The doctor–patient relationship is at the core of interpersonal interactions in the medical environment (1). A good doctor–patient relationship is beneficial to patient recovery (2), whereas a hostile one can affect loyalty and potentially lead to medical disputes. The rising trend of doctor–patient conflicts in China was previously reported (3) and has led to a focus on the relationship and communication.

Studies have shown that improved communication skills can enhance interactions between doctors and patients (4) and thereby prevent medical disputes. Moreover, patient-centered communication theories have been developed in recent decades (5, 6) and are considered crucial to improving medical care quality and outcomes (7). Patient-centered communication requires doctors to treat patients kindly, listen to patients' statements, and empathize with patients. However, considering the cultural and background differences in medical practice, this communication style may not be entirely applicable in all situations (8).

In China, public hospitals play a dominant role in healthcare work (9), especially with rapid aging of the population (10, 11) and urbanization (12, 13), leading to a large patient volume in public class A tertiary hospitals. To prevent dissatisfaction among large numbers of patients awaiting medical treatment, with doctors facing increasing pressure in diagnosis and treatment, they often must complete a patient's treatment within a short time, leaving insufficient time to listen to patients' statements, which usually lack professional clarity and contain many unnecessary details. When doctors need to provide effective medical services within a short time (2), communication strategy that require a lot of time become difficult to adopt in Chinese doctor–patient communication.

Poor communication is the main factor involved in medical disputes (14), and limited time is the fundamental reason for poor communication. This article suggests that, in China, the key to improving communication strategies is determining how medical staff can provide effective medical services and identify patients who are more likely to be dissatisfied so as to take appropriate measures and prevent the occurrence of patient dissatisfaction.

Cultural and educational backgrounds are important factors in medical disputes that affect patient communication preferences (15), yet few studies have addressed this. In the present study, we analyzed patients' cognitive levels and communication preferences regarding healthcare from different perspectives such as age, education level, type of medical visit, and residential region, aiming to identify patterns so as to help medical staff treat patients more effectively and reduce conflicts.

This research, based on a survey and analysis of patients visiting class A tertiary hospitals in Jiangsu Province, found that education level has a significant impact on patients, both in their expectations for curing their disease and their attitudes during doctor–patient communication. Specifically, the higher the education level, the greater the proportion of patients who demonstrate rational attitudes. This result is similar to Asjat's research (16) about patient's educational level and satisfaction with the quality of the mandibular denture bearing area and Doaa's research (17) about drug services. This work suggests that this phenomenon may be explained by the fact that patients with lower levels of literacy often hold overly optimistic expectations regarding curing their disease, while those with a bachelor's degree or higher tend to approach medical visits more rationally due to their higher health literacy. Saisai's research (18) also came to the same conclusion. The study also found that among illiterate patients, the proportion of those who believed their disease could definitely be cured was not high. Because patients' experiences and backgrounds may influence their communication with doctors (19), this article suggests that illiterate patients, who are often older individuals with rich life experience, tend to have more rational expectations regarding the cure of their diseases.

In Jiangsu Province, the gross enrollment rate for higher education reached 54.7% in 2016 (20) and 60.2% in 2021 (21). Patients with higher education know how to reflect on themselves and are thus able to better communicate with doctors (22). Therefore, a large proportion of patients aged 19–50 years believe that they lack understanding about how to cooperate with doctors.

In regions with a higher economic level and social development, patients achieve higher levels of education (23). Research has pointed out that the level of economic development in Jiangsu Province improves from north to south, and the proportion of highly educated individuals in Jiangsu also increases from north to south (24). Therefore, in southern Jiangsu, where the level of economic development is high and the proportion of highly educated individuals is large, the proportion of rational patients is also high.

Compared with inpatients, outpatient and emergency patients have little time to interact with medical staff (25, 26). As patients need to cooperate with medical staff to conduct various examinations and make decisions in a short period of time, it is difficult for them to do these things well with limited medical knowledge; thus, outpatient and emergency patients are more likely to realize their limitations in this regard. This explains why the proportion of outpatient and emergency patients choosing the second option, i.e., that patients should fulfill their obligations but that many patients lack an understanding of them, is significantly higher than those choosing any other option in Table 3.

Based on the above results, two suggestions can be made. First, medical staff in different regions should manage patients' expectations of being cured by taking into account the local area and the patients' education level when interacting with them. For example, medical staff should be more cautious about giving overly optimistic expectations of cures to patients with lower education levels and those from northern Jiangsu to prevent subsequent medical disputes if the optimistic prognosis is not achieved. Second, when diagnosing and treating patients, medical staff should choose the most suitable communication methods based on the patients' age, education level, type of medical visit, and residential origin. For example, when facing adult patients with high education levels in outpatient or emergency departments, explaining in detail how they need to cooperate with the diagnosis and treatment is more conducive to communication. For patients who are over 60 years old, have a lower level of education, or are from northern Jiangsu, it is recommended to show humanistic care through gentle words and tones. This is more conducive to building a harmonious doctor–patient relationship.

This study has some limitations. We only conducted a sampling survey of public class A tertiary hospitals in Jiangsu Province. Since Jiangsu's overall economic strength is among the highest in China, it is uncertain whether the suggestions are applicable to provinces with weaker economies or to other countries. Additionally, the survey was limited to public class A tertiary hospitals, which have a significantly different daily patient volume than primary and secondary hospitals; therefore, the suggestions may only be applicable to public class A tertiary hospitals.

This survey of patients in public class A tertiary hospitals in Jiangsu Province found that the higher the education level and the higher the economic development level of the region, the higher the proportion of rational patients seeking medical care. Additionally, outpatient and emergency patients are more willing to learn how to cooperate with doctors’ diagnosis and treatment than inpatients are. Thus, it is recommended that medical staff in different regions choose appropriate doctor–patient communication strategies.