncratic
cxarn ple s. The proccss of learning refers to any ~ctivity in which the
conceptual sys\ems having lo do with explanalions of illncss, he<lling, ;\J1d
lcnrrier rnust dassifr two or more diffen nt cvcnts or objects inlo a single
pr cventivc practices.
ciltegor)' w ith some idenlifying charactc ristic in common. Thc devclop-
In any given individual, the acqulsülon of a conceptual system is a
menl a nd rcfinement of concepis takes place over an exlended period of
Iunction of thal individual's life cxperiences. Thus the nature and structure
lime and is generally bclicved lo progrl!SS from a íew globill, relatively
oí that .systern are íunctions of Ihe accurnulation of ecological dernand,
undilfc rcntiated concepls lo a more highly articulal ed and hierarchically
cultural, and societal influences, and idiosyncratic experience. To thc
orgi1l1 izcd systern.
degree the individual is succcssful in acquiring useful "ecological"
Conccpts in ccrtain dornains ma}' develop more rapidly and m"y be
conccpts, then to lhat degree will he survivc in the ccological selting; lo lhe
more highl}' diffcrentiatcd than concepts in othcr domains. For example,
degree that useful social and cultural con ce pts are atlalncd, succcssíul
an enginecr will have a highly differentiated sel of concepts with regard lo
sociocultural adaptation will [ollow, to the dcgrce that uscful but socially
engincering principies such as stress and mechanics, but may ha ve lcss
acceptablc idiosyncratic concepts are acquir ed. then lo lh<ll degree will Ihe
diífcr cnt inted concepls in such dornains .as medicine or marine sciences.
individual survive as a psychologlcalty as well as physicillly independenl
Similarly, sorne paticnts may have highly diííerentiated concepts con-
organism, lt is pcrhaps this lalter catcgory of deterrninants lhat accounts
ccrning lhe function of an organ's system, say the gastrointestinal system,
for the uniquc individual differences we all enjoy: individual differences
while othcr patients may ha ve more highly articulated notions about lhe
no! just in values, beliefs, attitud cs, and behaviors but, more irnportantly.
Iuncticns of the respiratory system. Obviously, this articulation of concepts
distinct ancl unique diííerences in Ihe ways we organizc, calegoril.e, and
is tied closely to exper iential events. WherC<1S a polar Eskimó m;¡y have a
process íníormation. Il is this vcry irnportant individual difference in
highly e!ifferentiated sysrem of construcls with regard lb expericntial
conceptual slructu re l hat is lhe key lo underste nding thc hu rnan COJl1JllU-
íactors rclatcd to survival in he arctic, conccpts
í associat ed with principies
nication process so essential lo efficaeious heallh care.
Of cvcnts not in lhat realm of lhe Eskirno's expcrience are either
undcrdcveloped or nonexislenl (Bcrry, 1975).

Nonverbal Communication
At the outset one rnust distinguish betwecn mcaning and messagr. in
Conceptual Structure and Ecology discussing nonverbal behavior. A messilge is the information trnnsrn itt e d
This suggests that concepts and how Ihey are organized are in part through lhe production 'of iI bchcvioral code ff()111 il "scnding" or
detcrrn ined by the ecological seulng in which lhe individual íinds himself "encoding" person lo a "recciving" or "decoding" persono The messages in
and that concepts cvolvc. in part, in response lo the or¡;anism's aucrnpts lo bchaviors that constitute such a comrnunication systern are preslIl11<1bly
ndapt to environrue ntal dcmands. Thus conceptual systems have survival known by all people who participnte as senders and receivers. Meanings in
value in Ihat they enable the individual to predict and control life a cornmunication system are more than Ihe messilges scnt. The me¡¡ning
cxpcricnces (Kelly. 1955). For exarnple. Berry (1975), Dawson (1977), and that the encoder attaches in his or hcr mind \0 the bchavior being
others have repoded distinct differences betwcen hunter-gatherer and produced consists of the encoders' feelings, ideas, memories, and views of
agricullu:i11 societics, not only in the content of Iheir conceptual systems, the world at the moment that lhe behavior is codifiecl ilnd Iransmiltee!. lhe
but <1lso 111the slructure or manner in which information is organized. message carried in lhe behilvior is only a smal! parl of the rne;lnings lhe
These finclings hilve lee! Berry and Oawson lo hypolhesize that dislincl encoder intcnded,however. Sill1ilnriy, the lI1eilning Ih,,1 the decodcr
conceptual systel11s <1Swell as social systems evolve in response lo Ihe altaches to the reccived behavior<11 lT1ess;lge is differen! from lhe mess"se
specific ecologieal dcmilnds tlpon a group. In turn, Ihese unique con- itself, owing to lhe decoders' memories of p;1s1 relationships, currenl go;¡ls,
ceptual social syslems give rise lo specific sociill practices ilnd values that moods, <1nd vicws of Ihe world. 1l should be also noted Ihat lhe decoder
over time become identified as cultural a!tribules, although lhe origins of can altach an ascribed meaning to behilviors when Ihose behaviors, in f¡¡ct,
these cusloms may never have been fully realized, or may h¡¡ve become ha ve no codified message.
 142 14J
).E. Carr and P.E. Mnxirn

th e premise that facial expr essions carry arbitrarily coded messages of Tab!e 1. A Partial List of Caz e=Ccstur e Co mblnations and Thcir Messages"
affect. lt has additionally distinguished part-whcle distinctions in non-
Caz e ge~lure cnrnhlnation Me.sose
verbal behavioral that ar e confused in the work of Dirdwhistle; that is, this
work points out the degrce to which p.rrticular facial [e~tures contribute to Look al, shake head al I want yOl! arid the oth e rs lo listen and change my vicws.

the wholc [acial gestalt, while noting t hat it is the whole gestalt alone that Look al, eyebrow flash !..ook al al1 the trouble these orhers have causcd and how
carries the message, 'no: partial features. This work, however, has be en they are being blamee! lor il.

restricted lo looking only at facial expressions, only in static, not inleractive Look al, extcnd palrns Let's agree on I his.
situations, and only with prcviously defined messages. 1..001< .1. nod no J Ihink your views are wrong on this.
1\ third and more promising line of research, developed by. writers su eh Look .1, shouldcr shrug J ree¡_anxiou~ bccause I dont k now e noug h, I reel rOl! pul
as Scheflcn (1964, 1966), Watzlawick el al. (1967), Eibl-Eibcsfeldt (1970), me on the spot, bul l'rn not .ngry; I like you.

and Smilh et al. (1974), emphasíz cs behavior in an interpersonal setting as Look al, cycbrow r.ise They ~nd I agrce; you a nd í hc orhers shou ld .vic\V it íhls
the communication rnodcl. This rescarch assumes that arbitrarily coded way loo.

nonverbal behavior rcpresents an older, evolutionarily earlier mode of Look al. finge, flag This is why I Ihink this way and your way is wrong.
cxpression than verbal language. It further assurnes the existence of Look .w'Y. srnile I p.rlly agree wilh yOl! and perhap; ;hould do Ihi~
behavioral message co nt inu it ies in human and rnarnrna lian noriverbal dilferenlly, but thclr ",ay is ridiculous.
communication. Much previous work on primate social cnrnrnurticatinn Look a\Va)', nod no I can't decide whal lo Ihink 01 all these eonOicling virws.

has led to a methodology Ior defining behavioral catalogs, which is !..ook .\Vol', settle I'm <1!1xious about our di~f1gre'{'ing.
adaptable to human nonverbal catalogs. For example, work with rhesus Look away. groom I think I dis.gree wilh you about Ihis. but I dnn't havr
a nd pigtail monkeys has produced a method Ior defining rnessages e nough lnforrnatio n lo decide.
cont ain ed in nonverbal bchavior. The rescarcher collects examples of Look away, rub nosc I think we would ¡;el alonr, j( you wr-r e n'! 50 in cpt.
particular bchcviors se en in different monkeys and relates thern to co- Look away, rnouth cover I arn c rnb arrnss ed .11 not knowing enollr,h about Ihis and
occurring subsets of social contexts in which they invariably occur, that you k now i1.

Message st atcrncnts for human gaze, gesturcs, and Iacíal expressions have Look a way, no geslure I am unsur e of rnys cl! and 01 our rrlationship.
sirnilarly bcen derivcd by collecting cxamplcs 0[" the co-occurrcnce of Lock .al, 510w blink Why don'! y{lU appr eclate me and glve my ideas a chance?
rionvcrbal be havio rs wit h verbal staterncnts (Maxirn, 1982b). Verbal Look .1, srnile I Ihink we 'gree tlris is the "'.y lo procccd. cvcn ir othcr s
content analysis scherncs developed by Goltschalk et al. (1969), Yiney and don't.
Westbrook (1976), a n d others allow o n e to then categorize the verbal Look • t·, sclf-gcstor e Despüc .11 thal has bccn sníd, Ihi3 is why my vl r w will
discourse. In a recent study, Maxim examined over 3000 co-occurr ences of preve corr cct.

51 cornrnon gaze-gesture combinations amlSOO verbal content categaries Look al, no gcslu,. I arn being open and want a rclatlorrs hip.
take n from videotaped discussions betwecn 30 pairs of human subjects. Look al, stceplc r'think you are generally right in your vicws and I sid e
Each gaze-gesture combinalÍon was found to co-occur with a subset of wilh you but lecl de ícnsive.

verbal content categories. Thus Maxirn developed a "message statcment" Look away. nod yes I guess I agree with sorne of whot yO\J sny, but I'rn nol
lar a particular gaze-gesture combination by assuming that there was a sur e I side wilh you.

close similarity between the message contained in Ihe nonverbal behavior Look .1, licio lips 1 leel asharned and sorry about the way l'vc b ecn thinking
and .eting.
and the message contained in the verbal content catalogo Table 1 gives a
tentative list of sorne of these gaze-gesture combinations and their derived Look al, 'hcad lilt Maybc we could be on thc same sido o" part Clr Ihis.

message staternent. As can be seen, the messages appear to address Look al, $wing leg Don'l bl.me me or Ihe 0lher5, we already reel badly aboul
lhis.
relationship issues on three dirnensions: affiliation-<:lisaffiliation, asscrtive-
nes5--submissivenes5, and certainty-uncertainty. Look al, bile lip YOll are righl ."d I have becn w'ong aboul Ihis.

WhiJe the aboYe lines of research hold promise, considerable work Look .1, nod yes I side with yOll.

remains to be done in Ihis nrea before the physician can be aSSllred he or 'Modi[ic,1 trom M•• lm (1982b).
slle knows what messages accompany particular nonverbal behaviors
observed during inleractions with patients.
 140 141
l.E, Carr and P.E. Maxirn Cornmunication Rcscarch and thc Dllclor-P.llil'l1l Rclationsb ip

This dísparily belween mcssage and meaning is greater in nonverbal behaviors, those with arbitrary coding, are of special inlerest beca use they
Ihan in verbal communicalion systems. Nonverbal communicalion sys- are commdnly observable in doctor-patient relationships. Their mes~ages
tems are formal systems. The number of possible messages is finite; bear no visual resemblance lo what they signify and they ccnsist of
rnessages are fixed to particular gestores, facial expressions, and body gestures, gaze directions, facial expressions. body positions, and body
posttions. The message of each nonvcrbal behavior remains fixed and postures. Research in nonverbal communication in recenl years has
passive, so that stringing bchaviors together does not appear to create new focused on these behaviors and attempted lo define their messages. Early
messagcs, and other past or future nonverbal behaviors do not define a attempts at .definition were very simplistic and ranged frorn the highly
context determining the meaning of an individual's behavior. Iri contrast, specific to the highly general; Ior example, "the particular movcments. are
verbal communication can be viewed as an informal system. It is open found to be correlaled with particular índices for a particular person In él
ended in rhc number of possible messages that can be constructed. Th·e particular contcxt" (Dittman, 1962); "movements in general express aHccl
messagc carried by each word is active, so that stringing words togethcr in general" (Sainsbury. 1955).
cn~ates.ll~w messages no! found in the consti!uents alone, and the string of Though research in the last ten years has c1eveloped more sophistication
words IS itself a context that further refines the messagc oi the constituents, in methodólogy then is implied by the aboye statements, rcviews by
Thus Ihe verbal systerns' messages can more closely match the complex Wiener et id. (1972) and Harper el al. (1978) underscore the conceplual
meanings attached to lhern by encoder and decoder rhrough the flexibiliry and methodological problerns inherent in Ihis research. Wiener el al.
of serial message ordering. concludcd, "Therc is little consensos about. any sel of bchaviors which can
An early issue in discussing nonverbal behavior, rhen. is to determine ·be considered to serve communication functions, and the literalure
which bchaviors coristitute a communicalion system bearing messages. consists, Ior thc most part, of a fragmented and unsystematic array of
Thc universe of nonverbal behaviors can be usefully divided into those reporrs. with almost any conceivable behavior considered by one or
Ihal are idiosyncratic, and p,ossibly meaningful, but have no message, and another investigalor to have sorne communicative significance" (p. 186).
thos e which are communicative and carry commonly understood mes- This difficulty of reaching a consensus on lhe catalog dcfinitions of
sages. Idiosyncralic behaviors might convey a particular meaning to a nonverbal behaviors is matchcd by the difficulty in logically defining the
single recciver, but not lo others, A physician, for exarnple, will ascribe messages contained in such bchaviors.
signi{icance lo an idiosyncralic behavior, bascd on his expericnce, Three research strategies have had prominence in this area. l3irclwhistle
although th e behavior may have no meaning at all to the casual (1970) has attempted to analyze the meaning of nonvcrbal behaviors.
observcr, . especially movement, in a Iashion analogous to the tre~tme~t of la~guage
11 is generally agre cd that Ihe sum tolal of distinguishabls nonverbal by linguistic scholars (e.g., whal are the minimum basic ~nlt~ required to
signals Ihat can be used in nonverbal communication is in excess of 100 communicate a message7). !-lis approach makes no dístínction betwe en
(Brannigan and Hurnphr ies, 1974; Dirdwhistle, 1970; Granl, 1969). This message and meaning or bctwe en idiosyncratic and c.ommuni.cative
repcrtoir e is larger than that of most anirnals by a factor of 2-3, although il" behaviors as dcfined aboye. This approach attempts to ue mearung lo
exceeds only slightly the repertoir e of Ihe rhcsus monkey and chimpanzce every movement and lo discove r a syslem of meaning peculiar to the
(Wilson, 1975). lnclud ed in su eh a repertoire are three coding principies as particular pe ople in volved arid thcir relatlonship. l3irdwhistle h~s been
dcfined by Ekman ancl Friesen (1968b): arbitrary cedes, iconic cedes, and relatively unsuccessful in his atte mpts to spcciíy a catalog of be.h;¡vl~rs that
inlrinsic codeso have gencrality lo many pcople. and lo specify messages contained 1Il such
Someone who closes his fisl and hits someone is delivering an behaviors apart frorn the meanings embedded in Ihe social context, the
intrinsically coded mess;:¡ge: 11 is not a message similar to aggression, it is personality variables of the participants, and their verbal exchanges.
aggression. lntrinsically coded behaviors are rhose in which Ihe behavior A second research slrategy is excmplificd by the work of Ekman ill~d
and its mcssage are the same. A person who raises a clenched fist in a Friesen (1968a,b). This group has focused p r irnar ily 011 lhe study of _faCIal
salute or who runs a finger under his ihroat to signify "an unfortunale expressions. The facial expression message is assu,:,ed to be ~ particular
outcorne" is performing iconically ceded behavior. Iconically coded aHect such as anger, fear, sadness. surprise, happi n ess, or disgust. T~e
behaviors carry the clue lo their message in their behavior. The message is research tasks then focus on the degree lo which static poses of facial
clear and understood by everyone in the culture. These two classes of expressions can be decoded correctly by pcople from diverse ~ultures or
nonverbal behaviors are so obvious in their messages as to be easily the dcgrce to which different facial fealures afEect the decoding o: the
decodable by the physician and nol parlicularly useful, The Ihird class of p reviously defined aHect mess<lge. This research has gane [ar lo validate
·" 144 l.E, Carr and P.E. Maxim Communication Research and ihc Doctor -Patient Rclatiorish ip 115· .

Paralinguistic Communication breathing, etc.) and volee sel (fa ligue, agc, and oth er physioIogical
pecularities ·o( the speaker's volee). but were unable to demonstrate an}'
This label is generally assigned to aspi .cts of verbal behavior not explicitly consistent relation berween ceded paralinguislic cues and any particular
a part o( language itself but that serve to contribute to or amplify the emotionaI states, One of the difficulties encountered was an inability to
message in the communication, as well as pro vide information about the obtain reliability in judges' ratings of certain cues.
sendero Paralinguislic characteristics such as pitch, tone, volum e, articu- Among the range of emotional statcs, anger, anxiety, sadness. and
lation. resonance, lempo, modulations, and so forth, provide information happiness ha ve been more reliably judged than fear, love, and surprise,
that may be essential to correctly underslanding the intent of a message. A which are the more difficull emolions to ide ntify. Those individuals who
number of studies have also shown that the vocal characteristics of an are more sensitive to decoding emotional paralinguistic eues tend to be
individual relale lo personality type, as measured by a personality test or more adept al expressing affect via such cues. Zuckerman et al. (1975) had
inferred by an observer (Harper el al., 1978). However, it would be naivc 64 college rnen and 37 women encode six cmolions by Irying lo irnitate
to conclude that such relations are sufficienlly robust to permit indis- emolions of anger, happiness, sadness, fear, surprise, .and disgust in Iheir
criminant prediction. For one thing, paralinguistic characteristics and the ir videotaped facial expressions and audiolaped state ment 0(, "1 lvave t o Icave
meaning may vary between ethnic, socioeconomic, or geographic groups, now." Each person was then asked lo classify the emolion po rtraycd
and without awareness of these differences can lead lo confusion and visually and vcrbally by the othcrs, The rcsulls indicated that those with
misinlerpretation in communications. the best ability to encode emotions were the best at clecoding it, alt hough
Of greater int er est lo researchers has be en the hypothesized role of no one had outstanding ability. In making auditory judgments, m e n and
paralinguistic characteristics in communicating the emotional state of an women 'did better raling the ernotions of lhose of the sarne sexo Howcver,
individual. In general, the reported relation between vocal cues and affect in making visual judgments, men and women did belter raling emolions of
appears lo be far more substantial than the relationship to personality. those of the opposite sexo Women were found to be slighlly bctter ovc rall
Davitz (1964) has shown lhat sensitivity to emotional paralinguistic cues is in both encoding and decoding emotions t han meno A similar study by
relaled to perceptual and cognitive factors (auditory discrirnination of tone . Buck et al. (1974) also found that women were belter encoders lhan rnen.
and rhythrn, verbal inlelligence, spatial analytic ability, and knowledge of as evidenced by the greater accuracy with which both male and Iernalc
focal characteristics) but is unrelated to 33 personality variables measured judges could deeode female ernotions. Rosenthal and Def'aulo (1979),
on four different psychological tests. This is not surprising, since affective however, found lhat women lost thcir encoding-decoding advantage
staies (e.g., leve, hate, joy, and fear) have more immediate social and when their facial or verbal cues were presented Ior briefer periods of ti me,
survival value and therefore are more likely to have social re(erent cues more closely approximating lhe way cues are seen in everyday lifc.
with high consensual validation. Personality characteristics, by contrast, Frorn th e physician's perspective, anxiety and dcpression rank among
have less social communicative value and are more 'idiosyncratic in thcir the most significant of affective sta tes, not only because lhey r e pres ent
development and nature. important clinical conditions per se, but also because they are often cr itical
Dittman and Wynne (1966) conducted an extensive study of the role of indicators of the patient's emotional and cognitive response lo disease and
paralinguislic cues in interviews; they coded Iinguistic junctures (dividing trenlment. For a variety of reasons, ranging from individual persona lit y lo
points in the flow of spe ech). stress (the increase ancl decr ease in louclness cultural role, patients are nol always candid about their worries, Iears, and
with clauses), and pitch (the rise and (all of fundatnental frequencies of the depression relative lo medical careo A subtle behavioral cue may be lhe
speaker's voice) and attempted to correlate these variables with different physician's Iirst and only indicalion that the patient is anxious ¡¡n.d
emotional states. While trained judges could reliably agree on changes in subse quent inquiry may reveal a dislorled impression of the natur e of .hls
these variables and the emotion they Ihought was being conveyed, Ihc or her disease, mísund erstanding as to the purpose of he surgical
í

change in these variables showed no consistent pattern with any particular pr ocedure and its outcome, or misinformation .about his or her chances (or
emotion. These investigators also : coded paralinguislic vocalizations of survival.
three typcs: vocal characterizers (Iaughing, crying, voice breaking, etc.). There is no simple re lation bctween anxiety and bchavio ral cues that cm
vocal segrega les (ult, JIII"" ult 111111, etc.), and vocal qualifiers (extra in crease be applied indiscriminantly to all people. Sociocultural prescriptions for
in loudncss, pitch, and duration placed on some words), but reporled thal lhe meaning of cues m¡¡y vary and individual responses to both lhe
vocal characterizers and vocal segrcgales occurred too infrequently to be intensity and quality of the affecrive stat e can cover a wide range. On th e
useful in correlaling thcm with a particular spcaker's emotion. They also basis of such findings, we may eoncludc, as did Davilz (1964), lhat thc
triecl to code voice quality (tempo, rhythm, precision of articulation, commllnicalion of affective rneaning via p¡¡ralinguistic elles is a funclíon o(
 Communicatlon Rcscarch and thc Doclor-Pillicnl Rcl.,linl1~hir ·H7
146' I.E. Carr and P.E. Maxirn

the observcr's eognitive and pcr ccptual abilities ralh e r than his other states such as anxiety, depression, conflict, pr eoccupatlon with
pcrsonality traits or the personality traits of lhe observed. Such perccptual- distracting ideas or messagcs, and olhcr lorrns of interual stress. as
cognitive abilities are not uecesse rily rclaicd to verbal me,1Iling or the well as external or environrnental stressors.
Iinguistic aspccts uf the communication Thc ilbility lo accu ratcly perccivc the 4. COllfllscd Im:sclltnlioll. While at firsl glance this would aprear lo be n
crnot io nal implicatlons of an individuat's paralinguistic cucs, within the problem thal is self-cvidcnt. ,,11 loo often jt is a problern that is
context of various socia I int eracl ions, is a pcrccptunl or cogn itive capability of ignorcd by the physlcian. The physician may have well in rnind lhe
the observcr thal has lillle lo do with pvrsoriality and which is quite dislinet specific points he or she wishcs lo make lo the patienl regarding thc
from lhe 1;lIlgui1ge facility of lh e observad. It is M\ interpersonal pcrccptual- lreatrnent regimen or information about lhe disorder in question;
cognitive skill and, likc ilny skill, improves with practice an d trilining (C;¡rr, however, a confused or disjointe d pr cscntation, lacking in logical
1982). Thus, co ntrary to the popu lar nation a mong physicians that ernphathic sequen ce, full)' illustrated with Ihe use of highIy technical ¡argon,
ability is <1fixed quanturn thal must be conscrvcd by r ationing it lo orie's lengthy sentences, and unfamilinr idiornat ic phrases may completely
patients, rclevant rcsearch indica+es t hat emparhic abilit y, like al1y skill, can obscure the meaning of Ihe ml?ssage the phys ician wishes lo irnpart.
o nly be rnaintain e d and incrcased lhrough cxercise, Indced, failure lo do so 5. IlIlrllsiOl1 af persollnl molives nilo idiosY'lcrntic Ifn¿,ils. The physician has
C<111 onl)' lcad lo its d ccr ease and eventual disuse, only lo experience the seerningly cooperative and compliant paticnt
who somehow lnevitably mar'i1ges to sabotagc lhe treatrncnt rcgirncn
to rcnliz e that things are no! always as the y secm. lntrusion of
unconscious thoughts. affcct. and mofivation inlo the doclor-patient
rclalionship is a problem of whieh the physician musl be constnnt ly
Factors in Interrupted or Ulocked Cornmunlcation
aware.
Pcrhaps it is a co mmentary on the state of thc a rt Ihi11 rnore can be said 6. UlIslrlleo nssumptions. lnevitably in ilny cornmunicative interaction, lhe
about what can go wrong wilh comrnunication than about what will sender mily be cspccially liablc to make cerrain assumptions about
guarantcc hat it will go
í right. In gel1er<ll, howevcr, r csear chcrs on the rcceiver and therefore lo cast lhe message in these lerms. lf these
cornmunication agree as to sorne basic c¡¡tegories of barriers lo elíective assurnptions are unwarranled. thcn the recciver ma)' be opcrating
communicarion (e.g., Parry, 1967; Miller. 1967; Watz.lawick et al., 1967). under a distincl handicap in being ólble lo receive and proccss thc
I. Lnck of el Call1llll(llicntioll TI1cdill111. Frorn a pragmalic standpoint, the inforination. For exarnple, the physicinn may assurne that thc patient
most basic kind of problem is a lack of communication facilities. In a is familiar wilh certain lechnieal or mcdical terms lhal he or she is
physician's practicc. it may be simply a lack of commonality in. using lo describe the patient's current disorder. If that assurnption is
I¡mguage, for example, an English-speaking physician wilh a Spanish- unwarranted, then the physician's highly lechnical cxplanation will
speaking patient. Or the problern mily be more subtle; Ior exarnple, in be totally rnisunderstood by the patient. Similarly, the patient can
his or her hurry lo complete the physical exarnination, a physician entertain unstated assumptions about the physician: for cxarnple, that
providcs no opportunity for communicalion belween hirn- or herself on the basis of a minimal dcscription of symptoms the physiclan is
and t he palient. lotally familiar witb the patient's condition or that in referring the
2. IllfOrllln/ioll ouerlooi', lf we assurn e that a rnediurn Ior cornmunieation palient to a specialist, the paticnt's Iarnily physician has full)'
exists, problell1s Illil)' oecur if the receiver lacks lhe c<lpncily to receive informed the specialist as lo lhe paticnt's condition, family bilCk-
i1nd process the information. Thi5 may be the result of limilations on ground, and so on.
lhe receivers of an intellectuill, lingtristic, social, or experienliill nature. 7. IlIcompnlibilily of conceptual syslcms. Relólled to lhe previous ítem, lhis
Or it mily be the resull of too mueh inform<ltion or information thilt is is probably the most importi1nt )'et least a!tended lo of the polentii11
loo complex; for example, lhe receiver ma)' be faced with a problem barriers lo meaningful communicati.on. 80th doctor al1<l piltjent bring
of having to deal with compeling slimuli ineol11ing at lhe same lo lhe doctor-palient relalionship a highl), idiosyncratic conceptual
time. or belief systern reflective of highly individualized life-Iearning
3. ois/me/ioll. In comrnunicalion theory terms, this is often referred lo as experiences. In large part, the abilil)' of two reople to communicate
"noise" and includes the various kinds of phenomena that are not successfully depends on tl·c degree to which there is sirnilarity in the
relevant to the message being communicated but whích may conceplunl s)'sterns they e¡.ch bring to lhe communiciltion siluation.
inlerfere wilh ils transmission or receipt. These include a(fective The degree to whicl; one person, the physician, m<l)' innuence lhe life
14B l.E. Carr and P.E. Maxirn Communicalion Research and th e Doctor-Palienl Rclationsb ip 149

of Ihe other person, the patienl, is similarly dependenl upon the While we have come to associate the concept of roles with resear ch in
degree lo which the conceptual systems are compatible, permilting the social 'sciences, historically the term is borrowed direclly frorn the
facilitative cornmunication (Kelly, 1955). theater and was used there as a melaphor intended lo denote that con duct
which adheres to certain parts in a drama rather than to the players per se
who read ,or recite the parts. Thus, in contrast lo the rnain body of
Social Roles and Communication
psychological inquiry, the study of the isolated individual is not the focus
In our discussion of the communication process between doctor and of our coneern here; instead, as Sarbin and Allen (1968) have suggested,
patient, we will now consider the impact on that process of the social roles the questions that should guide our observations of social behavior and its
played by both Ihe physician and the patien!. Much has been written aboul eonsequences are of this type: (1) ls the conduct appropriate to the role?
the doctor and patient roles and the pressures on the individual that are (2) Is the enactrnent proper? That is, do es the overt behavíor meet the
inherenl in each. One is templed lo assurne that the differenees in these normative standards thal would serve as evaluational criteria for the
roles are largely a function of difference in education and expertise with observer? 15 the performance to be evalualed as good or bad? (3) Is the
regard to the practice of medicine. lf this assumption were correel, we enactment convincing? That is, does the enactment lead the observer lo
might conclud e that sinee doctors know abóut good health praetices, thev declare unequivocally that the incumbent is legitimately occupying thc
know how to be good patients. In fact, whether or not the physician position?
successfully fulfills his professional role in no way implies that"he is It is apparenl from Ihe natu r e of these questions that our concern h er c is
capable of suceessfully assuming the patient role, and numerous studies wilh constellations of behavior that are consensually agreed upon by
have shown Ihat physicians are as a rule abysmally poor patienls. For mernbers of a social or cultural group and that behaviors are sufficiently
exarnple, while almost al! physieian.s rceommend annual physician exarns discrele and therefore identifiable as to be capable of being communicated
for their patients, between one-third and two-thirds of them fail to practice frcrn one person to another. and from one generation lo anolher, wilhin
what lhey preach. lt would be naive to assume that this reflects either th e that cultural group. We know that any member of any organized saciety or
physicians' lack of need for medical attention or th e ir ability lo self- culture group must develop more than a single role. lf he or sh e is lo
diagnose. Logic dictates thal the physician is as subjeet to having successfully function within that group, then what is required is a
significanl asymptomalic problems as an)'one in the populalion at large repertoire of well-practiced, realistic, a nd socially accepted roles. A person
and sorne studies even suggest that the level of undelected significant with such a repertoire is thus much bett er equipped to meel the societal
asymptornalic problems may run significanlly higher arnong physicians demands placed upon him Ihan is a person whose repertoire of roles is
lhan among comparable groups of business executives. Since such quite meager. Thus the roles define the social structure by which
problems are generally picked up through routine physical examinations, inlerpersonal interaclions are carried out within the societal graup and
Ihe physician's ignoring of his or her own adviee can hardly be justified on involve a eomplex constellation of behaviors, affecls, cognitions, posiurcs,
the assumption of laek of need. Whal is perhaps more significant, however, staruses, and even distincl language forms. The ver)' nature of the concept
is rhe Iact that physicians with diagnosed disorders tervd lo ignore these oí role implies that not only are ther e prescriptions Ior what behavior is lo
symploms or wait twice as long Ir orn their outset to seek medical help as occur in an interpersonal inleraction, but also prescriplions for the
do lay persons. communication. The best example of this, of course, is that in many
Numerous statistics are often cited too illustrate the impact of physician cultures various roles will have distinct linguistic forms associate d wit h
role demands upon the individual. Drug abuse is much more comrnon them so that the individual, in assuming a role, also assurnes <1 readily
among physicians than among the' general public, one-third of all identifiable language formo
physician hospitaliz ations are gene rally caused by alcohol and drug use, Sinee the notion of interpersonal inter actio n is inherenl in the concept
the suicide Tale for physicians is double that of the general adult of role, it is riecessary lo look at th e way in which role expectations impact
population, physician pilots are involved in fatal light plan e crashes at a upon the behavior of th e participanls i,n this interaclion. By r~le
rale Iour times that of civilian noncommercial pilots, and so on. While expectalions we refer to that conceptual bridge that connects social
these slatistics suggest that the concepl of roJe is indeed a significant factor structure on the one ha nd with the role bchavior of the participanls on th e
in the physician's existence, they provide us with little insight into the other 'hand. Role expeetation refers to those rights a nd privileges,
nature of the role itself or the mechanics by which it cvokes such drarnatic duties, and obligation's of the person who occupies a role as pcr ceived by
("()nseouences. other persons in complemenla'ry roles. Once an individual has be en
15U j.l,.... '-lll' UII\,o I .•...•.• , ' •••.••••0 ••

identi(ied as occupying the physician role, Ihe person m Ihe comple- This is 'nol to say that roles and role expectations do not change. Under
mentary role, the paticnt. immedialcly invokes certain expectations certain circurnstances, roles go through (1 natural evolutionary course, as
(beliefs, constructs, or concepts about the nature of the physician role) can be se en Irorn the variety of role changes associatcd with the
about th e physician's anlicipated behavior that thcn influcnce Ihe way the devcloprnental process throughout adolescence and early adulthood.
pa+icnt shall behavc. As can be seen these role expectations may or may Certainly \his must represen! problcrns in interpcrsonal cornmuniration,
not have anything to do with tht individual who is occupying Ihe for role change rnusl by neccssity be accornpnnied by changes in role
physician role. As a rcsult, lhcr e is polcntial for a br eakdown in expcctations, role dernands, and the form of communlcation between the
cornrnunication if the physician is cither unawar e of the expectations 01' is partieipants. Much h;,ls becn written a bout the irnpart and consequcncc of
unable lo fulfill lhern, ' change in life-styles upon <In individual and specifically of Ihe impact of
Role expcctations Vill'y along several dirncnsions, the rnost irnportant of these changcs upon interpersonal relationships and the <lbility lo com-
wh ich includc (1) lhe degree oC generalily or speciíicity, (2)' t h e ir scope or municatc (Sheehy, 1976). The most fre<"]uently menlioned by-producls oí
extcnsiveness, (3) thcir degrec of clarity or uncertainty, (4) thcir dcgree oí such role changes are dissolutions of r clationships and social r calliancc,
agreement 01' disagreement among [hose pcrsons in Ihe complemcntary Allention has recenlly been íocused upon Ihe cornplex inl ernctinn
roles, and (5) the degree to which they relate to formal or informal between sex and role cxpectation, especially in light of the dramatic
pcsitions wilhin the social structure. alteration in traditional feminine roles now occurring wil hin our own
[( wc look al ca eh onc of thcse dimcnsions with regard'to lhe physician culture. The trnnsition frorn Ihe studcut lo Ihe doctor role is sulficicntly
role, we observe th at lh e role is Iair ly spccific: hat is, wc are able to spcciíy
í truumat ir, but add lo l hat l hc comp licating sltuatlo» o( Iri1nsilion (rOI11
preciscly rcquired behavior, how and whcre the bchavior should be fcmale coed to doctor and one can be¡:;in lo apprcciate Ihe complexity and
exccutcd. and the exact penalty for nonadhercnce lo the role cxpectation. sometimes apparcnt incongruity in role expectations in our culture
Also, the role is fairly restrictcd in scopc, having relevance to a narrowly rec¡uired by individuals in cornplemcntary roles.
circurnscribed ar ea of a pcrson's lile. Ncxt, Ihe role certainly possesses a In li1I'ge part, the precipitation of role t:!xpeclCllions nrid the Clppro-
high dcgrce of clarity, nnd therc is a greal dcal uf consensus among other prietcncss oí those expe ctal ions are dependenl lIpOI1 Ihe successful
persons conccrning the role expectations with rcgord to physicians' completion oí an e ar lier process of role idcntificntion 01' role perception.
bchavior. Fina lly, Ihe role expeclations clearly relate to a highly formal, By.thcsc tcrms, we refer to Ihe accuracy wilh which Ihe individual is able
social position within t he social strucrurc. Thc physician's role is one about lo perccivc inleractional behavioriJl cucs <111(1 draw from thcrn conclusions
which alrnost cvery mcmber of our socicty has a great deal of knowledge about thc role of thc othcr persono The eues lo which we rclcr are quile
and Ior which thcre is ¡¡ high dcgr ee of consensus about the role and variable and may include such things as gross skeletal movcments or
cxpcctatíons associated with it. verbal acts, physic¡ue, posture. clothing, and perhaps evcn [ncial exprés-
What specifically ar e lhe mechanisms by which the role expectations of Si0I15. They may also rder to adornmenls or visible cmblems and baclges
thc patient affect the role enactment of the physician? We have already of office, uniforrns, and só on. Thus we concern ourselves here not only
implied that rhc role expeettllions ¡¡re, in fact, specifications for adherence with accuracy of perceptioll, but él more irnportant cognitive variable, lhat
to group nonns. In sorne respects lhey are culturaIly ddined job is, the ability to correctly deduce fram Ihe cue the appropriate inforrn"lion
descriplions. Therdore, assuming Ihat there is social consensus as to the relevant lo Ihe carrying on of Ihe interpersonal inlertlclion. lt is an
n;¡llIre of lhis job descriplion, the palienl wiIl be judgmentally concerned esli'lblished principie in social-ps)'chologicill research Ihal Ihe ilccuracy
wilh Ihe appropri¡¡teness and propriety wilh which the physician fulfiIls with which an individu¡¡1 is able lo pereeive such inleraclional cues in
lhe role oblig¡¡tion. There is no c¡uestion that p¡¡tienls expecl physici¡¡ns to others is direetly rclated lO Ihe ac(uraey wilh which Ihal same individu¡¡l is
behilVE: in particular Wil)'S. Social intcrilclion, Iherefore, should be effective able lo perccive his 01' her own role. This empirical rel¡¡lionship belween
and salisfying so long as both p¡¡rlicipanls behave in accordance with those the perceplion o( self ,1Ild thi1t of others once agi1in dr.rnonstrilles the
rules and expeetations. According to S¡¡rbin and AIlcn (1968), "cltlrity of important role played by cognilive process in interpersonal reliltionships
role expectation can be defined as the differences betwcen the optimal and communication.
amount of information needed about role expectations and the amount As we have alreildy said, the concept of role is a met<Jphor for denoting
actually available to a person." Certainly Ihe amount oE information socially ilppropriale behavior Or modes of intcrpersonal inleraction in
impinging on the I~y public via the v<1rious media sources concerning Ihe social situillions. Thus whether or not <In individuéll is ¡¡ble lO successhdly
physician's role is sufficient to provide clarity with regard to role C<1rryoul the pr¡¡ctice of¡¡ role is nol only dependent uron his 01' her ¡¡bilily
expectalions for the physici,an. to learn the appropríi1te i1plitudes and behavior;¡1 skills involved in Ihe
 .' .,'

".
157.'
j.E. Carr and P.E. Maxim Comrnunicatio n Research and the Doctor-Patient Rclationship 153

carrying out.of that ~ole, but also on the ability lo perceive accurately, for It is tempting to assume that noncompliance is a problem belonging
example, to infer validly from available cues the social. positions of others entir elyto the patient and that a review oí the available researeh lilerature
as well as of the self and to infer appropriale role expectations for the would reveal to us the demographic characteristics of a noncompliant
positions involved. patient, allowing us lo rnake predictions about which patients are likely to
be most problematic. In his review of the delerminants oi patient
cornpliance. Haynes (1976) Eound that demographic Eeatures (e.g., age and
Communication and the Problem ot Noncompliance
scx) of patients are not directly related lo complianee. However, he did
The problem of p.a.tien~ noncompliance with lhe therapeutic regimen is find evidence Ihat they afEect the patient's accessibility to the health eare
one of. the mo~t c~ltlcallssues faced by (he practicing physician -attemptíng systern, rher eby indireetly relating to ultimate complianee rates.
lo dehver. efficacious health careo While there is a tendency lo define Are compliance rates a function of diagnosis or disease? There does not
noncomphance as a "management problern," a review of the available appear to be any consistent evidence to supporl the notion lhat corn-
lileratl.l~e quickly reveals that a major contribuling factor in compllance i~ pliance rates are related lo the nature of the illness or diagnosis. Jt is often
lhe ablhl~ of the physician to communicate effeclively with the patient. assumcd that psychiatric patients in general tend to be less compliant,
To. date, the most comprehensive trealment of the subject has be en especially those with diagnoses of schizophrenia or persona lit y disorder.
provid ed by Sackett el al. (1976), who reviewed 185 original studies of However, 13erg et al. (1982) have recently rcported thal diagnoses o(
noncornpliance. The literature shows that patients who enter the heallh schizophrenia and personality disorder had no relation to medication
care s~st~Il_1.wilh symptomalic complaints tend lo keep approximately 90% compliance ·in a c1inie population where 30% of patients suf'Ie rcd
~f their ~nltlal appointments, whereas patients who are 'nonsymptomatic schizophrenia, 24% neurotic depression, 22% persona lity disorder, 12%
(i.e., patlents who are referred inlo th e health care system Ior routin e major affective 'disorder, and 12% schizoaffectivc disorder. The overall
screenings, pl~ysical ~xams, etc.) keep only about 50% of their appoint- c1inic cornpliance rate was 59%.
ments: Comphance with short-terrn medication regimens declines rapidly Is compliance a funclion of the naturc of lhe therapy program? The
over tune, alrnost o n a day-to-day basis, unlil that rate stabilizes at about literature cbnsistently supports the hyp.othesis that cornpliance is iI direct
50% for patients who are on long-term medication. Of course, lhese funclion of certain features of the therapy programo For exarnple,
gc~erillizations ~~e subject lo variable interpr etntions.: depending on a trcatment regimens that r equire more extensivo b chavioral changos 011 lhe
vartely oE co n dit ioris .in the doctor-patient relationship. For exarnple, part of'the patient (especially wherc such behavior a l changes involve long-
comphance rates deteriorate rapidly, especially in instances of acute. illness standing life-style or habil patlerns) are more likely to be associated with
wh~re the patie.nt's condition has been suddenly responsive to the medical significantly reduced cornpliance rates. Sirnila rly, lrealment programs that
reg_'men. What 15 remarkable is that eventually the reportad rares appear to ínvolve highly cornplex fe atures are more like ly to result in re duced
converge at about the 50% level, compliance. The sarn e thing can be said oE t rcatm ent program5 that tend to
Evaluations of th e lilerature are especially difficult because oE the be long termo There does not appear to be any clear relation between
cuorrn ous m~thodolog.ical problems in a n area that has only recently compliance and sidc effects, although lhe pr oblem has not be en cxten-
bcgun. to r ecerve attention from researchcrs. To begin with, definitions oE sively studied.
compl~ance. vary significantly. For sorne physicians, noncornpliance may Is cornpliance a function of the patient-therapisl interaction? Again, the
be defined m terms of any patienl who deviales from a prescribed regimen literature provides sorne fairly consistenl findings in this arca. In general,
of treatment. For other physicians compliánee with 75-80% oí the the closer the degree of medical supervisión ayer the treatment regimen,
treatmenl program may be deemed an unqualified suecess. Methodo- the more likely the patient is to comply. This Einding is based lIpon
logical problems, however, go beyond simple definition of the nature of research comparing campliance filies for outpatient, day-care, and h05-
Ihe. b.eas!. For exarnple, it may be Ihat lo insist upon a single universal pitalized palients, and also on a nurnb er oE outpatienl studies in which thc
defJnlt~on of the noncomplianl parient, applicable to the full range of degree of medical supervision was varied. A variant of this finding is that
potential trealment regimens, is overly simplistic and unrealistic. The the longer a patien! has to wait for any aspect of lhe trentment program,
required level 'of cornpliance by a patient for efficacious trealment oE a lhe less likely it is that there will be compliance.
condition such as a eold may be quite differenl Irorn the level of Some of the most extensive work with regard to lhe relation between
compliance Ior efficacious trealment of a condition such as emphysema. patienr-therapist int eract ion and compliance rate has involve d the
There(ore one ne eds to look al the range o( pararncters involved in parient's perccivcd lcvel of satisfactio n with the lherapist. Compliancc is a
compliilnce to beller ilppreciale ils nalure. iunction of th e lc vcl uf sat isfa ct ion. which in turn is a Iu nct ion of lhe
 154. ).E. Carr and P.E. Maxim Cornrnunicntion Research and thc lJoclor-Pillienl Rel~lionshir ',lJ5' :

dcgre e to which the patient's expectations are met by the therapist and are increases in eompliance and improvernenls of therapeutic outcornc. In
unrelated to the attitude the patient holds toward either the heaith care assessing the implicalions of this finding, we must ke ep in mind that lhe
systern 01' doctors in general.. rnajority of sludies have {ound no assoclation bctwcen palients' knowl-
In thcir study, Derg et al. (1982) Iound that 75% of patients who edgc about lheir diseases and compliance. Nor is thcre any evidence to
subsequcntly wer e no ncornpliant lo prr-scribcd medication dosage would . SUggc5t a r elation betwe en intelligcncc and compliance. This suggesls Ihat
indicare prospectively that they were not goil1g to be cornpliant: for the critical elernent is indeed comrnunicational. but not simply in terrns of
cxamplc. lhey g;wc negiltive or equivoca] answers., al thc time the thc clarity of the messnge being communicated. Rather, consislcnt with the
mcdication was prescríbcd, to qucstions reBClfding their willingness 01' evid ence ciled earlicr, the clarity of lhe messilge nnd ils consistencv tuilll Ihe
ability lo take the medication. Furtherrnore, they gave clcar reasons as to prt/iclll's cxislillg herllllr (are be/ie( syslcII' Me essenlial. Thus the litcrature
why lhey pr obably wou ld not co mply: They Ielt they were being coerced; suggesls lha! probability of cornpliance should be increosed in lhose cases
Ihey ha ve 110 money; thcy though thcy were getting too little or loo much whcre the physician is able to accurately perccive lhe hcalth carc belicf
medica+ion: 01' Ihey predicted that they would forget to lake it. Such systern :of the patient and Iorrnulate trcatrnent recommendatlons and a
rcasons, should thc physician take the lime lo elicit thern, are probably descrip~ion of lhe lreatmenl regimen in lerms lhil! are consistenl with t ha!
currcctablc by active intervention and negotialion, thercby leading lo systern.
much beucr cornpliancc. . Ley (1977.) has revicwed psychotogtcaí studics of docior-patient
In his review of thc soclobehevíoral paramctcrs of cornpliance, however, cornmunication and sirnil¡nly concludcd lhill improvcd r ornrnu rrirnl io n
Bcckcr (1976) argued that the "health belief systern" a patient maintains appears to dcpcnd upon lhe ability of the physician lo (1) accurately
has a dircct influcnce on lhe poticnt's acceplance of prevcntatlvc health determine the paticnt's Iears and worr ies, (2) assess the paticnt's
carc rccommcndations. whereas the paticnt's knowlcdge .of diseases and cxpcctations and cornrnunicatc lo lhe palien! wherher or nol thcse
thcrapy does not. lleckcrconduded that compliance with one aspcct of the expectations can be rnct and why, (3) provide iníor mation about lhc
trcatment program favors the probabillty lhat there will be cornpliance diagnosis: its rncaning, nnd ils implicntions with regilrd lo the cause of
with other aspccts of thc pr ograrn, with the criticaI element in predicting illness, (1) adopt a fricndly ralher than a businesslikc atlitudc. (5) nvoid
cornpliance being the presence or absence of a stable and suppor+ive medica! jargon, ami (6) spcnd lime in con versal ion regarding noruncdical
f,ul\ily structurc .. topics, Tlve ernphasis in thcse six poinls is less upon lhe rornmunicatiun oí
Tlie availablc lileratu re appcars to support a he~lIh bclief model lhat factual mcdlcal informalion than il is upon lhe establishment of il condition
contains thrce essential clerncnts: of trust and iufluence with rcgard lo thc patlent, LE'y pointcd out lh al in
order lo incr ease thc understanding of lhe paticnt wil h rcgard lo hls or hcr
1. Thc paticnt's cva lu atio n of a hcalth condition as delermined both by
condition, materials concerning the condition and thc lreillmenl rcgimen
his pcrceived likelihoocl of gelling thc disenso and his perceptions of
should be prcscntcd lo lhe paticnt in a slri1ighlforwi1rd and concrete
lhc probable scvcrity of the disease. The resull is a state of"readiness
lashlon. P~ticnls often lack thc elerncntnry, technicnl. and mcdical
lo la ke action."
knowledge r equircd lo undcrstand ll1i1ny lrcillmenl rcgimens; furlher-
2. The patien!'s eVillualion of IhE' rccommelldcd he¡¡lth behavior in
more, they often hilve misconceplions Ihil! milil;,le ilg;¡inSl proper
lerl11s of il:; fcasibilily and efficaey weighed agélinst cslimates of lhe
underslilnding (e.!j., the palienl's belicf system ••bout heilllh care prac-
physicill, ps)'ehological, financial, ilnd olhE'r costs of, or barriers to,
tices). Ley contended lh ••t lhe chief probkm in pillirnt campliilnce is lhe
lhe proposed bchavior.
lendcr;1cy of lhe Pil!ienl to forBet up lo 40-50% of lhe inlendE'd mcss;1ge
3. A "elle to acHon" musl oceur to lriggcr the recommendcd heallh
allywhere from'5 to 80 minules following ·lhe consultiltion, but olher
behavior; lhis stimulu~ can be eilher intE'rnal (c.g., symptorns) or
researeh suggesl~ lhal lhe problem is less one of forgelling and more onE'
exlcl'llal (e.g., élclvice [rom family, friends, mass media, and other
of inildequalely understancling lhe inilial rnessage. To. enSIHE' Illilximill
communicalio ns).
understallclinB ;'\nd recal! of lrCéllment inslruclions, Ley ell1philSiz.ed lhe
Some furthE'r insighl inlo lhe possible detcrminanls oC Ihe complianee following points:
problem m"y be gained by ¡¡ review of Iypes of programs thill have proven
lo be SUCCE'ssful when reducing noneomplianec. In general, ;¡ review of the 1. Whcnever possible, proviclc Ihe píl!ienl wilh inslruclions illlcl ¡¡dvicc
lilerature illong lhese lines suggesls Ihill behavior¡¡1 and mullipIe slrategies at lhe stilrl of Ihe inforllléllion session; lhal is, m<lke 1.hE' crilic,,1 poinls
hold a subslilntial edgc over cclucationill s!rillegics in lenns uf bolh inilially.
 ·.'. 156 Communieation Research and the Doctor-Patient Rclationship 157
..... j.E. Carr and P.E. Maxim

2. When providing instructions and advice, stress the importan ce of the wrong, since the outcome is proving to be not what the physician had led
instructions. the patient to expect.
3. Use short words and sentences.
4. Use explicit calegorizalions where-er possible.
Conclusions
5. Repeat Ihings wherever possible.
6. When giving advice, ma ke it specific, detailed, and concrete. "Social and behavioral scientists hav e long acknowledgcd that an indi-
vidual's success in coping with the social environrnent is lilrgely deter-
In studies where Ihese recommendations were lested recall and miried by th e degree lo which that person is 'able to develop a sufficiently
understanding on the part of the patients increased by 10:"20%. differentiated cognitive representation of the environment (Zajonk, 1968).
The issue often arises as to whether or not the patient should be toId all The principie has Ear-reaching irnplications Ior mcdical practice and
of th~ .details ~f his or her disorder. Surveys indicare that the majority of indieates that rescarch focusing upon the cognitivc processes in social
physicians believe that patients shouId not be told (69-90%), but in fact, interactions should prove valuable in advancing our understanding oE
when questioned, Ihe majority of patients indicat e thal they do want to what contributes lo successful therapeutie intervention. Furthcrmor e, the
~now as much as possible about their illness, even if it is fatal (77-89%). success ofa social interaetion is also a Eunctio.n of the degrce to which therc
~.urthermore, outcome studies indicated that life adjustment following is compatability among the ·participants in the levcl of difEerentiation of
illness was ía r better among inEormed patients than among those who had their cognitive structures.
been uninformed or misinEormed. This "eognitive compatability" has be en deEined as onc pcrson's (e.g.,
The work of [anis (1958, 1971) has underscored the significance of thc the doctor's) ability to accurately per ceive and communicale within th e
relation that exists between the degree to which the palient is inEormed system of cognitive dimensions used by another (e.g.. the palient) to
and the patient's adjustment to ilJness and/or health care procedures. In conceptualiz c his or lver exper icnce (Landfie ld and Nawas, 1961\) and is
his studies of íactors affecting patienrs' recovery from surgery, [anís found the fundamental psycholo.gical process underlying the concepl of clllpnl},y.
that paticnts with prior inEormalion about the specific unpleasant out- Cognitive compatability is clefincd not only in terrns of similariiy in the
comes they might expcct showed belter pre- and postoperative adjustment concepts uscd in conccptualiz ation bUI, more importantly, similarity in the
than those patients who r e ceive d no information. lnformed patients degree to whieh their conceptual dimensions are differentiated (Tr iand is.
showed less Iear prior to Ihe procedures, less anger, greater confidence in 1960), The physician and patient may shar e a common dimension such as
the outcorne and in the skill of the doctor, and Jess emotional disturbance painful-nonpainful, but for onc individual (the patient) the dimension
overall. Janis hypothesized thal by having such information available prior may be poorly differ entiated, allowing hirn to make few discrirninations
lo the surgical procedure, the patient was able to anticipate the Eear he among a given grpup of stirnulus conditions ("everything causes pain,
would experience and to rehearse adapting and coping responses in the doctor"), whereas for another it may be highly differ entiatcd. permitting
Iace of perceived danger. 13y being uninformed, the patienl was deprived him lo pcr ceivc a greater nurnbcr oE diffcrences al1long Ihe sarne group
of the opportunity to anticípate this fear and adequately prepare íor it. As a stimulus .condition. Whether· doclor and patient agreed íhat a given
result, he was left lo feel helpless when the clanger actually appearecl. This, condition was painful would not nccessar ily depend upon whether or not
in turn, led lo the expectation of vulnerability, disappoinlment and distrust they uscd the same sernantic labcl, but whcther they shar ed a relatively
in the physician, and, consequently, feelings of Iear and anger. cornmon degree oí diEferentiation of that conceptual dimensiono Therefore
Clearly, by provicling the patient with full and complete information th e more me aningful "functional" similarity of th e ir conceptual structure
about Ihe sensations, pain, uncornfortable cxcrcises, or unpleasanlness of could be distinguished Irorn merely thc "sernantic" si m ilarity and
various treatment rcgimens, rhe physician may evoke some degree of fear operationally defined in terms of the clegree lo which the level oE
and anticipatory anxiety in Ihe patien!. However, as [anis pointecl out, this diEEerentiation of one approach ed the levcl . of diffcr cnt iation o l the
may in facl prove to be adaptive [or the patient in thal when these events other (Carr, 1982).
do occur Ihere will be no surprises, no feelings of IOS5 of control or that The principle of cognitivc compatability offcrs a possible explanation for
events are proceeding oulside o[ the rcalrn of expectation, and therefore several of the d ilernrnas of health car e r escarch. We hav e suggested t hal

no basis for anger or fear in response. The palient does not Ie el thal he or cognitive incompatibility could account for problems of noncompliance
and hc ("ilure (l( doelor and patienl lo ilgree about lhe oulcol11c o( lhe
she has been cleceived, misled, or worse, perhaps, that something is going
í
 ..
158 J.E. Carr and P.E. Maxirn
Comrmmicntion Rescarch and thc Dortnr-Pntie n! Relatiunship 1;0' , .. ",

tr eatrncnt (Rogcrs, 1967; Carr and Wl)iltenbaugh, 1969). Nawas and

Landfield (1963) hypoihcsiz ed that mosl improved patients should show a but, more importantly, a n appreciation of the indigenous conceptual
siguificant incr ensc from pre- to postth :r~ry in the nurnber of concepts framework and the cognitive processes by which those faclors are assigned
borrowccl Ir orn the doctor, wher cas le ast improved patienls should show a menning.
dccrcasc. l nst cnd lhey Iound that irnprovcd paticnts showcd a dccr(!osc in
the nurnbcr of constructs borrowcd Irom the doctor. In a subsequent References
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cornrnu nication betwe en lhe pal ie nt nnd t he therapist wi/hill lllc poticnt's R. l-layncs, €ds.: Complinnce with Ther.1pculic Hcgillwns. Ilalt irnorc, Maryl.lnel:
lOllgl/nsl' di"'CIl$ioIl5 was essentiallo trentrncnt success, but Ihnl communi- [uhns Hopkin5 I'rCS5. .
cat ion wilhin lhe t hcrnpist's langllilge dimensions was not. Bcllllgi, U. 1965. The dcvclopmcnt of inlCrrI.lgnlive structurcs in childrcn's spccch.
If paticnts are conccrnccl with whether they are understood by lhe 111 K. Ricgcl. e d.: Thc Dcvcloprncnt of Lnl1g\l~r,r Funclions. Univcrsüy of
Michignn L.lngu~ge Devclopmcut Progr"m. Rcport No. !l, pp. 103-137.
doctor arid base their judgment of the lreatmerit outcome on this
Der!;, J., P. Maxirn, and J. Brinktcy. 19(12. Unpuhlisb ed manuscript, Dcpl. ..ol_
pcrccption. th en lheir ability to assum e the dcctor's frame of rcference is
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IcS5 re IcV;1I1t to lhe Ir c atm e nt proccss than lhe doctor/s ilbility lo assume.
Berry,' J. 197 .i. Ecology. cultural adapl;¡lion ,1nd p~)'chot()gical clirrcrcnti,1lion:
lheirs. Fu rtherrnore, while a mcaningful undcrstnnding of the patient's life Tradilional patlerninr, nnd acnrll\lrali\'l' stress. 111It Oristin, S. Oochnl!r, anr]
situation, p roble 111 s, and modcs of ;¡djllsll1l(:'nt mny rcquire the dortor's W. Lonncr, cds.: Cross-Cultuml Prrspcc!ivC5 un 1.,C,1rning. Nr w York: Wilry, pro
ilpprl'ci;¡ling lhe paticnt's cognilive: dirncnsions and lh e ir level of differ- 207-230.
en+iation, Ihis does nol nccessarily imply thilt the doclor uses thc patient's 13irdwhiSllc, R. 1970. Kinl'Sics and COI1I\?xl: I~ssays Qn Do"y f'vh,lion and Cornmuni-
vilnl;lge poinl whcn it comes lo the task of cvaluaring outcornc. Indeed, in cation. Phil.1Clclphia, Pennsylvauia: Ul1ivcrsily or I'cnnsylvi\ni;¡ Prcss,

response lo lhe d cmands for "professiona!" evaluation, the doctor is more Drannigi\n, C, and D. Humphr ics, 1'174. Human nonvcrbal bchavior. a rucans of
cnrnrnunication. 111 N. G. llurton-Iones. cd.: Elhological Studics nr Child
like1y to sh ift back lo lhc more familiar pcrsonnl conceptual slruclure or a
llchavlor. Cambridge, Englanel: Cambridge Univcrsuy Pruxs, pp. J7-6~.
"profcsslonal" viJnt~ge' poinl compriscd of the heor etical 01' conceptual
í

Buck. R.. R. E. Millcr, nnd W. F. CM l. 1971. Scx. pcrsonallty. ~l1d ph)'~i,.,lnf,ic~1

dirncnsions acquir cd through profcssional training.
variables in Ihr conununlrntlnn of ~rrecl vin (~cial cxpressiun. [ournal of
Thc rescarch on dortor -patient cognitive cornpatibility has shown thal Prrson~lily and SOCi.11P5)'chology JO:5137-596.
not onl)' is it ;¡ critica] filctor in predicling the success of tr eatrncnt Carr, J. 1982. Personal construct thcory i1nd. ps)'cholherilpy rcscarch. 111 A. Land-
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111 J. ShlÍ('n, W. Hunl, J. Malari17;l:O, .me! C. Sil\'i1gC, ccls.: R{'se~rch in Psyrho-
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origins, \lsi1ge, ill1d CQdil1g. Sl'rniolicn 1:4'1-98.
 , ,
",.o

'1óO
,: '-r ..
• r"
¡.E. Carr and P.E. Maxim
Com mun icat io n R"~l'.1fch anel lhc' DOCI()r-l'<1Iienl Rl'I.1Iion~hip 161

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