A Systematic Review of Patients’ Experiences in Communicating with Primary Care Physicians: Intercultural Encounters and a Balance between Vulnerability and Integrity

Communication difficulties persist between patients and physicians. In order to improve care, patients’ experiences of this communication must be understood. The main objective of this study is to synthesize qualitative studies exploring patients’ experiences in communicating with a primary care physician. A secondary objective is to explore specific factors pertaining to ethnic minority or majority patients and their influence on patients’ experiences of communication. Pertinent health and social sciences electronic databases were searched systematically (PubMed, Cinahl, PsychNet, and IBSS). Fifty-seven articles were included in the review on the basis of being qualitative studies targeting patients’ experiences of communication with a primary care physician. The meta-ethnography method for qualitative studies was used to interpret data and the COREQ checklist was used to evaluate the quality of included studies. Three concepts emerged from analyses: negative experiences, positive experiences, and outcomes of communication. Negative experiences related to being treated with disrespect, experiencing pressure due to time constraints, and feeling helpless due to the dominance of biomedical culture in the medical encounter. Positive experiences are attributed to certain relational skills, technical skills, as well as certain approaches to care privileged by the physician. Outcomes of communication depend on patients’ evaluation of the consultation. Four categories of specific factors exerted mainly a negative influence on consultations for ethnic minorities: language barriers, discrimination, differing values, and acculturation. Ethnic majorities also raised specific factors influencing their experience: differing values and discrimination. Findings of this review are limited by the fact that more than half of the studies did not explore cultural aspects relating to this experience. Future research should address these aspects in more detail. In conclusion, all patients seemed to face additional cultural challenges. Findings provide a foundation for the development of tailored interventions to patients’ preferences, thus ensuring more satisfactory experiences. Health care providers should be sensitive to specific factors (cultural and micro-cultural) during all medical encounters.

Introduction in order to put forth a certain aspect of their identity in a given context, thus allowing them to cross cultural or micro-cultural boundaries and play with their different identities [18].
Culture, micro-cultures and ethnicity thus play important roles in the transmission and interpretation of messages. Applied to medical encounters, this conceptualisation suggests that all medical encounters are intercultural from the outset, since being a physician involves having been socialised in a specific micro-culture; biomedicine. To this regard, Beagan et al. [19] show that medical socialisation neutralizes sociocultural differences among medical students. Consequently, medical students tend to overlook and neglect sociocultural influences in medical encounters.
However, cultural and micro-cultural influences should not be disregarded when exploring physician-patient communication, since ignoring such influences can contribute to maintaining health disparities and discrimination in healthcare and beyond [20,21]. Indeed, the lack of sensitivity to cultural aspects can lead to perceptions of discrimination; a subjective experience that has been demonstrated to engender adverse effects on health in the long term, thus perpetuating health disparities [22].

Previous Literature Reviews
Results from previous reviews provide valuable insight with regard to which behaviours foster satisfaction among patients, patients' expectations and desires with regard to communication, and to potential specific factors that may impede on communication with EMPs [6,9,23]. However, they present some limitations that restrict our understanding of communication difficulties. First, previous reviews neglected to consider patients' lived experiences either by including only observational studies seeking to establish associations between physicians' behaviours and various outcomes (e.g. patient satisfaction) [6,9] or by focusing only on patients' expectations of what a consultation should be like and on patients' preferences and desires regarding physicians' behaviours [23]. Meanwhile, authors emphasize the need to consider the patient's lived experience in order to tailor interventions and communication [24][25][26]. Second, quantitative methods predominate in previous reviews. Although quantitative methods allow establishing associations between variables, qualitative studies should also be examined since they allow a profound and detailed understanding of patients' experiences. Third, cultural aspects at play in communication are not explored frequently in previous reviews. Besides, studies included in reviews that explore cultural aspects most often equate culture with ethnicity. Neglecting culture or reducing it to "race" or "ethnic" categories tends to biologize sociocultural isssues [14] and to maintain health disparities and discrimination in healthcare and beyond [22]. To the best of our knowledge, no previous review has explored, from the patient's perspective, potential broader cultural influences on patients' experiences. Considering culture's central role in the transmission and interpretation of messages, its influence should be explored.

Study Purpose
Qualitative studies targeting patients' experiences in communication have been conducted but these studies remain scattered and must be synthesized in order to gain a global understanding of patients' experiences. A global understanding of experiences of a culturally diverse patient sample could help shed light on both universalities cutting across cultures and particularities relating to incarnating the patient role.
The current systematic review has three objectives. First, it aims to explore patients' experiences in communicating with a primary care physician (PCP). Second, it intends to investigate specific factors pertaining to EMPs and their influence on EMPs' experiences in medical encounters. The third objective is exploratory in nature and consists of investigating specific factors related to micro-cultural belonging which influence ethnic majority patients' experiences in medical encounters. More precisely, three research questions are to be answered: 1. What are patients' experiences in communicating with a primary care physician? 2. What specific factors influence ethnic minority patients' experiences of communication?
3. What specific factors influence ethnic majority patients' experiences of communication?

Sampling
An electronic search of relevant databases was conducted for qualitative studies targeting patients' experiences in communicating with a PCP. No date criterion was set and only articles published in French or English were eligible. Two researchers entered the same key-words in four databases (PubMed, Cinahl, PsycNET, and IBSS) and independently selected articles. Keywords were "physician-patient relations" and "health communication" and "qualitative". See  26 IBSS,56 PsycNET). Articles were first selected by reading the title, next, by examining the abstract, and last, by reading the full text. When titles did not provide enough information to classify articles, abstracts or full text were inspected. Articles were excluded if they did not target patients' experiences of face-to-face communication with a PCP using a qualitative design. The first selection, according to titles and abstracts, yielded a total of 219 articles. During this first selection step, the goal was not to reach perfect inter-rater agreement, but to include the largest amount of studies. After deletion of duplicates, 152 articles remained for full text inspections. During this step, 95 articles were excluded on the basis of targeting patients' desires and expectations (11), targeting physicians' perspective (2), not targeting communication in primary care settings (50), not targeting faceto-face communication (22) or targeting communication with the health care system in general  (4), and for being quantitative or mixed-methods studies focusing mostly on quantitative results (4) or observational studies (2). Following full text inspection, 57 articles remained.

Study Design & Data Analysis
Noblit and Hare's [27] meta-ethnography method was utilized to synthesize qualitative studies. In short, their method involves an in-depth reading of selected articles, followed by a synthesis of studies. To synthesize studies, common concepts across studies must be identified and the relationship between these concepts must be described.
A previous review of qualitative studies in the field of healthcare communication has successfully applied this method to review literature relating to working with interpreters [28]. Furthermore, Britten et al. undertook a worked example and conclude that their meta-ethnography (and thus potentially future meta-ethnographies) "offers evidence that qualitative synthesis is possible and may be able to provide clearer and more succinct findings for practitioners and policymakers than individual studies or narrative reviews" [29, p215].
The matrix method was employed to organize and analyze the data [30]. Garrard [30] recommends the use of a spreadsheet software which allows an easy comparison of studies. For this review, each article occupied a row and columns were organized to document authors, year of publication, journal, country, sample size and description, study objectives, method, a summary of findings, and syntheses.
More concretely, each study was first summarized under one column named 'Summary of findings'. Summaries were then read in-depth, in order to inductively identify common concepts. For each emerging concept, a new matrix was created and summaries of studies were incorporated in the matrix. A first synthesis occurred in order to describe how each concept evolved from one study to the next (see Results). Next, a "line-of-argument synthesis", as described by Noblit & Hare [27], was undertaken in order to explain how each concept related to one another from one study to the next. This second type of synthesis calls for interpretation of relations between concepts with the aim of producing an explanation of the phenomenon under study (see Discussion).

Quality Evaluation
Tong et al. [31] developed a checklist to guide readers in the quality evaluation of qualitative articles. The checklist is divided in three domains which should be discussed in order to allow readers to evaluate quality: research team and reflexivity, study design, and analyses and findings. Fifty-two of the 57 articles discussed aspects from all three domains and were evaluated as possessing a good quality. Five articles neglected to present information relating to the first domain. They were nevertheless judged as good quality since they were shorter papers and might simply have faced space restrictions (see S1 Table for details).

Description of Studies
Publication dates varied between 1995 and 2015 (Fig 2). The majority of studies were conducted in North America (n = 28) and in Europe (n = 20; Fig 3). A total of 1872 patients took part in the studies included in this review. As can be seen in Fig 4, patients belonging to many cultural and micro-cultural groups were included in this review. Twelve of the studies did not specify a cultural group (referred to as the general patient population) and 14 studies targeted specifically EMPs. See Table 1 for an overview of studies.

Patients' Experiences of Communication: Three Major Concepts
Three major concepts emerged in response to the first research question: a) experiences evaluated negatively, b) experiences rated as positive, and c) outcomes of these communication experiences. Negative experiences raised by patients revolve around feelings of vulnerability related to enacting the patient role. Positive experiences generally relate to being treated with respect, thus allowing patients to maintain a sense of integrity. The third concept relates to repercussions of communication.

Negative Experiences: Vulnerability
Ninety-three percent of the studies (53 of the 57) reported results relating to the state of vulnerability associated to enacting the patient role. This concept seems to be omnipresent in the experience of communicating with PCPs. In fact, from 1995 to 2015, patients from a wide range of countries and micro-cultures report feeling vulnerable when communicating with PCPs.
This vulnerability stems from four overlapping and occasionally interdependent categories of experiences: disrespect, time constraints, dominance of biomedical culture, and helplessness ( Table 2).
Disrespect. This category relates to being treated with disrespect. This experience varies in intensity from patients reporting feeling as if they are not being taken seriously to patients recalling being stigmatized, mocked, and discriminated [46,68]. Other examples raised were not listening to the patient or ignoring the patient, disrespecting the patient's privacy (e.g. allowing interns to attend a consultation without warning the patient), interrupting the patient, dismissing the patient's expertise regarding the illness, and not recognizing the patient as an autonomous and self-reliant individual [34,41,49,62]. Consequently, such experiences led to patients not wanting to disclose or fearing disclosing important health information (e.g. psychological illness, sexual orientation, alternative medicine use) and patients developing other ways of expressing pain so it would be recognized and taken seriously, such as crying [34,46,88].
Time Constraints. Time constraints translate in the patient reporting feeling unworthy of the physician's time, feeling like a burden, feeling rushed, not properly listened to, feeling stressed, not having the opportunity to tell their story, to ask questions, or to broach all issues [52,58]. Time constraints limit discussion to physical symptoms and psychosocial aspects are neglected. Consequently, patients explain feeling dehumanized, and they compare their experience to being part of an assembly chain or feeling like a number [71,74]. Physicians' behaviours are also perceived to be more disagreeable in response to time constraints [82]. Physicians are perceived to ask fewer questions or ask more close-ended questions, seem disinterested, focus on the physical symptoms related to the disease, limit social talk, and tend to utilize jargon to rapidly explain the condition [45,69,89].
Dominance of Biomedical Culture. As described by patients, biomedical culture served to orient conversations towards physical symptoms and biological aspects of one's condition and made it very difficult for patients to obtain or to discuss psychosocial information regarding their condition (e.g. emotions and impact of illness on their life) [47,77]. Although some patients recall attempting addressing psychosocial issues and being dismissed, most patients report waiting for the physician to broach psychosocial aspects and report not feeling confident  in raising such topics. Consequently, patients did not have the opportunity to tell the physician about pertinent psychosocial information relating to their illness [53,90]. Without such information, it is difficult for the physician to have a global understanding of the patient's psychosocial context and to tailor the treatment plan to the patient's context. In addition, the dominance of biomedical culture fosters an asymmetric physician-patient relationship which must be endured by patients. For instance, they describe physicians as leading the consultation, sometimes in a paternalistic way, by orienting the conversation towards physical symptoms and by leaving no room for psychosocial aspects related to the condition. Patients are left powerless and with little control, thus explaining their lack of confidence to broach psychosocial topics. Some patients even described the negative experience of feeling like a child because the physician behaved in such a paternalistic manner by deciding on the treatment plan, resorting to complicated jargon, and neglecting the patient's expertise with regard to the illness [49,55,62,89]. Helplessness. The dominance of biomedical culture could serve to partly explain the category of helplessness. Patients of all cultural and micro-cultural background reported feeling helpless during consultations. Events that triggered such feelings were: having to expose oneself and to disclose intimate information, undergoing intimate procedures, not being in control of the consultation while being stuck in an asymmetric conversation pattern, and having to repeat this experience often with a series of doctors. In addition, patients report not understanding the physician's explanations and jargon and feeling too shy or intimidated to ask for clarifications, the obligation to disclose sensitive information (e.g. non-adherence) and the experience of fear and anxiety with regard to communicating about certain unavoidable health-related topics (e.g. sexuality, abuse), undergoing intimate procedures without being prepared by the physician, experiencing discomfort with certain doctors but having to undergo the examination, and difficulty expressing one's symptoms and setting the agenda [33,47,50,54].

Positive Experiences: Preserving Integrity
Positive experiences were raised by 43 of the 57 studies (75%) and are attributed to certain relational skills, technical skills, as well as certain approaches to care privileged by the physician (Table 3).
Relational Skills. Patients raised many examples of positive communication experiences that were due to physicians' satisfactory relational skills. Patients appreciated when their physicians were empathic, careful listeners, open-minded, non-judgemental, respectful, friendly, compassionate, and seemed genuinely interested [32,65,91]. These qualities made patients feel less ashamed to discuss sensitive topics and attenuated their fear of being judged [83,87]. Some patients enjoyed when the physician used humour to alleviate the tension, others recall appreciating the use of appropriate touch (e.g. hand on shoulder), and some raised the general idea that perceived similarity to the physician made communication more agreeable [32,43,56,59,63,76]. For instance, some men and women voiced preferring same gender physicians, some African Americans preferred African American physicians, and some patients with religious beliefs preferred communicating with a physician who shared concordant beliefs. Finally, the opportunity to upkeep the relationship and build on it over time (i.e. continuity of care) was often raised as positive [36,38].
Technical Skills. Patients appreciate a competent physician who takes time to investigate, gives the patient time to talk and to ask questions, is attentive to details, asks further questions, initiates conversations about sensitive topics, provides enough information, and successfully educates the patient [45,46,48,81]. Furthermore, patients report being grateful when physicians tailored their word choice, thus avoiding incomprehensible jargon, or took time to explain the condition by utilizing images and text, and ensured that the patient had understood [44,55,79,90]. Finally, patients value physicians who take appropriate action, such as ordering appropriate tests, referring patients to proper specialists, and establishing a correct diagnosis [40,56]. Such satisfactory technical skills may diminish feelings of vulnerability a patient may be experiencing. For instance, some men report that they felt more at ease and less intrusion when physicians took time to explain intimate procedures [42].
Tailored Approach to Care. Tailoring the approach to the patient and individualizing care seems to ensure a positive communication experience. A majority of patients emphasized the importance of feeling personally understood in one's context and cared for in a biopsychosocial approach in contrast with being treated as a number [66,70,72,86]. Furthermore, they appreciated when physicians valued their opinion and when they had an egalitarian relationship and a partnership with their physician [35,71,73]. Nevertheless, a minority of patients reported appreciating when physicians engaged in more paternalistic behaviours and enacted the role of the expert [40,52]. In short, patients' discourse suggests that the key to providing a positive communication experience to all patients is to tailor the approach to their preferences.

Outcomes of Communication
The third concept relates to outcomes of communication as perceived by patients. Inverse outcomes were recalled by patients reporting mostly unsatisfying communication experiences compared to their satisfied counterparts (Fig 6).
Outcomes of Satisfactory Communication. Patients who experienced positive communication reported beneficial outcomes [65,90,92,93] which are classified in four categories: a) fostering the relationship, b) higher quality of care, c) enhanced patient autonomy and adherence, and d) satisfaction (Table 4). Satisfactory communication led to the development of a satisfactory relationship since positive experiences fostered trust and a sense of partnership [48,68,81]. Patients also evaluated care as being of higher quality since patients report being able to disclose important but sensitive information and thus equipping physicians to make proper referrals to address these issues [46,55,57]. Furthermore, patients report feeling more autonomous which leaves them with a feeling of control and responsibility, being more motivated to change and to adhere to the treatment plan and more empowered to ask questions and seek more information [60,66,94]. Finally, patients report being satisfied as illustrated by reduced feelings of vulnerability, a relief from stress and pain, as well as patients feeling consoled, supported, cared for, valued, and welcomed [40,61,65,70].
Outcomes of Unsatisfactory Communication. Patients also discussed harmful consequences ensuing from negative communication experiences [68,75,77,78,95] which are grouped in four categories: a) relational issues and distrust, b) lower quality of care, c) overuse or underuse of resources, and d) dissatisfaction and non-adherence (Table 5).
Relationships were hard to establish with unsatisfactory communication as patients reported distrust and lack of faith in the physician [35,39]. Furthermore, quality of care was reported as inferior since patients had not had the chance to disclose all pertinent healthrelated information, therefore proper referrals were not given and the treatment plan did not suit the patient or was poorly explained [67,70,77]. Following an unsatisfactory consultation,

Factors Influencing Ethnic Minority Patients' Experiences
In order to address the second research question, studies reporting on EMPs experiences were compared to studies investigating the general patient population. Although experiences were similar among both groups of patients, EMPs did raise distinctive experiences which relate to four categories of factors: a) language barriers, b) discrimination, c) differences in values and beliefs, and d) acculturation issues. These factors exerted mostly a negative influence on communication (see Tables 6 and 7 for a summary). Language Barriers. Difficulties associated to language barriers were discussed by EMPs and impeded on communication [25,52,80]. EMPs describe the challenge associated to accessing a professional interpreter [32,58]. Consequently, some patients turned to informal interpreters (e.g. child, husband, or friends). Although a minority of EMPs raised feeling comfortable with informal interpreters [54], most patients reported feeling embarrassed, guilty, and uncomfortable when consulting with informal interpreters [32,54,57]. Moreover, patients feel the presence of these interpreters constrains discussion about sensitive topics, mental health topics are avoided, and disclosure of intimate information is difficult or impossible. In short, consulting without professional interpreters or with informal ones made communication challenging and sometimes impossible. As a result, patients were at risk of receiving inadequate care.
Discrimination. EMPs raised experiences of discrimination based on their cultural belonging [80]. For instance, African Americans felt they were treated according to the stereotype of being unintelligent, being work shy and lazy, and having an unhealthy diet, and being poor [63,86]. For Pakistani-born migrants in Europe, some felt their traditional clothing   Explore the ways in which facework influences physician-patient interactions for Achi patients Aboriginals experience serious discrimination (e.g. being ignored, physically and psychologically abused, and neglected). Physicians do not take into account cultural beliefs and norms when communicating (e.g. speak directly to patient and criticize their habits, for Achi, need to communicate indirectly to remain polite and respectful).

Dahm (2012) [69]
Australia 7 Non-Native English speakers from Europe and Asia, 10 Native English speakers (n = 17) Explore relationship between perceived time constraints, jargon use, and patient information-seeking EMPs feel the same about jargon and time constraints as general patient populations, but they do not focus and complain as much about short consultation times because consultations are even shorter in their countries of origin. Majority of patients evaluate experience as positive because of status equalization effect between ethnic minority physician and patients. However they mention language barriers associated to foreign physician's accent.
(Continued)  Table 7. Specific factors influencing EMPs' experiences in communicating with a physician (language barriers, discrimination, differences in values and beliefs, and acculturation issues).

Specific Factors Affecting
EMPs' Experiences

Examples
Language Barriers Difficulty accessing professional interpreters, obliged to turn to friends and family members, discomfort when consulting with untrained interpreters, some topics are not addressed with untrained interpreters Discrimination Based on their cultural belonging, treated according to physicians' stereotypes Differences in Values and Beliefs Differences in health and illness representations (e.g. emotional distress is not health-related), differences in beliefs regarding respect for authority and need to maintain harmonious relationships; patients remain silent and do not contradict physicians, differences in time concepts Acculturation Issues More acculturated to host culture experience less language barriers and understand patient role in the host culture doi:10.1371/journal.pone.0139577.t007 impacted on the consultation with physicians acting surprised when these women proved to be intelligent and able to follow the consultation [32]. Some comparative studies allow stipulating that discrimination is a particularity of communication between EMPs and physicians. For instance, a focus group study conducted in the United-States illustrates that African Americans and Hispanics raise experiences of discrimination that remain absent from White Americans' discourse [35]. Studies targeting Aboriginal populations conclude that discrimination is experienced in fair amounts by these EMPs. Marked distrust, described as ensuing from historical trauma, is obvious in their discourse and ongoing experiences of discrimination makes access to care difficult and impedes on help-seeking behaviours [48,68]. For instance, Aboriginals in Guatemala report experiencing serious discrimination such as being mocked, abused, and insulted because of their indigenous background [68]. Aboriginals in Canada report feeling discriminated against since their selection of clinics to attend is restricted and they feel as if physicians treat them as inferior and talk down to them [48].
Differing Values and Beliefs. Studies raised specific examples of communication difficulties due to differences in beliefs and values. For instance, EMPs' health and illness representations sometimes differed from the physicians' and led to communication difficulties. Some Vietnamese patients believed that speaking about an illness would engender its development [58]. This belief was not considered or understood by physicians. Consequently, physicians attempted to discuss prevention measures for certain illnesses which left Vietnamese patients in states of fear or distress. Moreover, these patients may remain silent about recently appeared symptoms for fear of causing the illness to progress faster, thus impeding on early detection of illness. Another American study showed that for some African, South American, and Asian refugees in the United-States, emotional distress is not perceived as health-related, therefore, psychological distress is not discussed with physicians [72].
Differences in values and beliefs relating to respect for authority, the need to maintain harmonious relationships, time conceptions, and communication norms also seemed to engender communication difficulties. For some EMPs, the need to show respect for authority is much higher and the patient must avoid conflict at all cost with the physician [54,75]. Therefore, patient participation is minimal. Despite the wish of some EMPs to be recognized as experts of their illnesses, most reported remaining passive in order to respect authority and to preserve the relationship with the physician [84]. Regarding the need to maintain harmonious relationships, Hispanics in the United-States explain that certain topics, such as sexuality, are taboo because they could put relationships at risk (e.g. disclosing abuse) [57]. Concerning beliefs about time, Canadian Aboriginals believe it is a sign of respect to give someone time and to get to know the person [48]. This conception clashes with mainstream Canadian culture and Aboriginal patients report harmful consequences of time constraints, such as distrust. Concerning communication norms, for Aboriginals in Guatemala, direct communication is interpreted as rude, insulting, and careless [68]. These patients thus report negative experiences when communicating with physicians in Guatemala who disregard Aboriginal communication norms. Finally, for some South Asian patients in the United-Kingdom, social talk initiated by the physician is perceived as intrusive and is therefore unappreciated [25].
Acculturation Issues. Although previous factors exerted mainly a negative influence on communication, acculturation may exert both positive and negative influences. Acculturation is a process which results from the contact between two cultures [96]. Following this contact, changes may be brought upon one's cultural identity. For instance, some EMPs may identify to both their culture of origin and to the host culture while others remain affiliated only to their origins.
Some studies suggest that individual acculturation profiles may influence communication experience. For instance, a Norwegian study shows that EMPs rate their experiences differently according to their level of integration in the Norwegian society [52]. More precisely, the most integrated appreciated social talk, inquiry about psychosocial information, and being responsible for their care. In opposition, the less integrated did not appreciate when their opinion was solicited since they do not possess medical expertise, when physicians inquired about personal information since they perceive such information to be unrelated to medical issues, and disliked being given autonomy and responsibility. Another study conducted in the United-States shows that Hispanic migrants report the need to develop a warm relationship with their physicians before they feel safe sharing private information. On the other hand, United-States-born Hispanics seem to understand that the physician's primary role in the United-States is to heal; therefore, they attach less importance to developing a warm relationship [57]. Finally, another study suggests that patients who are more acculturated to the host culture have more knowledge of the host culture's language and escape dealing with language barriers [25].
In short, EMPs' individual acculturation profile may exert an influence on communication experiences and must not be neglected. The positive influence of acculturation to the host culture is probably due to EMPs learning and adhering to the patient role as prescribed in the host country [52]. In contrary, the less acculturated EMPs remain unsure of their role as patients in host countries and thus evaluate the experience as unpleasant [52].

Factors Influencing Ethnic Majority Patients' Experiences
In order to address the third research question, studies exploring experiences of ethnic majority patients belonging to other minority or micro-cultural groups were compared to EMPs' and to the general patient population's experiences. Similarly to EMPs, patients belonging to other minority or micro-cultural groups also experienced additional distinctive communication difficulties (Table 8). These micro-cultural groups include, among others, patients with psychiatric disorders, religious patients, adults with intellectual disabilities, women going through menopause, and chronically ill adolescents.
These patients also experienced disrespect in higher proportion and intensity than the general patient population. For instance, adults with intellectual disabilities and adolescents with chronic illnesses report stronger feelings of being dismissed and unrecognized as autonomous individuals [38,41,94]. Examples of physicians' disrespectful behaviours are addressing parents and support workers about the patient without the patient's permission, making eye contact and talking to accompanying adults and not to the patient, and addressing the patient in childish ways. Furthermore, psychiatrically ill patients [39,44,46] and menopausal women [40] also experience being labelled and treated accordingly, homosexual patients report being the target of inappropriate and rude remarks regarding their sexual orientation [46], Elderly patients report experiencing frequent and unpleasant ageism [67], and patients receiving or in need of opioid therapy feel they are instantly labelled as drug addicts and feel they have to battle with the physician to defend their need for the treatment [82,85].
Differences in values and beliefs and its negative effect on communication were also raised. For instance, some patients with different religious orientations experienced physicians dismissing their beliefs or avoiding such topics of conversation, thus acting as a barrier to building a satisfactory relationship [43]. Experiences of alternative medicine users are similar as they report feeling their beliefs are dismissed and thus fear discussing such topics [49].

Discussion
The main objective of the current systematic review was to synthesize qualitative studies exploring patients' experiences in communicating with PCPs. The secondary objective was to examine specific factors influencing EMPs' experiences. The third objective was to explore specific factors raised by ethnic majority patients to gain a better understanding of micro-cultural influences on patients' experiences. To our knowledge, this is the first systematic review of qualitative studies investigating patients' experiences in communicating with a PCP.
Surprisingly, the first study to explore patients' experiences in communicating with a primary care physician was published in 1995. As depicted in Fig 2, only 3 studies were published before the year 2000 and as of 2002, a steady interest in patients' experience is apparent. This increase in interest would concord with, and could partly be due to, the popularisation of the patient-centered care approach which was developed during the 1980s but became central to researchers and health professionals only a few years later [97]. It is also possible that the increase in publications concords with the gradual acceptance and opening to qualitative research methods in medical research.
Regarding the first objective, patients reported both negative and positive experiences of communication which lead to either beneficial or harmful outcomes. Negative experiences relate to feeling vulnerable due to experiences of disrespect, time constraints, dominance of the biomedical culture, and helplessness. Although patients reported more negative experiences, they also recalled positive experiences relating to the opportunity to preserve one's sense of integrity by being treated with respect by an empathic and competent physician who is capable of individualizing care. Outcomes of communication depended on the patient's evaluation of the quality of the interaction. Patients raised positive outcomes, such as being satisfied and motivated to adhere to the treatment, and negative outcomes such as feeling frustrated and experiencing distrust in the physician.

Counterbalancing Negative Experiences
The meta-ethnography method encourages the researcher to synthesize studies in a fashion that can provide a line of argument illustrating the relationship between concepts. In order to better understand the relationship between the three major concepts, a balance metaphor is depicted below (see Fig 7). Positive experiences are weighed on one side of the balance and negative experiences on the other. As suggested by findings, negative experiences weigh more (i.e. are more frequent) than positive experiences. Depending on the balance's position following a consultation, the patient may report more positive or negative outcomes. This metaphor implies that positive communication experiences could offset or alleviate the unfavorable outcomes ensuing from negative experiences.
This relationship between vulnerability and integrity has been previously discussed [24]. Irurita [24] reports that hospitalized patients in Australia discussed feeling vulnerable due to losing control over their bodies but raised strategies they could engage in to preserve a sense of integrity. The author however concludes that strategies patients can engage in are limited and that to preserve patients' integrity it is the responsibility of healthcare providers to engage in behaviours allowing the patient to remain in control and active in the care process.
Conversely, other authors underline the benefits of interventions aimed at patients to help them develop skills to better engage in communication in the health care process [85,87]. These interventions prove to be helpful to patients and provide another avenue to ameliorating communication in health care. Interventions should indeed be aimed both at the patient and the physician in order to optimize care.
The context of physician-patient relationship can account for such ubiquitous feelings of vulnerability [98]. Power, expertise, and authority are attributed to the physician, while the patient is left without control and obliged to cooperate. Considering such an asymmetric relationship it is unsurprising that patients are left feeling vulnerable and that the physician has the duty and power to help patients retain a sense of integrity in the process. Indeed, results of this review show that despite some patients' efforts, it seems to be difficult to preserve a sense of control partly due to the dominance of biomedical culture in medical consultations.

Cultural Particularities
Findings relating to the second objective show that specific factors make the task of communicating with physicians more challenging for EMPs. It is the presence of these additional factors that could explain the higher rates of communication difficulties in intercultural dyads. These factors mainly exert a negative influence on communication and are classified in four categories; language barriers, discrimination, differences in values and beliefs, and acculturation issues. These categories resemble those raised by Schouten and Meeuwesen [6] in their review of communication difficulties in intercultural dyads. Interestingly, their review included only observational studies but results from the current review suggest that patients' actual experiences concord with the accounts of observational studies. Findings relating to the third objective show that some ethnic majority patients also experienced additional distinctive communication difficulties. Neuliep's [16] contextual approach of intercultural communication can shed light on these findings. According to this approach, all interactions are nested within interconnected contexts which shape the communication. The first context is the general cultural context; all interactions take place within a general culture (e.g. national culture) which shares beliefs, norms, and rules. Within this context, Neuliep [16] introduces the micro-cultural context which also influences communication. Micro-cultures refer to all groups within the general cultural group who possess different beliefs, traditions, and behaviours than the general culture. One can belong to many micro-cultures depending on, for instance, one's sexual identity, profession, gender, and age.
It is precisely these micro-cultures which serve to nuance some ethnic majority patients' experiences, since their belonging to other micro-cultural groups influences their experiences of communication. This finding confirms the stipulation that all medical encounters are in fact intercultural. Communication in medical settings should be understood within its context, and cultural and micro-cultural influences should be taken into account. These micro-cultural groups seem to also be afflicted with stronger vulnerability from the outset. This affliction on EMPs and other micro-cultural groups can be depicted by the balance metaphor; an additional weight presses down on the negative experience side. For these patients, it is possible that it would take more consideration and sensitivity from the physician to make positive experiences offset harmful consequences of negative experiences.

Strengths, Limitations, & Future Research
This review confirms the pertinence of qualitative methods for obtaining rich and detailed accounts of patients' experiences in communication. The consistency in methods used by studies allows for rigorous comparison of results (46 used individual interviews and 14 used focus group interviews). Moreover, by including studies with heterogeneous patient samples, this review achieved one aim of qualitative research; it managed to identify trends across a diversity of participants in order to gain a general understanding of the experience [99].
In spite of these strengths, the current review and included studies present some limitations. First, only French and English articles were eligible. Second, studies published in books or other means than journals have not been examined since only peer-reviewed publications were targeted. Second, although diversity in samples allowed extracting general trends in experiences, generalizations to all types of patients must be made cautiously. Third, the preponderance of negative experiences over positive experiences may be due to a research bias towards investigating difficulties. Future studies should explore positive experiences in order to provide concrete examples of appreciated communication experiences.
Furthermore, some limitations concerning culture restrict our understanding of cultural aspects. For instance, a majority of studies (59.6%) neglected considering culture's influence on patients' experiences, despite previous evidence demonstrating culture's potential influence on communication [6,7,100]. Moreover, a majority of the studies exploring cultural aspects omitted to present a definition of the terms and concepts used, which in turn limits the interpretation of their results. Additionally, designs used by studies that do examine cultural aspects of patients' experiences limit our capacity to differentiate context from cultures or micro-cultures. Therefore, knowledge relating to intercultural communication remains nebulous. Future studies should undertake in-depth investigations of EMPs' experiences by privileging intercultural comparative methods as they would allow differentiating context from culture. For instance, studies could compare migrants' experiences of communication with a physician with those of locals. Future research should also consider the influence of EMPs' individual acculturation profile on communication experiences, since current findings suggest this profile can serve to nuance such experiences.
Considering that micro-cultures can also influence communication, all medical encounters could be characterized as intercultural. Future research should investigate if existing intercultural communication approaches are applicable to all medical encounters. Better still, it would be pertinent to compare EMPs' experiences with those of patients who are also perceived as different on the basis of their belonging to certain micro-cultures. This would allow the development of an encompassing theory and approach based on relations to all types of differences and not only ethnic differences.

Conclusion
In conclusion, universal aspects of incarnating the patient role have been uncovered. Vulnerability will likely persist to be part of patients' experiences due to the asymmetric physicianpatient relationship. However, physicians should strive to treat patients with dignity and respect in order to alleviate the harmful effects of negative experiences. Physicians should also be more considerate and sensitive when communicating with EMPs and other micro-cultural groups as they seem to be experiencing more vulnerability from the outset.

Practice Implications
Previous authors [24,26] underlined the necessity of considering the patient's experience in order to develop interventions aimed at adapting communication in healthcare. By considering patients' experiences across 57 studies, this review provides clear and concrete results which can help tailor interventions to patients and will ensure more satisfactory experiences. Findings provide concrete examples of both positive and negative experiences which can inform healthcare providers regarding appreciated communication behaviours and disagreeable behaviours which may need to be modified. The balance metaphor and the concepts of integrity and vulnerability provide medical students and staff with concepts that are easily understandable and relatable and may facilitate the exercise of putting oneself in the patients' shoes. Such concepts and metaphors may be used to render communication skills teaching more accessible and relatable. Finally, findings underline the necessity for physicians to remain aware of and sensitive to specific factors (cultural and micro-cultural) at play during communication. It is thus imperative that medical students be exposed throughout their training to these factors and their influence in order to overcome the neutralizing effect of medical socialisation. Healthcare workers, on the other hand, should reflect on these factors and keep them in mind when intervening with all types of patients.
Supporting Information S1 PRISMA Checklist. PRISMA Checklist for systematic reviews. (DOC) S1 Table. Quality evaluation of included studies according to three domains of the COREQ checklist: research team and reflexivity, study design, and analysis and findings. Sub-categories of each three domain were selected as evaluation criteria. Studies presented good quality when a checkmark is indicated in at least one category of each domain. All but 3 studies had a checkmark in all three categories. These three studies failed to elaborate on the domain of Research Team and Reflexivity. (DOCX)