intimacy and therefore the risk of rejection or shame, or to exaggerate to obtain protection or care. they also discuss the idea of protecting or maintaining an ego ideal.: 165 generally, palmeira and sterne suggestion discussions about the amount of information and detail parties wish to discuss, viewing obtaining truth as an ongoing process to increase truthfulness in doctor–patient interactions. palmeira and sterne suggest that physicians acknowledge their lack of knowledge, and discuss the amount of detail they wish to discuss to avoid deception.: 167 physician bias physicians have a tendency of overestimating their communication skills, as well as the amount of information they provide their patients. extensive research conducted on 700 orthopedic surgeons and 807 patients, for instance, found that 75% of the surgeons perceived they satisfactorily communicated with their patients, whereas only 21% of the patients were actually satisfied with their communication. physicians also show a high likelihood of underestimating their patients' information needs and desires, especially for patients who were not college educated or from economically disadvantaged backgrounds. there is pervasive evidence that patients' personal attributes such as age, sex, and socioeconomic status may influence how informative physicians are with their patients. patients who are better educated and from upper or upper middle-class positions generally receive higher quality and quantity of information from physicians than do those toward the other end of the social spectrum, although both sides have an equal desire for information. race, ethnicity and language has consistently proven to have a significant impact on how physicians perceive and interact with patients. according to a study of 618 medical encounters between mainly caucasian physicians and caucasian and african american patients, physicians perceived african americans to be less intelligent and educated, less likely to be interested in an active lifestyle, and more likely to have substance abuse problems than caucasians. a study of patients of color showed that having a white physician led to increased experience of microaggressions. studies in los angeles emergency departments have found that hispanic males and african americans were less than half as likely to receive pain medication than caucasians, despite physicians' estimates that patients were experiencing an equivalent level of pain. another study showed that ethnic-minority groups of varying races reported lower-quality healthcare experiences than non-hispanic whites, specifically in treatment decision involvement and information received regarding medications. other studies show that physicians exhibited substantially less rapport building and empathetic behavior with both black and hispanic patients than caucasians, despite the absence of language barriers. medical mistrust mistrust of physicians or the healthcare system in general falls under the umbrella of medical mistrust. medical mistrust negatively impacts the doctor–patient relationship, as a patient who has little faith in their physician is less likey to listen to their advice, follow their treatment plans, and feel comfortable disclosing information about themselves. some forms of communication by the physician, such as self-disclosure and patient-centered communication, have been shown to decrease medical mistrust in patients. medical mistrust has been shown to be greater for minority group patients, and is associated with decreased compliance, which can contribute to poorer health outcomes. research of breast cancer patients showed that african american women who received concerning mammogram results were less likely to discuss this with their doctor if they had greater medical mistrust. another study showed that women with higher physician mistrust waited longer to report symptoms to a doctor and receive a diagnosis of ovarian cancer. two studies showed that african american patients had more medical mistrust than white patients, and were less likely to undergo a recommended surgery as a result. benefiting or pleasing a dilemma may arise in situations where determining the most efficient treatment, or encountering avoidance of treatment, creates a disagreement between the physician and the patient, for any number of reasons. in such cases, the physician needs strategies for presenting unfavorable treatment options or unwelcome information in a way that minimizes strain on the doctor–patient relationship while benefiting the patient's overall physical health and best interests. when the patient either can not or will not do what the physician knows is the correct course of treatment, the patient becomes non-adherent. adherence management coaching becomes necessary to provide positive reinforcement of unpleasant options. for example, according to a scottish study, patients want to be addressed by their first name more often than is currently the case. in this study, most of the patients either liked (223) or did not mind (175) being called by their first names. only 77 individuals disliked being called by their first name, most of whom were aged over 65. on the other hand, most patients do not want to call the doctor by his or her first name. some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues. transitional care transitions of patients between health care practitioners may decrease the quality of care in the time it takes to reestablish proper doctor–patient relationships. generally, the doctor–patient relationship is facilitated by continuity of care in regard to attending personnel. special strategies of integrated care may be required where multiple health care providers are involved, including horizontal integration (linking similar levels of care, e.g. multiprofessional teams) and vertical integration (linking different levels of care, e.g. primary, secondary and tertiary care). turn-taking and conversational dominance researchers have studied the doctor–patient relationship using the theory of conversation analysis. one of the key concepts in conversation analysis is turn-taking. the process of turn-taking between health care professionals and the patients has a profound impact on the relationship between them. in most scenarios, a doctor will walk into the room in which the patient is being held and will ask a variety of questions involving the patient's history, examination, and diagnosis. these are often the foundation of the relationship between the doctor and the patient as this interaction tends to be the first they have together. this can go a long way into impacting the future of the relationship throughout the patient's care. all speech acts between individuals seek to accomplish the same goal, sharing and exchanging information and meeting each participants conversational goals. research carried out in medical scenarios analyzed 188 situations in which an interruption occurred between a physician and a patient. of these 188 analyzed situations, research found that the doctor is much more likely (67% of the time, 126 occasions) as compared to the patient (33% of the time, 62 occasions). this shows that physicians are practicing a form of conversational dominance in which they see themselves as far superior to the patient in terms of importance and knowledge and therefore dominate all aspects of the conversation. a question that comes to mind considering this is if interruptions hinder or improve the condition of the patient. constant interruptions from the patient whilst the doctor is discussing treatment options and diagnoses can be detrimental or lead to less effective efforts in patient treatment. this is extremely important to take note of as it is something that can be addressed in quite a simple manner. this research conducted on doctor–patient interruptions also indicates that males are much more likely to interject out of turn in a conversation than women. men's social predisposition to interject becomes problematic when it negatively impacts a woman physician's messages to her patients who are men: she may not be able to finish her statements and the patient will not benefit from what she was about to say, and the physician herself may fall prey to the socially conventional man's interjection by letting it cut short her professional commentary. conversely, men physicians need to encourage women patients to articulate their reactions and questions, since women interrupt in conversations statistically less often than men do. a hurdle can arise from how the thinking process goes: a patient typically relates their story in chronological order, where symptoms, test results, consulting opinions, diagnoses and treatment are intertwined. a provider tends to design their approach in a step-by-step analytical manner, extracting as much details out of symptomatology, then past medical and social history then tests then coming to a suggested diagnosis and management plan. addressing this upfront and at the onset of the visit and carving enough time for both can help avoid unnecessary interruptions on either part, improve provider-patient relation and constructively facilitate care. other involved individuals an example of where other people present in a doctor–patient encounter may influence their communication is one or more parents present at a minor's visit to a doctor. these may provide psychological support for the patient, but in some cases it may compromise the doctor–patient confidentiality and inhibit the patient from disclosing uncomfortable or intimate subjects. when visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level. having family around when dealing with difficult medical circumstances or treatments can also lead to complications. family members, in addition to the patient needing treatment may disagree on the treatment needing to be done. this can lead to tension and discomfort for the patient and the doctor, putting further strain on the relationship. telehealth with the extensive use of technology in healthcare, a new dynamic has risen in this relationship. telehealth is the use of telecommunications and/or electronic information to support a patient. this applies to clinical care, health-related education, and health administration. an important fact about telehealth is that it increases the quality of the doctor–patient relationship by making health resources more easily available, affordable, and more convenient for both parties. challenges with using telehealth are that it is harder to get reimbursements, to acquire cross-state licensure, to have common standards, maintain privacy, and have proper guiding principles. the types of care that can be provided via telehealth include general health care (wellness visits), prescriptions for medicine, dermatology, eye exams, nutrition counseling, and mental health counseling. just like with an in-person visit, it is important to prepare for a telehealth consultation beforehand and have good communication with the healthcare provider. an interesting outcome of telehealth is that doctors have started to play a different role in the relationship. with patients having more access to information, medical knowledge, and their health data; doctors play the role of a translator between technical data and the patients. this has caused a shift in the way that the doctors see themselves concerning the doctor–patient relationship. doctors who are engaged in telehealth see themselves as a guide to the patient and undertake the role of a guardian and information manager in the description, collection, and sharing of their patient's data. this is the new dynamic that has risen in this ancient relationship and one which will continue to evolve. bedside manner a medical doctor, with a nurse by his side, performs a blood test at a hospital in 1980. a good bedside manner is typically one that reassures and comforts the patient while remaining honest about a diagnosis. vocal tones, body language, openness, presence, honesty, and concealment of attitude may all affect bedside manner. poor bedside manner leaves the patient feeling unsatisfied, worried, frightened, or alone. bedside manner becomes difficult when a healthcare professional must explain an unfavorable diagnosis to the patient, while keeping the patient from being alarmed. dr. rita charon launched the narrative medicine movement in 2001 with an article in the journal of the american medical association. in the article she claimed that better understanding the patient's narrative could lead to better medical care. researchers and ph.d.s in a bmc medical education journal conducted a recent study that resulted in five key conclusions about the needs of patients from their health care providers. first, patients want their providers to provide reassurance. second, patients feel anxious asking their providers questions; they want their providers to tell them it is okay to ask questions. third, patients want to see their lab results and for the doctor to explain what they mean. fourth, patients simply do not want to feel judged by their providers. and fifth, patients want to be participants in medical decision-making; they want providers to ask