Linguistic Features of Power Dynamics in Triadic Dementia Diagnostic Conversations

Abstract

Objective

The purpose of this study was to examine linguistic expressions of power during dementia diagnosis disclosure.

Methods

Videotapes of dementia diagnosis disclosure sessions were reviewed to examine linguistic features of 86 physician-patient-companion triads. Verbal dominance and pronoun use were measured as indications of power.

Results

Physicians dominated the conversation, speaking 83% of the total time. Patients spoke more than companions (10% versus 6%). Dementia status was only related to the amount of time companions spent talking. Physicians used fewer first person singular and more first person plural pronouns than patients and companions. Power indices did not predict anxiety, depression, or satisfaction with the medical visit.

Conclusion

During the disclosure of a dementia diagnosis, physicians tend to dominate the conversation, exerting their social status through a variety of linguistic features. Patients and companions are not more distressed or dissatisfied as a result and exert their own subtle attempts to assert their role in the conversation.

Practice implications

Recognition of a hierarchical structure within healthcare interactions may be the first step toward maximizing patient outcomes. Evaluating patient expectations and preferences regarding physician communication style may be the most effective way of promoting patient-centered healthcare communication.

1. Introduction

Clear, collaborative conversations between individuals with dementia and their physicians facilitate information exchange [1, 2], treatment planning [3, 4], and compliance and satisfaction [5, 6]. Yet these conversations are complex for many reasons, including the relative imbalance of power between patients and their healthcare providers. A physician, with relatively more knowledge, expertise, and prestige, may influence conversations by controlling the information provided, choosing topics covered, or using medical jargon [7, 8]. Cognitive impairment further complicates the power dynamic, as physicians may adopt a paternalistic approach to compensate for patient deficits [9]. Likewise, companions accompanying cognitively impaired patients can influence conversation dynamics [10, 11].

This study examined expressions of power among physicians, patients, and companions during dementia diagnostic conversations. We chose this situation because 1) diagnostic conversations involve both information giving and receiving and are likely to evoke expressions of power [1], and 2) the delivery of a diagnosis is a critical moment in dementia care, when dominance can set the tone for future interactions [12]. We studied two linguistic manifestations of power. The first was how much time each party spends talking. This index of social dominance has been used in previous research and likely reflects many variables, including the extent to which patients and companions are encouraged to offer input [13, 14]. In the context of dementia, physicians and companions may dominate conversations even more in order to compensate for real or perceived patient impairment.

The second expression of power focuses on pronoun use. Linguistic researchers have suggested that pronoun use is a reflection of self-perceived social status [15, 16]. People in lower status positions use more first person singular pronouns as an attempt to gain approval from people in higher status positions [17]. People with higher status, secure in their position, focus on the group rather than themselves and therefore use more first person plural pronouns [18].

2. Methods

2.1 Participants and procedure

Participants were evaluated at an Alzheimer's Disease Research Center. A description of recruitment and sampling can be found elsewhere [19]. Following a clinical interview and exam, the physician shared a diagnostic formulation with the patient and companion. These conversations were videotaped and transcribed. Eighty-six interactions were analyzed. Patients and companions answered questions regarding anxiety, depression, and satisfaction with their appointment 2-3 days after the session. Characteristics of the sample appear in Table 1.

Table 1. Demographic characteristics of the sample.

Characteristic	Individual Seeking Evaluation (n=86)	Companion (n=86)
Age, mean (SD)	72.93 (8.10)	62.46 (13.72)
Female, n (%)	52 (60.5)	60 (69.8)
Race, n (%)
Black	8 (9.3)	5 (5.8)
White	78 (90.7)	77 (89.5)
Education, yrs, mean (SD)	14.52 (3.48)	15.1 (2.84)
Relationship to patient, n (%)
Spouse	---	50 (58.1)
Child	---	21 (24.4)
Other Relative	---	8 (9.3)
Friend	---	7 (8.1)

Note. Sums of cells may not equal 86 because of missing responses.

2.2 Measures

2.2.1 Verbal dominance

We calculated the proportion of time each person spent talking during diagnostic feedback (number of words spoken divided by total number of words spoken by all individuals) [14]. Patients and companions also estimated the proportion of time each person talked. The discrepancy between actual and estimated time spent talking (estimate–actual) was calculated; positive scores indicate overestimation, negative scores underestimation.

2.2.2 Pronouns

We used text analysis software (Linguistic Inquiry and Word Count (LIWC) [20]) to calculate the ratio of first person singular and plural pronouns relative to all words.

2.2.3 Outcomes

Anxiety was assessed with the 20-item State-Trait Anxiety Inventory [21]. Depressive symptoms were assessed with the 15-item Geriatric Depression Scale [22]. Satisfaction with the diagnostic visit was assessed with the Dementia Care Satisfaction Questionnaire [23].

2.3 Analyses

We used analyses of variance (ANOVAs) to assess differences in actual and perceived verbal dominance. Independent samples t-tests were used to determine whether verbal dominance was influenced by dementia status. ANOVAs were used to compare differences in pronoun use. Bivariate correlations were calculated to examine associations between verbal dominance, pronoun use, and gender of all participants, patient and companion age, and relationship between patient and companion (spouse versus other). Small numbers of non-White participants precluded meaningful race comparisons. Finally, we conducted hierarchical regressions to determine whether pronoun use and time the physician talked predicted patient and companion anxiety, depression, or satisfaction, controlling for age and dementia status.

3. Results

Figure 1 presents means and standard deviations for actual and estimated time talked. Physicians dominated the conversation, F(2,255)=2511.51, p<.001, speaking on average 83.3% of the total time (SD=9.63, range=56.68%-98.70%). Patients spoke 10.3% of the time, companions 6.3%. The proportion of time physicians and patients talked did not differ based on the patient's dementia status, t(84)= - .113, p=.910, and t(84)=1.857, p=.067, respectively. Companions spoke more when patients had dementia (7.7%) than when they did not (3.7%), t(71)= -3.735, p<.001.

Figure 1. Actual and estimated proportion to time spent talking, for each participant.

Patients and companions underestimated the proportion of time physicians spoke (F(2,223)=59.94, p<.001) and overestimated the proportion of time they themselves spoke (patients, F(2,223)=42.84, p<.001; companions, F(2,223)=28.11, p<.001). Compared to patients without dementia, patients with dementia more extremely underestimated the time physicians talked, t(58)=2.364, p=.021, and more extremely overestimated the time companions spoke, t(58)= -2.879, p=.006. Relative to companions of dementia patients, companions of patients without dementia overestimated the amount of time they themselves spoke, t(77)=2.386, p=.019.

There was a significant difference in the use of first person singular pronouns across participants, F(2,255)=95.55, p<.001. Physicians used fewer singular pronouns (M=2.31) than patients (M=8.49) and companions (M=4.22). Companions used fewer singular pronouns than patients (p<.001). There also was a significant difference among individuals in the use of first person plural pronouns, F(2,255)=30.71, p<.001. Physicians used more plural pronouns (M=2.34) than patients (M=0.85) and companions (M=1.31).

Demographic characteristics were not significantly associated with verbal dominance or plural pronoun use. However, older patients (r=.26, p<.05), older companions (r=.33, p<.01), female patients (r=.24, p<.05), male physicians (r= -.51, p<.01), and patients accompanied by a non-spouse (r=.31, p<.01) tended to use more singular pronouns.

None of the indices of verbal dominance or pronoun use predicted depression, anxiety, or satisfaction.

4. Discussion and conclusion

4.1 Discussion

This study examines linguistic manifestations of power during dementia diagnostic conversations. Physicians dominate these discussions, taking up over 80% of the speaking time. This may reflect their relative knowledge and the context of a diagnostic evaluation, as physicians provide information about dementia. At the same time, patients and companions use subtle linguistic techniques to assert themselves. Consistent with previous research on pronoun use as a reflection of social status [17, 18, 24, 25], patients and companions (particularly of an older age) use more first person singular pronouns than physicians, perhaps as a way of focusing attention on their perspective. Conversely, physicians use more first person plural pronouns, which may be an attempt to foster partnership, though this may not be a successful strategy [26].

Dementia introduces unique complexities because of the impact of patient cognitive impairment and the paternalistic stance physicians and companions may adopt. In the current study, however, conversations were similar regardless of a patient's dementia status, except that companions talk more when the patient has dementia. In this situation, companions may play the role of information surrogates, though at the risk of neglecting patient input.

Though previous studies have suggested a relationship between physician dominance and patient satisfaction [13, 27], in our study, linguistic attributes are not associated with patient or companion satisfaction, depression, or anxiety. One potential explanation is that perceptions do not match the reality. Patients and companions underestimate the amount of time their physician talks and overestimate the amount of time they themselves talk. Therefore, what might look like an asymmetric conversation to an outside observer might not feel that way to people in the room, particularly older, frail patients who tend to prefer physicians who are more directive [28, 29].

Healthcare interactions often include multiple people, each with their own perspective, together in a situation with its own unique demands. In light of this diversity, we found only sporadic associations between linguistic expressions of power and demographic characteristics. In fact, the standard deviations for most of our dependent variables were large, suggesting genuine variability in practice, despite our homogenous sample and the constraints of the diagnostic situation. Power dynamics might play out differently in other contexts (e.g., follow-up appointments, conversations with other types of providers).

4.2 Conclusion

During the disclosure of a dementia diagnosis, physicians tend to dominate the conversation, exerting their social status through a variety of linguistic features. Patients and companions are not more distressed or dissatisfied as a result and exert their own subtle attempts to assert their role in the conversation.

4.3 Practice implications

Recognizing the social hierarchy in a healthcare interaction may be the first step in establishing relationships that maximize patient engagement. Subtle linguistic features may deserve attention as one indication of the dynamics playing out in a healthcare conversation. Once attuned to these linguistic features, clinicians may find it beneficial to ask about patient and companion expectations of their physician, the quantity and type of information they want, and their preference for involvement in their care [12]. Likewise, identifying the extent to which patients wish to have third-party family or friends involved in the conversation (if at all) would be useful. Truly patient-centered care may involve being mindful of social hierarchy and identifying patient expectations, rather than applying a universal algorithm to guide healthcare conversations.