Review
Optimal matches of patient preferences for information, decision-making and interpersonal behavior: Evidence, models and interventions

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Abstract

Objective

A comprehensive review was conducted of the theoretical and empirical work that addresses the preference-match strategy in physician–patient communication.

Methods

Searches were conducted on Medline, PsychINFO, InFoTrac One File Plus, Sociological Abstracts, and Dissertation Abstracts through 2004. The following keywords were used: patient preferred and received information; patient preferred and actualized treatment decision-making; patient–physician beliefs in shared decision-making; patient–physician match, fit, or concordance; reciprocal relationship or mutuality; doctor–patient affiliation, control, relationship; match/fit between patient and physician in affiliation, control, or relationship.

Results

Findings revealed varying degrees of support for the positive effects of matching patients’ preferred levels of information, decisional control, and consultative interpersonal behavior.

Conclusions

Findings justify not only continued but expanded research efforts in this area that would incorporate recommended changes in research design and implementation.

Practice and research implications

Assessment strategies and match interventions are discussed that, if evidence continues to be supportive, might routinely optimize patient–physician encounters toward more positive outcomes. Methodological guidelines are suggested that can improve future preference-match studies of the patient–physician interaction. Practitioners need to consider adoption of patient-match assessment and intervention strategies in addition to recent exclusive concentrations on patient-centered and shared decision-making approaches.

Introduction

Physicians search for an optimal interactive role they can adopt during consultations with patients. Various writers have provided models of contending provider roles [1], [2], [3]. More recently authors have proffered physician roles that offer clear alternatives to the paternalism of previous generations [4], especially with formulations of patient-centered medicine [5], [6], [7], [8] and shared clinical decision-making [9], [10], [11], [12]. In light of the evidence supporting these latter models, Ong et al. [13] admonished that physicians accomplish three important goals through their communications with patients: establish a good interpersonal relationship, facilitate information exchange, and facilitate patient involvement in decision-making.

As a consequence of increasing respect for patients’ autonomy the practice of medicine has become less authoritarian and more patient-centered [14]. Investigators report that patient satisfaction and other outcomes tend to be linked to friendly and non-dominant physician interpersonal behavior [15], information provision by doctors [16], and to more active patient participation in their care [12], [17], [18]. Because of these developments, physicians increasingly feel pressured to adopt a more egalitarian and participatory role during medical consultations with their patients. An accompanying belief prevails that a one best way governs optimal interactions, with relationships between physician role behaviors and patient outcomes being constant across all patients [19].

Careful reviews of the evidence, however, conclude that, although many patients want to be fully informed and actively discuss health issues with their physicians, a sizeable proportion prefers to have little or no detailed information about their condition or involvement in medical decisions. Caution is also suggested by findings that offering a choice of treatments to patients sometimes precipitates increased emotional distress [20] and that pressure to be more active in decision-making can provoke noticeable anxiety in passively inclined patients [21].

As a result of demonstrated individual differences in patients’ preferences, it is increasingly evident that matching physician communication to patients’ desired levels of information and control may be a more rational response to medical ethics and consumerism than advocating increased control for everyone irrespective of preferences. Commentators [22], [23], [24] warn that it can be harmful to provide detailed information to those who do not want it or to impose choice on those who want their doctors to decide about treatments. Schattner [23] states that “respecting patients’ autonomy should [also] include identification of those patients who wish to know less, and complying with their choice” (p. 136). Some patients paradoxically exert control by choosing to let the physician be the authority. Recent ethical discussions at medical conferences [25] determined that patients have the right to delegate responsibility for decisions to their physicians. Steele et al. [26] concluded that existing evidence “does not support an across the board application of an ‘activated patient’ approach to medical care. A mechanical application… that is not responsive to patients’ varying needs may not produce the desirable outcomes attributed to this ideal model of patienthood” (p. 20).

It seems no longer veridical, then, to assume that relationships between physician behaviors and patient outcomes are constant across all patients. Numerous authors have suggested instead that patients may benefit from physician efforts to interact, not in some standard or fixed manner, but in ways that fit or match patients’ preferred or desired level of information and participation in treatment decisions [12], [19], [22], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35]. Any matching approach requires that efforts be made first to identify or assess patients’ preferences for involvement, then to tailor patient–physician interactive roles accordingly.

In light of the emerging emphasis on differential physician role, the time seems propitious to examine in detail the literature that addresses matches of patient preferences during medical interactions. What does the preference-match evidence indicate in regard to the three central areas of information provision, shared decisions, and interpersonal behavior? If evidence supports the effectiveness of matching patients’ preferences, what mechanism seems to mediate the relationship between match occurrence and subsequent medical success? Do more appropriate match assessment and intervention strategies and approaches need to be devised? Can one find theories that might provide guidelines for future preference-matching research? The purpose of this paper is to provide a comprehensive review of these and related issues.

It is helpful to distinguish “preference-match” studies from studies of patient–physician “concordance.” Concordance studies look at the degree of similarity or agreement between a characteristic or behavior shared by patients and their physicians. Both physician and patient are assessed for similarity or agreement on the characteristic or behavior of interest. Then the degree of concordance (high versus low) found is simply summarized or different levels of patient–physician concordance are examined as predictors of subsequent patient outcome. Concordance studies have assessed the congruence, similarity, or agreement of physician–patient:

  • 1.

    gender [36], [37], [38],

  • 2.

    race/ethnicity [39], [40], [41],

  • 3.

    age [42],

  • 4.

    vocabulary level [43],

  • 5.

    identification of the patient's core medical complaints or problems [44], [45], [46],

  • 6.

    designation of medical information important for the patient's care [47], [48], [49],

  • 7.

    recall of specific information discussed during a consultation [35], [50], [51],

  • 8.

    beliefs about the desirability of particular patient or physician behaviors [52], [53], [54],

  • 9.

    estimates of patients’ preferences for information and involvement [55], [56], [57].

    A term distinct from concordance seems necessary to capture the meaning of studies of patient preferences to be examined in the present paper. A concordance study of preferences necessarily would assess both patient and physician preferences. It would require asking the patient and the physician to record separately their personal preferences regarding the extent to which the patient should participate in medical decisions, or their individual preferences regarding the extent to which the patient should be provided information regarding his/her condition and treatment, or their preferences for interpersonal behavior during their interactions. In each case, an assessment would be made of the degree of agreement between a patient's and a physician's reported preferences. In contrast, the studies we review below do not compare patient and physician preferences. Instead, a comparison is made between a patient's preference and that patient's extent of actualization of the preference—that is, between a patient's preferred amount of information versus information actually received; between a patient's preferred level of participation versus level actually enacted; between a patient's preferred versus actual interpersonal behaviors. In all these cases a measurement is made, not of the patient and physician separately, but of two instances of the patient's behavior, preferred and enacted, and the degree of difference present between them.

    We use the term “preference-match” to describe these latter studies, which are the target of our review. Instead of comparing the extent to which a physician and patient exhibit the same behavior or characteristic, preference-match studies assess the degree of difference between a patient preference and what is actually realized during the consultation. The less the difference between a patient's preferred and actualized behaviors, the better the match; the greater the difference, the more a mismatch has occurred. Although other patient match areas can be identified [for example, between patients’ expectations and treatments received during medical interactions [18], [58], [59]], our review will restrict itself to preference-match studies of:

  • 10.

    medical information desired by patients during their consultations [60], [61], [62],

  • 11.

    patients’ preferred level of participation in treatment decisions [63], [64], [65],

  • 12.

    patients’ preferred interpersonal behaviors [66], [67], [68].


Our review thus targets preference-match findings from the three important content areas that Ong et al. [13], as well as two subsequent medical conference proceedings on patient–physician communication [69], [70], identified as central for physicians’ communications with patients.

This paper first reviews preference-match studies in the three areas just defined and, with one exception, will not review investigations of doctor–patient concordance. The exception is one overlapping patient–physician concordance area, the congruence of physician and patient beliefs about (or values regarding) the desirability of patient participation in medical decisions (type 8 above). Preference-match studies will be found to be relatively sparse with findings often embedded parenthetically among other results. Second, the paper reviews conceptual models that show promise for guiding preference-match research. Finally, we discuss assessments and interventions that might routinely optimize patient–therapist matches toward positive patient outcomes, should evidence continue to support the validity of a match strategy.

We make one further distinction. An overwhelming number of empirical studies assess the general effects of information acquisition, participation in decisions, and physician interpersonal behavior on groups of patients. Findings support that patients generally experience positive outcomes from receiving information, participation in treatment decisions, and interacting with physicians whose interpersonal behaviors are low in control and high in affiliation. These general studies, however, are not preference-match studies and are not included in this review. Match research does not concentrate on what happens to patients in general, rather focuses on the degree of preference actualization within specific patient–physician interactions. Match studies, thus, evaluate the extent to which high versus low patient preferences interact with high versus low actualizations (of information, participation, interpersonal behavior). Although preference-match studies can also routinely evaluate the general effects on groups of patients of high or low preference or occurrence, they focus on degrees of preference matches and their associations with patient outcomes. The hypothesis pursued is that the closer the match between patient preference and occurrence, the more positive or successful will be subsequent patient outcomes.

Section snippets

Methods

For the present review, comprehensive literature searches were undertaken through Medline, PsychINFO, InFoTrac One File Plus, Sociological abstracts, and Dissertation abstracts through 2004, as well as through inspection of individual study bibliographies. The following keywords (and grammatical variations) were used: patient preferred and received information; patient preferred and actualized treatment decision-making; patient–physician beliefs in shared decision-making; patient–physician

Match of the patient's preference for medical information

Studies that addressed the general information needs and preferences of medical patients have been reviewed elsewhere [10], [27], [71], [72], [73], [74], [75], [76], [77], [78], [79]. These studies typically survey groups of patients or individuals in the general population asking them to report the amounts and/or kinds of medical information they would want if they were scheduled to interact with a physician. They are not asked to report on information they wanted or received from their actual

Theoretical models of patient-preference match

Three formulations have been offered that explicitly address the patient individual differences that have emerged from studies of doctor–patient relationship. They hopefully will serve as guides to future match studies in medical interactions.

Discussion

The relative indifference one encounters to patient preference-match research may reflect in part the belief that match findings offer few if any practical implications for medical practice. If particular matches are more successful, what difference does it make to physicians’ actual practice? Is it likely that physicians are able or willing to adjust their behaviors to different patient preferences? If physicians have only a “hammer” in their tool chest, whether or not a patient is shaped like

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