A Presentation of Central Communication Aspects in the Patient–Provider Relationship—Potential Learnings for Community Pharmacists

Several studies have shown that communication between patients and HCPs is still not optimal in integrating patients’ perspectives on how best to manage their diseases and their medication. One such area where encounters between patients and professionals still needs to develop to better incorporate the patient’s perspective is pharmacy practice. The aim of this study was therefore to explore and present new typologies and communication aspects of HCP-patient relationships since a comprehensive literature search in 1997 conducted by Sondell and Söderfeldt, and relate the findings to pharmacy practice. In total, 11 articles were identified by applying the techniques of a purposeful literature search. The articles covered aspects of: shifting and adapting roles during the encounter, techniques to ensure individualizing in the encounter, avoiding inappropriate routines, coping with internet-informed patients, achieving mutual goals, dealing with uncertainty including avoiding rigid preconceptions, using social conversation, incorporating patients’ prior experiences, aligning language, adapting greetings and exploring the cultures and communication patterns of patients from other ethnic backgrounds. The variety of these communication aspects points to the immense complexity of communication as a practice discipline. This article has presented some of the literature that pharmacists can consult, in the endeavor of improving their communication practices.

or sub-categories to take into account by pharmacists. The strategies by Kripalani and Jacobson provided some specific input into how pharmacists should incorporate patients' perspectives, but apart from that, the presented models did not always specify exactly how communication could be enacted.
Continuing from Ilardo and Speciale (arguing that the communication should be patient centered) and taking into account the points by Sondell and Söderfeldt and Shah and Chewning (that the dynamic interaction between the patient and the provider should be the focus point when communicating in health care), we aimed at presenting and discussing 'new' communication aspects of the HCP-patient relationship. Hence, the focus of this paper is to discuss more recent communication aspects that pertain to particular elements in the interaction between the two parties (patient and HCP), rather than just one of the parties. At the same time, we want to present aspects which might be consulted by community pharmacists in order to incorporate them into their daily practice. The paper thus has a practice agenda rather than a research-based agenda as compared to the review by Shah and Chewning, and is more in line with the original aim of Sondell and Söderfeldt, though focusing on another group of HCPs, here community pharmacists.

New Communication Aspects in the Patient-Provider Interaction of Relevance for Pharmacists
In the following, we will introduce the pharmacist reader for a variety of communication aspects which are all of relevance, we trust, for the interaction between a pharmacist and a patient. The focus has thus been on materials that illustrate different approaches on how to better engage with patients, by making the communication more individual and personally relevant for the patient. Despite the fact that professions vary in their role perception [14], and that communication in the pharmacy differs from other types of meetings due to the pharmacy staff's limited knowledge about their patients' clinical issues, lack of privacy in the pharmacy and that medicinal products are purchased during the encounter, pharmacy practice can presumably still learn from other areas of health care practice. Therefore, we also discuss this type of literature. In total, eight different communication aspects will be covered, dealing with: We will present the communication aspects one by one, followed by suggestions for how each one illustrates new insights as compared to the review by Sondell and Söderfeldt, since this review was also focused on the interaction between HCP and patients. We then discuss the specific relevance of the aspects for community pharmacy communication.

Shifting and Adapting Roles During the Encounter
A new approach to describing pharmacist-patient relationships was undertaken by Austin et al. in 2006, who identified the following five different role pairs: analytic-authoritative, emotive-interactive, opportunistic-expedient, reliant-paternalistic, and autonomous-informative [15]. Austin et al. based the foundation of the role pairs on the type of 'patient' and the response of the pharmacist accordingly. Hence, if, for example, the patient took a more 'consumer-oriented' role in the pharmacy encounter, displaying a high need for personal control, the pharmacist adopted his/her role in this case to provide evidence and facts, leaving it up to the patient how to use the information.
This approach seems to expand on how power relationships develop as described by Sondell and Söderfeldt, where the roles seemed to stem from the HCP's initial choice of relationship. Austin et al., on contrary see the pharmacist adopting their behavior towards the patient. Who initiates the orientation of the relationship in a medical encounter is an important aspect to consider since it may affect the expectations, roles, and responsibilities, which could influence the encounter. With regard to furthering pharmacy practice, the study underlines some possibilities in the role-taking and initiation of a pharmacy encounter, including shifting between roles.

Coping with Internet-Informed Patients
In a study by Caiata-Zufferey et al. (2012), physicians' communication strategies for encounters with Internet-informed patients were investigated [16]. The Internet can result in the patient-physician interaction becoming more complex, as interaction patterns and expectations change. A typology of four communicative strategies used by physicians was therefore identified either as physician-centered or patient-centered: (i) "Resistance to online information:" physicians invalidated and discounted the patient's achieved knowledge from the Internet, (ii) "Repairing online information:" physicians warned about Internet searches, (iii) "Co-construction around online information:" physicians showed understanding of the patient's point of view by assessing the online information brought in his/her attention at the consultation, and (iv) "Enhancement of online information:" physicians empowered the patient by encouraging him/her to take active and critical measures in their Internet research.
The typology shows a variety of new techniques that can be employed by the HCPs, since the study by Sondell and Sönderfeldt (1997) did not include technological aspects such as the Internet, which is an integral part of the HCP-patient relationship today. 'Enhancement of online information' can be seen as a variety of the consumerist relationship also described by Sondell and Söderfeldt, where the physician meets the patient's expectations for information and tries to empower the patient. Though consumerism in the pharmacy is not a new concept, discussion of how it applies to patients' use of new technologies including the Internet is a relatively new dimension to pharmacy practice. Every day, pharmacists meet patients who have consulted the Internet before visiting the pharmacy and hence, pitfalls in the communication or empowering techniques can be derived from this study. There was no overlap between the described models and the models presented by Sondell and Söderfeldt (1997) except for Frederikson's model of 'Information-exchange model of medical consultation. The authors themselves highlight one of the models found, 'The Theory of Goal Attainment' by King, which explains how the perceptions of patients and HCPs regarding objects, persons, and events influence their social behaviors and thereby social interaction in medical encounters. 'The Theory of Goal Attainment' thereby provides a basis for pharmacists to explore and understand how they can better achieve mutual goal-setting by tapping into the basis of patients' perceptions, perceptions the pharmacist can then attend to in order to obtain the desired health goals of the individual.

Bylund et al. (2012) gave a brief overview of selected interpersonal theories and models, and presented examples of their use in healthcare communication research (Goals-Plans-Action Theory, Uncertainty theories, Action Assembly Theory, Communication Accommodation Theory, Facework and
Politeness Theory, Speech Codes Theory, Social Penetration Theory, Communication Privacy Theory and Management Theory) [18]. The uncertainty theories were divided into two categories: the Uncertainty Reduction Theory and the Uncertainty Management Theory. The assumption behind classic uncertainty theory is that an individual's primary goal in communication is to increase predictability and decrease uncertainty of one's own behaviors and the behaviors of others, by (a) striving to predict the communication behaviors before an interaction, or (b) retroactively seeking to explain behavior. Uncertainty is thus a fundamental human condition that can stir a wider range of emotions and anxiety also in communication in health care; although, newer uncertainty theories question if people are indeed always motivated to reduce uncertainty.
The uncertainty theories thereby add a new existentialistic aspect to communication compared to the communication models and factors described by Sondell and Söderfeldt. In terms of pharmacy practice, the theories explain how both pharmacists and patients might sometimes, in their efforts to reduce basic uncertainty, jump to conclusions about the other party too soon, and thus misinterpret their motives. The theories point to the need for becoming more consciously aware of this fundamental psychological need when communicating and instead make effort to check if our interpretations are correct. The importance of social conversation as part of a medical encounter serves other purposes than the HCP simply using it to explore patients' backgrounds (as can be done during the bio-psychosocial relationship), such as to build a more equal and trusting relationship. Adapting a list with 71 communication skills into a pharmacy encounter lasting three minutes is of course not possible. The part of social or causal talk is certainly already practiced today in community pharmacy; however, considering exactly when and how to facilitate non-medical talk as part of the interaction over a pharmacy counter to better liaise with patients to further relevant talk about the medicines could be an important aspect to further patient-centered counselling.

Aligning Language
In the US, Vrana et al. (2018) studied the degree of semantic similarities in language used in communication between a patient and a physician during medical encounters, i.e., how similar or coherent the language is, which was assumed to influence the interaction [20]. The study described how the similarity of communication language depended on gender and ethnicity, with white physicians' conversations exhibiting lower semantic similarities with their patients than physicians with an Indian/Pakistani background. Likewise, female patients exhibited greater communication similarities with their physicians than male patients [20].
Focusing on how language is used in the dialogue provides an opportunity for pharmacists, as this study suggests that the development and outcome of an encounter can be influenced and changed by aligning the language across age, gender, ethnicity, etc. Ilardo and Speciale discussed simplifying language, but aligning language on a semantic level, considering the possible differences in the underlying meanings inhered in the language from various positions, hereby firstly acknowledging that multiple interpretations are possible, is a topic not often discussed in the pharmacy setting. This aspect is however crucial for how the encounter develops.

Building Cultural Competency
To build on aligning understandings, in 2009, Teal et al. suggested a 'culturally competent communication model' [21]. The model explores HCPs' communication and cultural sensitivity competences, suggesting that the HCPs, while practicing, should not only improve communication skills but also learn about and become culturally competent. Thus, HCPs should get acquainted with how possible differences in words and non-verbal expressions may be understood, in order to be ready to adapt their communication.
Many pharmacists meet patients with different cultural backgrounds daily. Being more curious towards and investigating these patients' understanding of medicines and the provided counselling, especially those specific ethnic groups often visiting the pharmacy, is a good investment to further patient centered communication.

Building an Equal Relationship
Barrere et al. (2007) investigated nurse-patient communication with regard to what specific actions during their encounters contribute to making the relationship more or less equal [22]. The choices made by nurses on how to interact with patients included: how nurses present themselves to (new) patients and by which name they address the patient; whether nurses focused more on personal or medical aspects during their talks with patients (and when and why to shift between personal and professional subjects), and if cues from patients were recognized and addressed.
The study by Barrere et al. thereby refers to the shift between private and professional roles and might appropriately be used for understanding which specific communication strategies to use to turn an encounter into a more patient centered and individual one. As presented also by Greenhill et al. [19], the importance of social/personal talk as a part of the medical encounter was highlighted along with how to best address the patient [20]. The study by Barrere et al. thus provides concrete and relevant communication strategies for pharmacists to consider on how to make encounters more equal and personal.

Conclusions
A variety of health care communication models, stances, aspects and results, all of relevance for the interaction between community pharmacists and patients, have been presented. The difference in the communication aspects points to the immense complexity of communication as a practice discipline. Rather than being overwhelmed and discouraged by this fact, we should rather perceive it as an opportunity for pharmacists. By taking small steps incorporating one new relevant communication aspect at the time, according to your individual background and the circumstances in which you practice as a pharmacist, could be a way to further patient counselling. This article has presented some of the literature that pharmacists can consult with to support them in this endeavor.

Conflicts of Interest:
The authors declare no conflict of interest.