patients mutually influence each other’s conversational behavior (Robinson and Roter, 1999; Del Piccolo et al., 2002; Street et al., 2003, 2005; Butow et al., 2004; Janz et al., 2004; Maly et al., 2004; Gordon et al., 2005; Kindler et al., 2005; Adler, 2007) and that physicians may take their cues in part from patients, who typically exhibit relatively passive behavior during office visits (Gordon et al., 2005, 2006a,b; Street and Gordon, 2006). Such passivity characterizes even physicians when they become patients. The average patient asks five or fewer questions during a 15-minute office visit, and many ask no questions (Brown et al., 1999, 2001; Sleath et al., 1999; Cegala et al., 2000; Butow et al., 2002; Bruera et al., 2003; Kindler et al., 2005). Among the most passive patients are those above age 60, those with more severe illness or multiple comorbid conditions (including psychological distress), those who are less well educated, and males (Butow et al., 2002; Sleath and Rubin, 2003; Street et al., 2003; Maliski et al., 2004; Gaston and Mitchell, 2005; Flynn et al., 2006; Gordon et al., 2006b; Siminoff et al., 2006a). Minorities also have been noted to be more passive in physician–patient interactions (Gordon et al., 2005; Street et al., 2005; Siminoff et al., 2006a; Gordon et al., 2006b). Moreover, a systematic review of randomized controlled trials and uncontrolled studies of interventions designed to improve the provision of information and encourage participation in decision making by patients with advanced cancer found that although almost all patients expressed a desire for full information, only about two-thirds wished to participate actively in decision making about their care (Gaston and Mitchell, 2005).

Correspondence between patients’ preferred role in decision making and their actual role during office visits with physicians, although intuitively compelling, has relatively little empirical support as a factor affecting patient outcomes and quality of care. However, such correspondence has been linked with reduced anxiety (Gattellari et al., 2001; Kahán et al., 2006) and depression (Schofield and Butow, 2003), satisfaction with treatment choices (Keating et al., 2002), and more appropriate treatment choices (Siminoff et al., 2006b). The NCI report Patient-Centered Communication in Cancer Care articulates a comprehensive research agenda for better understanding and intervening to improve patient–provider communication (Epstein and Street, 2007).

The Importance of Communication

There is reason to be concerned about findings of poor communication and lack of patient involvement. A substantial body of evidence indicates that effective physician–patient communication is positively related to patients’ health outcomes (Kaplan et al., 1989; Stewart, 1995; Piccolo et al., 2000; Heisler et al., 2002; Engel and Kerr, 2003; Kerr et al., 2003a,b;



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