Physician-patient interaction: what do elders want?

              Vieder et al • Original contribution JAOA • Vol 102 • No 2 • February 2002 • 73
The purpose of this study was to identify communication
styles and physician characteristics that correlate with
improved patient adherence and satisfaction during geri-atric
healthcare interactions. A multiphase study design,
incorporating the use of focus groups, socialization hours,
educational seminars, and survey questionnaires, was used
to discover the most effective methods for improving com-munication
between physicians and their geriatric patients.
Elders favored direct, interactive verbal communication
over alternative communication styles such as role-playing
activities or the use of visual aids. Chi-square analyses
showed that men desired more time with medical providers
than women, who instead expressed a preference for more
thorough explanations of disease processes. Further, men—
and African American men in particular—sought medical
advice from trusted friends more frequently than did
women, who often preferred to solicit medical advice from
family members.
The most significant barriers affecting physician-patient
interaction were created by patients’ inflated expec-tations
for consultation time and by physicians’ ineffective
presentation styles. This study also reveals that physicians’
characteristics and patients’ gender and race also impacted
the success of medical encounters.
(Key words: senior citizens, elderly, geriatric, patient
satisfaction, patient adherence, communication styles,
physician characteristics, physician-patient relationship)
The quality of the therapeutic relationship between physi-cians
and patients can greatly affect patient adherence and
treatment outcomes. This fact has decided implications for
elderly populations. In the United States, 13% of the popula-tion
is older than 65 years; one in eight of those is older than
85 years. Fink et al2 assert that 40% of all patients in the United
States are 65 years or older. Without proper training, physi-cians
will be ill-equipped to handle the specific problems of
their older patients.1
Numerous researchers have identified problems unique
to the elderly. Several studies3-5 note that older patients pre-sent
with complicated medical conditions that are chronic
and difficult to explain in a concise manner using nontechnical
terms. The rule of thumb for some geriatricians is to anticipate
that for every decade after age 40, a patient will have one
new chronic disease. Thus, physicians need to be increas-ingly
aware of more than just the chief complaint.1
Because of these factors, senior citizens are more likely to
leave medical office visits with an abundance of confusing and
sometimes conflicting information regarding disease pro-cesses
and medications.5,6 The anxiety experienced by elders
during physician office and hospital visits compounds this
problem. If physicians do not adequately explain treatment
protocols, older patients may feel confused and fail to seek
clarification.7 Physicians need to focus on obtaining a com-prehensive
view of the patient’s problems as well as pro-viding
the patient with plainly worded, thorough explana-tions.
In the not-so-distant past, physicians were revered as
the keepers of medical knowledge and were unquestioned in
their diagnoses and recommended treatment modalities. Sub-sequently,
to avoid being perceived as disrespectful or unin-telligent,
older patients may have remained passive during
medical interactions.4,7,8
However, modern medical encounters focus on a thera-peutic
contract, or relationship, in which patient and physician
share equal responsibilities. This paradigm shift further rein-forces
the importance to both parties of developing a strong
physician-patient rapport. Elders, more familiar with the “old
school” of medicine, may be uncomfortable with this new
medical model and may be reluctant—or unable—to take
an active role in their healthcare decision making.4,7 In addi-tion,
seniors may not be current with the continual changes
in healthcare terminology, technology, and treatment modal-ities.
This knowledge gap further exacerbates communication
problems.
Another serious communication barrier is the apparent
negative attitude exhibited by some physicians toward senior
citizens.4 Ageism, or prejudice against the elderly, is a problem
ORIGINAL CONTRIBUTION
Physician-patient interaction: What do elders want?
JASON N. VIEDER, DO, MBA
MICHAEL A. KRAFCHICK, DO, MBA
ANDREA C. KOVACH, PHD
KATHERINE E. GALLUZZI, DO
Dr. Vieder is an emergency medicine intern at Botsford General Hospital in
Farmington Hills, Mich. Dr. Krafchick is an intern at the Philadelphia College
of Osteopathic Medicine in Philadelphia, Pa. Dr Kovach is an assistant professor
and the director of the community health programs at Arcadia University in
Glenside, Pa. Dr Galluzzi is professor and chair of the Department of Geriatrics
at the Philadelphia College of Osteopathic Medicine, Philadelphia, Pa.
Address correspondence to Jason N. Vieder, DO, 23160 Halsted Rd,
Apt 121, Farmington Hills, MI 48335-3752.
E-mail: jvieder@yahoo.com
74 • JAOA • Vol 102 • No 2 • February 2002
ORIGINAL CONTRIBUTION
that can compound the existing frustration geriatric patients
experience during their healthcare interactions. Studies indi-cate
that physicians provide less information and support, and
are less egalitarian, less engaged, and less respectful with
their older patients.9
Because of the complexity of their medical problems,
elderly patients often require extra time and effort from their
physicians. Research indicates that patient age is inversely
related to visit length and treatment options.5,10 In the process
of examining what is needed by senior citizens to improve
their medical encounters, four research questions were used
in this study to evaluate the needs of geriatric patients:
  Which presentation styles used by healthcare professionals
are most effective in transmitting health-related informa-tion
to elderly patients?
  From whom do seniors believe they receive the most reli-able
medical information?
  Which characteristics of healthcare professionals promote
trust and build rapport with seniors?
  Do the elderly differ by gender and/or racial group in
their preference for any single health information com-munication
style?
Methods
A multiphase study was conducted during the summer of
1998 in Philadelphia, Pa, at four citywide senior centers. The
participants were functionally independent, cognitively intact,
and lived in the surrounding area. Forty subjects fully partic-ipated
in the study through an intervention site while 120 par-ticipants
from the three other centers completed surveys only.
All participation was voluntary, and subjects were informed
that the results gathered from their responses would not include
any type of identifying information.
The study consisted of four parts, discussed in greater
detail below:
  Focus groups were conducted to identify participants’ health
concerns.
  Socialization hours were used to establish the rapport
needed to interview participants about their healthcare
encounters.
  Educational seminars were held to observe which presen-tation
styles were most preferred by the elderly for com-municating
health and medical information.
  Survey questionnaires were distributed to identify whom
seniors rely on for medical health information and to deter-mine
how elders perceive physicians (ie, character and infor-mation
communication).
Focus groups
Four focus groups, each with ten elderly participants, were
used to document participants’ medical histories and determine
health concerns (Figure). Each tape-recorded session lasted
approximately 1 hour. After each meeting, the tapes were tran-scribed
and the transcriptions were reviewed to ensure accu-rate
reporting of participants’ comments.
Topics of greatest concern included diabetes, osteoporosis,
nutrition, arthritis, heat stroke, and heart disease. These par-ticipant-
generated topics were used to develop educational
seminars.
Socialization hours
Socialization hours were used to promote trust, build rapport
between patients and researchers, and gain insight into pre-conceived
notions held by seniors regarding healthcare. Seniors
were informally asked which characteristics and styles they pre-ferred
in their physicians. Participants were also queried about
what differentiated “excellent” physicians from all others.
For 6 weeks, 2 days per week were dedicated strictly to this
task. Each recorded session lasted between 1 and 2 hours, and
participants’ comments were documented in audiotapes and
written notations. These comments were later compared with
the survey results of the intervention sites to help determine
congruency between subjective and objective results.
Educational seminars
Educational seminars were conducted 1 day per week to eval-uate
participants’ preferred method(s) of presentation for
physicians communicating health-related information.
For 6 weeks, a different topic was discussed each week
using a different presentation style; no single style was used
more than once throughout the program (Table 1). All pro-grams
lasted approximately 30 minutes and included a topic
introduction, activities related to that week’s presentation style,
and a question-and-answer period.
Vieder et al • Original contribution
  Who has given you the best information about [insert
topic of the week]?
  What is the major problem with your doctor’s way of com-municating
with you?
  What is the best way your doctor could explain [insert
topic of the week] to you?
  How was your understanding of [insert topic of the week]
before the seminar?
  How was your understanding of [insert topic of the week]
after the seminar?
Figure. Examples of questions asked in focus groups
JAOA • Vol 102 • No 2 • February 2002 • 75
ORIGINAL CONTRIBUTION
to pose questions, the physician’s body language often indi-cated
a lack of openness to these questions—as demonstrated
by a lack of eye contact, moving toward the door before con-cluding
the consultation, and a hesitance to touch the patient.
These nonverbal actions gave the respondents a “rushed” and
uneasy feeling, which caused further anxiety, tension, and
forgetfulness.
Educational seminars and survey questionnaires
Patients’ preferred communication or presentation style—
Educational seminars were conducted to evaluate by gender,
race, and study site the most effective way of communicating
health-related information to senior citizens (Table 3).
Overall, the majority of all four surveyed groups (ie, men,
women, African American, and Caucasian) chose lectures as
their presentation style of choice (51%). Videotapes were also
judged to be helpful in assisting comprehension (men, 21%;
women, 20%; African Americans, 24%; and Caucasians, 19%).
Survey questionnaire
After each seminar, a multiple-choice questionnaire was dis-tributed.
The only change among weekly seminar question-naires
was the seminar topic itself. Similar questionnaires were
distributed at three other senior centers in the Philadelphia
area on a one-time basis. These surveys differed from the pri-mary
Philadelphia site surveys because only general (ie, not dis-ease-
specific) health inquiries were made. The non–primary site
participants answered this survey but did not participate in the
other educational aspects of the study.
The survey consisted of seven questions ranging from
specific seminar topic–related concerns to general questions
about physician-patient communication. The survey was for-mulated
using information gathered from the focus groups
and concentrated on the seniors’ most pressing concerns. Par-ticular
interest was paid to patients’ preferred presentation
styles for communicating medical information, their perceived
best sources of medical information, and their impressions of
physicians’ major deficits regarding interpersonal interactions.
Data analysis
Surveys were evaluated to assess the perceived needs and
wants of the study population in their medical interactions.
Descriptive statistics were used to describe characteristics of the
study population. Chi-square tests were created to evaluate pos-sible
preference differences by gender, race, and study site.
An alpha level of .05 was set for accepting significant differences
between comparison groups.
Results
The majority of the study’s participants were female (73%)
and Caucasian (82%). Most seniors in the study were 65 to 74
years (44%) or 75 to 84 years (38%) with relatively few of 85 to
94 years (18%; Table 2).
Focus groups and socialization hours
Qualitative information collected in the focus group sessions
and socialization hours emphasized a strong patient desire
for personal interaction with and patience from physicians.
Study participants placed a heavy emphasis on selecting physi-cians
who were patient, caring, empathetic, and compas-sionate.
Physicians who exhibited these traits promoted long-lasting
relationships with their patients. Study participants
further emphasized the need for establishing a feeling of com-fort
and trust with their physicians.
Physicians’ personal habits and their personal appear-ances
were also crucial to how study participants responded
to them. Overweight or unkempt physicians seemed to elicit
opinions of considerably less influence over the study popu-lation.
It was repeatedly emphasized during the course of the
study that physicians too often rush a patient visit and do not
give their patients time to ask questions. It was also reported
that when some physicians attempted to give patients a chance
Vieder et al • Original contribution
Table 1
Seminar Topic Schedule and Corresponding
Presentation Style by Week
Week Seminar topic Presentation style
1 Diabetes Video
2 Osteoporosis Literature
3 Nutrition Cartoons
4 Arthritis Lecture
5 Heat stroke Role playing
6 Heart disease Pictures
Table 2
Demographic Characteristics of the Study Population
(N = 160)
Category No. (%)
Race and gender
  African American
  Male 11 (38)
  Female 18 (62)
  Caucasian
  Male 32 (24)
  Female 99 (76)
Age (y)
  65-74 71 (44)
  75-84 60 (38)
  85-94 29 (18)
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ORIGINAL CONTRIBUTION
Chi-square analysis showed no statistical difference in
preferred presentation style between the intervention and non-intervention
sites, gender, or racial group.
Patients’ preferred sources for medical information—Most
respondents (Table 4) indicated that the most reliable source of
health-related information they received was from their physi-cians
(men, 56%; women, 62%; African Americans, 41%; Cau-casians,
64%).
Chi-square testing indicated a significant difference (P 
.05) for both gender and racial groups. Men were more apt
(30%) to consult their friends regarding medical problems than
were women (3%). Conversely, women were more likely (23%)
to discuss their medical concerns with a family member than
were men (12%). African Americans were more likely (34%) to
consult friends about medical problems than were Caucasians
(5%), who were in turn more likely (23%) than African Amer-icans
(7%) to seek health-related information from family mem-bers.
Problems with physicians’ communication styles as per-ceived
by patients—Subjects reported several barriers to com-munication
when interacting with physicians (Table 5). Many
respondents reported the feeling that physicians “rush” through
consultations (men, 40%; women, 36%; African Americans,
31%; Caucasians, 38%).
Participants also reported feeling that their physicians do
not spend enough time with them (men, 42%; women, 28%;
African Americans, 10%; Caucasians, 37%). Using words the
patient does not understand was the third most significant
complaint reported (19%).
Chi-square tests indicated significant differences between
the two racial groups in the sample population (P   .05), but
not between genders. Caucasian patients indicated that their
physicians were not spending enough time with them during
their visits. In contrast, the most important factor to African
American patients was being treated with more dignity and
respect.
Comments
The study results highlight the characteristics and communi-cation
styles common among physicians who are able to com-municate
successfully with senior citizens. The most consistently
desired traits identified by study participants were patience,
thoroughness, and clarity.11
Additionally, the study indicates that physicians treating
seniors are most effective when ensuring that patients’ office
visits are participatory, comprehensive, and educational.12
Patients reported better adherence to treatment protocol when
the attending physician is frank—yet remains empathetic and
caring.13 Also, it is important to note that study participants
often responded more strongly and intuitively to physicians’
nonverbal cues than to their spoken words.9
Participants were most responsive to physicians who
spent “sufficient” time explaining complicated modes of
therapy in a simple and interactive manner.3 But how does
one define “sufficient”? The study results show that senior
citizens often have high expectations regarding consultation
time with their physicians. Senior citizens did not specify the
amount of time they thought was necessary; they provided only
the general parameter of “the amount of time necessary” to
properly address all outstanding issues and questions.
Managed care plans often exacerbate many physicians’
existing time constraints, requiring shorter consultation times
to maximize the number of patient visits and minimize uti-lization
and costs.14 Due to an increasing workload, heavy
paperwork, and the demands of out-of-office visitations (eg,
nursing facilities, hospices, home), mandated shorter consul-
Vieder et al • Original contribution
Table 3
Preferred Presentation Style by Participants’ Gender and Race, and by Study Site
Gender, No. (%)* Race, No. (%) Study site, No. (%)
African
Category Male Female American Caucasian Intervention Survey-only
(n = 43) (n = 117) (n = 29) (n = 131) (n = 40) (n = 120)
Video 9 (21) 23 (20) 7 (24) 25 (19) 8 (20) 24 (20)
Literature 8 (19) 21 (18) 5 (17) 24 (18) 6 (15) 23 (19)
Cartoons 2 (5) 5 (4) 1 (3) 6 (5) 2 (5) 5 (4)
Lecture 21 (49) 60 (51) 15 (52) 66 (50) 21 (53) 60 (50)
Role playing 2 (5) 4 (3) 0 (0) 6 (5) 2 (5) 4 (3)
Pictures 1 (2) 4 (3) 1 (3) 4 (3) 1 (3) 4 (3)
*Percentages are rounded and are reported for each subgroup. Totals may not equal 100%.
Table 5
Patients’ Perceived Problems with Physicians’ Communication Style by Gender and Race
Gender, No. (%)* Race, No. (%)
Category Male Female African American Caucasian
(n = 43) (n = 117) (n = 29) (n = 131)
Rushes patient 17 (40) 42 (36) 9 (31) 50 (38)
Talks down to patient 2 (5) 12 (10) 10 (34) 4 (3)
Hard to understand the doctor 4 (9) 27 (23) 6 (21) 25 (19)
Not enough time spent with patient 18 (42) 33 (28) 3 (10) 48 (37)
Other 2 (5) 3 (2) 1 (3) 4 (3)
*Percentages are rounded and are reported for each subgroup. Totals may not equal 100%.
JAOA • Vol 102 • No 2 • February 2002 • 77
ORIGINAL CONTRIBUTION
mographic variables may explain the preference of African
American patients to consult friends about medical and health-care
issues rather than their physicians. The most significant
variable leading African American patients to seek healthcare
advice from friends, rather than from medical personnel, may
be a lack of familiarity with navigating the usage of our health-care
system. Further studies need to be conducted to determine
precisely why African Americans prefer consulting friends
instead of physicians. If physicians hope to treat the medical
problems of elders effectively, it is essential that they recognize
and respond appropriately to each patient’s background.
The major limitation of the study was the varying degrees
of complexity in the seminar topics. The effectiveness of each
presentation style was determined based on the seniors’ abil-ities
to understand and retain the information introduced
during these educational seminars. Because of the wide spec-tation
times are often unreasonable for primary care physi-cians
who wish to answer patient concerns appropriately and
fully. Keeler et al10 describe a positive correlation between
increased patient satisfaction and longer consultation times; this
correlation may encourage managed care plans (and Medi-care)
to fund the increased time seniors desire with their physi-cians.
Ong et al11 have reported the importance of recognizing
patients’ cultural differences and how these differences can
affect patients’ perceptions of “good medical care.” Most
notably, African Americans in the survey group report feeling
an attitude of “disrespect” coming from medical personnel
during consultations. This patient perception may contribute
to the increased preference of many African Americans to seek
medical advice from friends instead of healthcare professionals,
as noted previously. A combination of psychosocial or sociode-
Vieder et al • Original contribution
Table 4
Perceived Best Source of Information by Gender and Race
Gender, No. (%)* Race, No. (%)
Category Male Female African American Caucasian
(n = 43) (n = 117) (n = 29) (n = 131)
Family member 5 (12) 27 (23) 2 (7) 30 (23)
Friend 13 (30) 3 (3) 10 (34) 6 (5)
Pharmacist 0 (0) 8 (7) 3 (10) 5 (4)
Physician 24 (56) 72 (62) 12 (41) 84 (64)
Other 1 (2) 7 (6) 2 (7) 6 (5)
*Percentages are rounded and are reported for each subgroup. Totals may not equal 100%.
78 • JAOA • Vol 102 • No 2 • February 2002
ORIGINAL CONTRIBUTION
trum of seminar topics and their varying degrees of com-plexity,
a confounding factor existed in measuring the success
of each presentation technique. To determine which presen-tation
style yielded the maximal effectiveness, a different style
was used for each seminar topic (Table 1). This technique cir-cumvented
the natural human ability to process information
through repetition and increased familiarity.
Conclusion
If concerns raised by seniors during the course of patient con-sultations
can be addressed directly and more accurately, better
physician-patient interactions would result and better treat-ment
could be delivered. Our findings suggest that physician-patient
interpersonal skills training, specifically with regard
to the geriatric demographic, needs to become a more promi-nent
feature of modern medical education. This concept and the
related skills need to be introduced in the first 2 years of med-ical
school with an ongoing emphasis during clerkships and
postgraduate medical training.
However, physicians cannot bear the weight of the
problem alone. Insurance companies need to provide patients
with clear and concise literature regarding standard patient
treatment protocols. In addition, they should assist in edu-cating
patients on how to enhance communication skills with
their healthcare providers so that medical care is optimized.
Seniors themselves should also be encouraged to take a more
active role in learning to navigate the healthcare system in an
efficient and productive manner.
Inflated patient expectations about consultation length
and ineffective physician communication styles create the most
significant barriers in medical interactions with senior patients.
Other factors, such as the physician’s personal characteristics
and the patient’s gender and race, also play a large role in the
overall success of healthcare encounters.15 An improved stan-dard
of healthcare for this population can be achieved only
through a joint effort to bridge existing communication gaps.
Acknowledgments
The authors thank Melissa Herring, Ronald Klimberg, PhD; Jane
Dumsha; Valerie Hamaday; and Eugene Mochan, DO, PhD, for
their advice and support.
This paper won the student presentation prize at the 43rd
Annual American Osteopathic Association Research Conference in
San Francisco, Calif. The original abstract to this article was published
in the September 1999 issue of JAOA.
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