Outpatient communication patterns in a cancer hospital in China: A qualitative study of doctor–patient encounters

Abstract Objective The paper characterizes outpatient communication in a major cancer hospital in southern China with regard to the structure, style and focus of doctor–patient communication. Method Fifty‐one encounters between doctors and patients were recorded in the outpatient department of the cancer hospital and analysed inductively to identify patterns of doctor–patient outpatient communication. Results Outpatient communication in the cancer hospital is characterized by structuralized conversation, doctor domination of the conversation and a focus on technology during communication. These characteristics suggest an extreme inequality of power between Chinese doctors and patients at the individual level. They are also shaped by the institutional environment of Chinese hospitals. Discussion Measures should be taken at both the interpersonal and institutional level to improve doctor–patient communication. At the micro‐interpersonal level, public education and professional skills training are needed to improve communication and promote mutual understanding between patients and doctors. At the macro‐institutional level, changes are needed in terms of transforming the structural factors that shape doctor–patient communication. Conclusions Structuralized conversation, doctor domination of the conversation and a focus on technology during outpatient encounters present challenges to effective doctor–patient communication. These patterns are shaped by the institutional environment of Chinese hospitals and suggest the extreme power imbalance between Chinese doctors and patients.

cancer consultation may be more specialized, serious, complex and frightening compared to communication in general practice. 30

| Data collection
The research was carried out at a major cancer hospital in a southern city in China. The hospital is one of the most renowned cancer hospitals in the country, with almost 1500 beds and over 2500 professionals. It attracts patients from nationwide, and even some from

| Data analysis
This research is based on an analysis of the 51 recorded medical encounters. We conducted inductive analysis to detect the patterns of three aspects (structure, style and focus) of the observed interactions. The first and second authors coded all of the conversations and interactions line-by-line respectively, in the first round. They closely read all the recorded encounters and identified as many ideas and concepts as possible by attributing a conclusive sentence or words to each line (see Table 1). The medical encounters were coded with regard to the doctors' actions (eg confirming the patient's identity, medical history taking, interrupting), the patients and their relatives' behaviours (eg answering question, inquiring about alternative options, apologizing) and the conversation content (eg greetings, technology focus, social talk). All of these line-by-line open codes were inspected a second time by the two authors together to produce more focused coding according to the different aspects (structure, style and focus) of the communication. The focused coding in the second phase was more selective and conceptual than the initial phase line-by-line coding. 33 The above three aspects were summarized in this phase by identifying the most significant or frequent codes from the first round. The authors identified that the outpatient communication was structured with an emphasis on efficiency, the style of the conversations were dominated by the doctor (through various expressions), and the focus of the conversations was hard facts (eg physical reports and test results), manifested by the prominence of technology usage and technological terms. The analysis also situates doctor-patient communication in the broad institutional setting of an outpatient encounter.

| Structuralized communication with an emphasis on efficiency
As shown in Figure 1 below, a typical outpatient communication in the cancer hospital follows a standard procedure: (a) greeting and  Occasionally, the doctors spent more time with new patients who had complicated conditions. The time limitation for outpatient consultation shapes the structure of the doctor-patient communication.
The outpatient conversation tends to be brief and concise, and follows a certain pattern-the doctor asks questions and the patient answers them. The doctors need to gather information rapidly that is vital for the diagnosis and treatment. To achieve this, they must control every step of the consultation, first confirming the identity of a patient (or a patient's family member), then asking for the patient's medical history, reading the physical reports and checking the test results. After that, the doctors have normally formed a basic judgement in their mind. They then use the computer or make notes in a medical record book in order to issue a prescription. Only senior doctors who had an assistant at their side received any help with these procedures. During this phase, the doctors would briefly state their judgements and provide some instructions to the patients. In the course of an outpatient encounter, the doctors have neither the time nor the energy to pay close heed to individual patients' concerns, and rarely ask patients whether they have any questions.
They do not provide much information or fully explain their diagnosis, the expected course of the illness, and the use of medication, not to mention offering health education or behavioural risk factor counselling.
On the patients' side, they need to listen closely to the doctors' questions and quickly respond to whatever they are asked. Yet, the patients and their relatives frequently provide more details than the doctors request and speak in their own terms (see Table 5) to express their concerns. Patients and their relatives who are uncertain about the illness do ask questions. As one or more relatives are often present in the clinic, the communication scenario sometimes becomes chaotic, and invariably, more than one person is heard talking at the same time. In response, doctors frequently cut off patients and their family members. Yet the "noisy" voices from the patient side may indeed remind busy doctors of something they have forgotten, as the conversation in Table 2 indicates.
Patients and their relatives are frequently prevented from discussing the case in detail. The doctors only wish to be told the information they need. The doctor in the conversation in Table 2 did not wish to listen to the patient's son, because he was intensely reading the physical reports and films, but the son's words did remind the doctor to look at the ultrasound report. The patients' reminders to the doctors tend to happen during the medical history taking stage.
When doctors are proposing a treatment plan or giving instructions, most of the patients and their relatives would nod their heads though they have only a hazy notion of what the doctor is saying.
They do not dare to challenge the doctors' professional judgement.
Sometimes, patients or their relatives ask the doctors questions, which the doctors either respond to briefly, using some technical vocabulary, or ignore (eg suggesting that the staff members at the next physical check-up or treatment stage will explain everything to them). Through this process, doctors reconfirm their authority (see Figure 1).  Table 3).

| Vague expressions
When doctors are questioned by patients or asked for clarification, they often use vague expressions to give a brief response.
For instance, when patients request an accurate diagnosis and prognosis of their illness, doctors respond vaguely, using terms like "probably," "normally" or "there is a 30%-40% possibility that…" Doctors answer in various statistical or probability terms.
Although the numerical information to communicate risks and prognosis seems objective, it have limitations in application to unique and individual cases. 28 These expressions encompass many possibilities, indicating the uncertainty of cancer prognosis. They also protect doctors from giving incorrect information and prevent possible future disputes. However, these responses do not provide patients with the information they need to make a judgement and feel reassured.

| Forbidding expressions
Doctors use expressions like "You should never…," "You must not…" and "You are forbidden from…." to give instructions to their patients.
The strong tone used for the forbidding expression is intended to guide patients to act in a certain way and prevent them from wrongdoing. For instance, doctors tell lung cancer patients: "Never smoke again!" The strong tone of the forbidding expression is designed to make patients realize the seriousness of the wrong act and that it is better to follow the doctors' instructions. It also has the effect of prohibiting patients from asking any questions.

Dominant expressions Examples
Vague expressions "probably" "normally" "There is a 30-40 percent possibility that…" Rhetorical questions "What you want?" "What do you think?" Strong suggestions "You should…" "I strongly suggest that…." "I urge you to…" Forbidding expressions "You should never…" "You must not…" "You are forbidden from…." Order-giving "Go and have a chest radiography right now!" "Go to the Nasopharynx Department" Interruptions "OK, I know it already" "Don't talk now" "Stop" "Next (patient)"

| Order-giving
Doctors also give patients direct orders to guide their next moves.
These often occur during the final stage of the consultation. For instance, a doctor told a patient: "Go and have a chest radiography right now!" Order-giving at this moment indicates the close of the conversation. Using a strong tone, the doctors indicate to the patients and their relatives, who may still be hesitating and sometimes confused, to move on quickly to the next procedure, and in the process take control of the time and speed of the communication.

| Interruptions
The  Table 4). When the patient questioned the doctor, the doctor used his "expert" claim and a raised voice to interrupt the patient, and then gave orders to the patient to guide his next move. In some of the cases observed, the doctors were angered by the patients' questions or verbal challenges, and sometimes even exploded with rage at the patients.

| The focus on technology and the use of technological terms during communication
The diagnosis and treatment of cancer rely heavily on technology.
Placing emphasis on technology also helps the doctors to domi- "soft" data, mainly subjective experiences and feelings, and hence unnecessary, except for some basic information.
Other reasons for Chinese doctors' overemphasis on technology include the limited time available to make a diagnosis, which means that the doctors are unable to ask for a medical history and listen to the patients in depth. The structuralized communication also encourages doctors to rely on technology, for it is direct, objective and standardized. Moreover, Chinese doctors working at the forefront of hospital assume the multi-tasking role of an information processor, from collecting the patient's medical history, and analysing the information to taking action. They act as the gatekeepers of the hospital to decide which patients to admit and which to triage. All of these tasks must be based on objective "hard data." The emphasis on technology use has become a common strategy for doctors to process patients quickly in a standard and objective manner. Furthermore, with the deterioration of the doctor-patient relationship in China, technological evidence now protects doctors from medical complaints and lawsuits. 34 The over-prescription of pharmaceuticals and high-tech clinical tests in Chinese hospitals is also driven by the profit-motivated behaviours of Chinese physicians, because hospitals have linked physicians' incomes to their revenue generation. 35 In practice, by using these hard "facts," doctors can define certain decisions as purely technical matters that do not allow the patients' to negotiate or require their consent.
Yet, doctors and patients may have a different understanding of technology use. In this study, the patients often complained that the doctors only looked at the computer or radiologic film and also noted the endless examinations and tests they had to go through.
The difference between the patients and doctors' perceptions of illness and technology is also manifested in the words they used, respectively (see Table 5 below). The patients' illness narratives arise from their lived experiences, which concern the influence of their They enable doctors to evoke a sense of assured competence and retain control of the conversation. Yet doctor-patient communication processes include many non-technological parts: relationship building, understanding of the patient's viewpoint and shared decision making, etc., 37 which are essential for a therapeutic relationship. Unfortunately, they are not a major concern for the doctors in the outpatient clinic of the cancer hospital. In the recorded conversations, social talk was generally absent, and the doctors rarely expressed empathy with or tried to comfort the patients.

| Discussion
The doctor-patient interaction in a hospital setting is a special interaction, with the main focus being on diagnosis and treatment.
During a typical 5-10 minute outpatient encounter, the doctors take intentional control of the structure, content and speed of the com- tasks, and new technology (eg mobile applications for remote communication) can be adopted to promote communication. 47,48 Second, the marketized medical institutions should change their priority from efficiency to an emphasis on the quality of care that the patients receive. The inappropriate internal incentives that tie physicians' incomes to their revenue generation within Chinese hospitals also need to be reformed to provide more patient-centred care. 35 Moreover, for China's health-care delivery system, community-level health care should be improved to play the gatekeeper role and so reduce the pressures that doctors experience at the higher level hospitals. China's ongoing health care reforms provide an opportunity for these institutional and system changes to be carried out in the long run.

| Conclusion
Communication between patients and doctors in an outpatient setting at a major cancer hospital in China was found to have three

ACK N OWLED G EM ENTS
The author would like to thank all of the people involved in this research, and also thank the doctors, nurses and administrators at the cancer hospital for their help.