The effects of the presence of a third person on the physician-older patient medical interview

OBJECTIVE: To compare communication in triadic (three-person) and dyadic (two-person) older patient medical interviews and to determine the influence of the presence of a third person on the physician-older patient relationship. DESIGN: Matched sample of dyadic and triadic audiotaped outpatient medical visits. Audiotapes were coded with the Multi-dimensional Interaction Analysis (MDIA) system. SETTING: Hospital-based medical primary care group practice in a major urban teaching institution. PARTICIPANTS: Patients 60 years and older who were making their first visit to study physicians. In a sample of 96 audiotaped initial medical visits, 15 encounters involved three persons. These 15 cases were matched with 15 dyadic interviews for gender and race of the patient and for gender and race of the physician. MAIN OUTCOME MEASURES: Content, interactional processes, and specific language and communication behaviors of older patients, physicians, and third persons in the medical encounter, as measured by the MDIA system. RESULTS: The specific content and the quality of interactional processes of physicians were not affected by the presence of a third person. However, older patients raised fewer topics in all content areas (medical, personal habits, psychosocial, and physician-patient relationship) in triads than in dyads. Overall, patients were less responsive (ie, the quality of their questioning, informing, and supportiveness was poorer) on patient-raised topics in triads than in dyads. Patients were rated as less assertive and expressive, and there was less joint decision-making and shared laughter in triads than in dyads. Patients were frequently excluded from conversations in visits in which a third person was present. CONCLUSIONS: The presence of a third person in the medical encounter changes the interactional dynamics of older patient medical interviews and may influence the development of a trusting and effective physician-older patient relationship.