Objective To investigate which characteristics of the physician and of the consultation are related to patient satisfaction with communication and working alliance. Methods Real‐life consultations (N = 134) between patients (n = 134) and their physicians (n = 24) were audiotaped. All of the patients were aware of their cancer diagnosis and consulted their physician to discuss the results of tests (CT scans, magnetic resonance imaging, or tumor markers) and the progression of their cancer. The consultations were transcribed and coded with the “Defense Mechanisms Rating Scale—Clinician.” The patients and physicians completed questionnaires about stress, satisfaction, and alliance, and the data were analyzed using robust linear modeling. Results Patient satisfaction with communication and working alliance was high. Both were significantly (negatively) related to the physician's neurotic and action defenses—in particular to the defenses of displacement, self‐devaluation, acting out, and hypochondriasis—as well as to the physician's stress level. The content of the consultation was not significantly related to the patient outcomes. Conclusions Our study shows that patient satisfaction with communication and working alliance is not influenced by the content of the consultation but is significantly associated with the physician's self‐regulation (defense mechanisms) and stress. The results of this study might contribute to optimizing communication skills training and to improving communication and working alliance in cancer care.