Resources
Bibiliography and Abstracts of RIAS Studies through 2012

Following are abstracts of RIAS studies, listed in alphabetical order by author. Just click on a letter below to view the abstracts by the author's last name. Monographs and doctoral theses have their own page.

A     B     C     D     E     F     G     H     I     J     K     L     M     N     O     P     Q     R     S

T     U     V     W     X     Y     Z     Monographs & Theses

Abdel-Tawab N, Roter D. The relevance of client-centered communication to family planning settings in developing countries: lessons from the Egyptian experience. Soc Sci Med. 2002 May; 54(9):1357-68.
(Family Planning, Egypt)
Concern for client's rights in the provision of reproductive health services in the developing world has prompted intense efforts by international experts to promote client-centered models of communication as a replacement for more provider-centered approaches. Nonetheless, the usefulness or feasibility of cross-cultural transplantation of client-centered models of communication has not been examined. The present study examines the feasibility, acceptability, and effectiveness of client-centered models of communication in 31 family planning clinics in Egypt. Consultations between 34 physicians and 112 clients requesting family planning methods were audio-taped and analyzed for physician communication style. Client satisfaction was measured through exit interviews. Method continuation was determined through home interviews at 3 and 7 months from the index visit. Based on audio-tape analysis, two-thirds of physician consultations were characterized as physician-centered and one-third as client-centered. Client-centered consultations were only one minute longer than physician-centered consultations. A client-centered consultation was associated with a three-fold increase in the likelihood of client satisfaction and method continuation at 7 months. A high proportion of solidarity statements (positive talk) by the physician was predictive of client satisfaction whereas a high proportion of disagreement statements and directive instructions by the physician were predictive of method discontinuation. The study findings suggest that in Egypt, as in more developed countries, client-centered models of communication are likely to produce better client outcomes than provider-centered models, with no substantial changes in the structure of services.

Agha Z, Roter DL, Schapira RM. An evaluation of patient-physician communication style during telemedicine consultations. J Med Internet Res. 2009 Sep 30;11(3):e36.
(Telemedicine, United States)
BACKGROUND: The quality of physician-patient communication is a critical factor influencing treatment outcomes and patient satisfaction with care. To date, there is little research to document the effect of telemedicine (TM) on physician-patient communication. OBJECTIVE: The objectives of this study are to measure and describe verbal and nonverbal communication during clinical TM consultations and to compare TM with in-person (IP) consultations in terms of the quality of physician-patient communication. METHODS: Veteran patients (n = 19) requiring pulmonary medicine consultations were enrolled into the study. The study group included 11 patients from the Iron Mountain Veterans Affairs Hospital (VAMC) remote site. Patients had individual TM consultations with a pulmonary physician at the Milwaukee VAMC hub site. A control group of 8 patients had IP consultations with a pulmonary physician at the Milwaukee VAMC. Video recordings of medical consultations were coded for patient-physician verbal and nonverbal communication patterns using the Roter Interaction Analysis System (RIAS). RESULTS: There were no differences in the length of TM consultations (22.2 minutes) and IP consultations (21.9 minutes). Analysis of visit dialogue indicated that the ratio of physician to patient talk was 1.45 for TM and 1.13 for IP consultations, indicating physician verbal dominance. Physicians were more likely to use orientation statements during IP consultations (P = .047). There were greater requests for repetition from patients during TM consultations (P = .034), indicating perceptual difficulties. CONCLUSIONS: The study findings indicate differences between TM and IP consultations in terms of physician-patient communication style. Results suggest that, when comparing TM and IP consultations in terms of physician-patient communication, TM visits are more physician centered, with the physician controlling the dialogue and the patient taking a relatively passive role. Further research is needed to determine whether these differences are significant and whether they have relevance in terms of health outcomes and patient satisfaction with care.

Beach MC, Roter D, Larson S, Levinson W, Ford DE, Frankel R. What do physicians tell patients about themselves? A qualitative analysis of physician self-disclosure. J. Gen. Intern. Med. 2004 Sep; 19(9):911-6.
(Primary Care, United States)
OBJECTIVE: Physician self-disclosure (PSD) has been alternatively described as a boundary violation or a means to foster trust and rapport with patients. We analyzed a series of physician self-disclosure statements to inform the current controversy. DESIGN: Qualitative analysis of all PSD statements identified using the Roter Interaction Analysis System (RIAS) during 1,265 audiotaped office visits. SETTING AND PARTICIPANTS: One hundred twenty-four physicians and 1,265 of their patients. MAIN RESULTS: Some form of PSD occurred in 195/1,265 (15.4%) of routine office visits. In some visits, disclosure occurred more than once; thus, there were 242 PSD statements available for analysis. PSD statements fell into the following categories: reassurance (n = 71), counseling (n = 60), rapport building (n = 55), casual (n = 31), intimate (n = 14), and extended narratives (n = 11). Reassurance disclosures indicated the physician had the same experience as the patient ("I've used quite a bit of that medicine myself"). Counseling disclosures seemed intended to guide action ("I just got my flu shot"). Rapport-building disclosures were either humorous anecdotes or statements of empathy ("I know I'd be nervous, too"). Casual disclosures were short statements that had little obvious connection to the patient's condition ("I wish I could sleep sitting up"). Intimate disclosures refer to private revelations ("I cried a lot with my divorce, too") and extended narratives were extremely long and had no relation to the patient's condition. CONCLUSIONS: Physician self-disclosure encompasses complex and varied communication behaviors. Self-disclosing statements that are self-preoccupied or intimate are rare. When debating whether physicians ought to reveal their personal experiences to patients, it is important for researchers to be more specific about the types of statements physicians should or should not make.

Beach MC, Roter D, Rubin H, Frankel R, Levinson W, Ford DE. Is physician self-disclosure related to patient evaluation of office visits? J Gen Intern Med. 2004 Sep;19(9):905-10.
(Primary Care, United States)
CONTEXT: Physician self-disclosure has been viewed either positively or negatively, but little is known about how patients respond to physician self-disclosure. OBJECTIVE: To explore the possible relationship of physician self-disclosure to patient satisfaction. DESIGN: Routine office visits were audiotaped and coded for physician self-disclosure using the Roter Interaction Analysis System (RIAS). Physician self-disclosure was defined as a statement describing the physician's personal experience that has medical and/or emotional relevance for the patient. We stratified our analysis by physician specialty and compared patient satisfaction following visits in which physician self-disclosure did or did not occur. PARTICIPANTS: Patients (N= 1,265) who visited 59 primary care physicians and 65 surgeons. MAIN OUTCOME MEASURE: Patient satisfaction following the visit. RESULTS: Physician self-disclosure occurred in 17% (102/589) of primary care visits and 14% (93/676) of surgical visits. Following visits in which a primary care physician self-disclosed, fewer patients reported feelings of warmth/friendliness (37% vs 52%; P =.008) and reassurance/comfort (42% vs 55%; P =.027), and fewer reported being very satisfied with the visit (74% vs 83%; P =.031). Following visits in which a surgeon self-disclosed, more patients reported feelings of warmth/friendliness (60% vs 45%; P =.009) and reassurance/comfort (59% vs 47%; P=.044), and more reported being very satisfied with the visit (88% vs 75%; P =.007). After adjustment for patient characteristics, length of the visit, and other physician communication behaviors, primary care patients remained less satisfied (adjusted odds ratio [AOR], 0.45; 95% confidence interval [CI], 0.24 to 0.81) and surgical patients more satisfied (AOR, 2.22; 95% CI, 1.12 to 4.50) after visits in which the physician self-disclosed. CONCLUSIONS: Physician self-disclosure is significantly associated with higher patient satisfaction ratings for surgical visits and lower patient satisfaction ratings for primary care visits. Further study is needed to explore these intriguing findings and to define the circumstances under which physician self-disclosure is either well or poorly received.

Beach MC, Roter DL, Wang NY, Duggan PS, Cooper, LA. Are physician’s attitudes of respect accurately perceived by patients and associated with more positive communication behaviors? Patient Edu Couns. 2006 Sep; 62(3):347-54.
(Primary Care, United States)
OBJECTIVE: To explore the domain of physician-reported respect for individual patients by investigating the following questions: How variable is physician-reported respect for patients? What patient characteristics are associated with greater physician-reported respect? Do patients accurately perceive levels of physician respect? Are there specific communication behaviors associated with physician-reported respect for patients? METHODS: We audiotaped 215 patient-physician encounters with 30 different physicians in primary care. After each encounter, the physician rated the level of respect that s/he had for that patient using the following item: "Compared to other patients, I have a great deal of respect for this patient" on a five-point scale between strongly agree and strongly disagree. Patients completed a post-visit questionnaire that included a parallel respect item: "This doctor has a great deal of respect for me." Audiotapes of the patient visits were analyzed using the Roter Interaction Analysis System (RIAS) to characterize communication behaviors. Outcome variables included four physician communication behaviors: information-giving, rapport-building, global affect, and verbal dominance. A linear mixed effects modeling approach that accounts for clustering of patients within physicians was used to compare varying levels of physician-reported respect for patients with physician communication behaviors and patient perceptions of being respected. RESULTS: : Physician-reported respect varied across patients. Physicians strongly agreed that they had a great deal of respect for 73 patients (34%), agreed for 96 patients (45%) and were either neutral or disagreed for 46 patients (21%). Physicians reported higher levels of respect for older patients and for patients they knew well. The level of respect that physicians reported for individual patients was not significantly associated with that patient's gender, race, education, or health status; was not associated with the physician's gender, race, or number of years in practice; and was not associated with race concordance between patient and physician. While 45% of patients overestimated physician respect, 38% reported respect precisely as rated by the physician, and 16% underestimated physician respect (r=0.18, p=0.007). Those who were the least respected by their physician were the least likely to perceive themselves as being highly respected; only 36% of the least respected patients compared to 59% and 61% of the highly and moderately respected patients perceived themselves to be highly respected (p=0.012). Compared with the least-respected patients, physicians were more affectively positive with highly respected patients (p=0.034) and provided more information to highly and moderately respected patients (p=0.018). CONCLUSION: Physicians' ratings of respect vary across patients and are primarily associated with familiarity rather than sociodemographic characteristics. Patients are able to perceive when they are respected by their physicians, although when they are not accurate, they tend to overestimate physician respect. Physicians who are more respectful towards particular patients provide more information and express more positive affect in visits with those patients. PRACTICE IMPLICATIONS: Physician respectful attitudes may be important to target in improving communication with patients.

Bensing JM, Dronkers, J. Instrumental and affective aspects of physician behavior. Med Care 1992 Apr;30(4):283-98.
(Primary Care, Netherlands)
In a semi-replication study, 103 videotaped real-life general practice consultations of patients with hypertension were observed with Roter's interaction Analysis System (RIAS). RIAS consists of a detailed category system meant to measure each verbal utterance of physician and patient (distinguished in task-related behavior and socio-emotional behavior) and a set of global affect-ratings. In this article, only general practitioner (GP) behavior is studied. GP's behavior is related to panel-assessed quality of care on three separate dimensions (technical-medical, psychosocial, and the management of the physician-patient relationship). A remarkably high percentage of the variance in the quality assessments (ranging from 59% to 70%) was explained by RIAS. The global affect-ratings proved to have the strongest influence in all quality assessments. In addition, task-related behavior seems to be more important in medical technical behavior, whereas socio-emotional behavior, and especially the psychotherapeutic categories like reflecting, paraphrasing, showing agreement, and others, seem to be more important in the other quality measures. The results are compared with Roter's study; similarities and differences are discussed in light of adjustments in the methodology. A plea is made for cross-cultural comparisons in physician behavior.

Bensing JM, Kerssens JJ, van der Pasch M. Patient-directed gaze as a tool for discovering and handling psychosocial problems in general practice. Journal of Nonverbal Behavior 1995 Winter; 19(4):223-242.
(Primary Care, Netherlands)
In this study, one particular form of nonverbal behavior--patient-directed gaze--was examined in relation to the general practitioner's performance in psychosocial care. Data were available from a random sample of 337 videotaped consultations and accompanying questionnaires from both general practitioner and patient. The relevance of general practitioners' gaze in psychosocial care was demonstrated in several ways: (1) general practitioners' gaze was associated with affective verbal behavior and with instrumental behavior on psychosocial topics; (2) general practitioners' gaze was related to patients' share of talking and the number of health problems presented, especially as regards psychological and social health problems; (3) in consultations with a relatively high degree of patient-directed gaze, general practitioners were found to be more aware of patients' psychosocial history and were better at identifying patients suffering mental distress. Patient-directed gaze appears to be a useful technique, both for decoding people's mental problems and for showing interest in the patient's story. This may encourage the patient to talk about worries that would otherwise remain concealed. In medical education, nonverbal techniques should be taught as distinct from verbal communication strategies.

Bensing JM, Roter DL, Hulsman RL. Communication patterns of primary care physicians in the United States and the Netherlands. Gen Intern Med. 2003 May; 18(5):335-42.
(Primary Care, Netherlands, United States)
BACKGROUND: While international comparisons of medical practice have noted differences in length of visit, few studies have addressed the dynamics of visit exchange. OBJECTIVES: To compare the communication of Dutch and U.S. hypertensive patients and their physicians in routine medical visits. DESIGN: Secondary analysis of visit audio/video tapes contrasting a Dutch sample of 102 visits with 27 general practitioners and a U.S. sample of 98 visits with 52 primary care physicians. MEASUREMENTS: The Roter Interaction Analysis System applied to visit audiotapes. Total visit length and duration of the physical exam were measured directly. MAIN RESULTS: U.S. visits were 6 minutes longer than comparable Dutch visits (15.4 vs 9.5 min, respectively), but the proportion of visits devoted to the physical examination was the same (24%). American doctors asked more questions and provided more information of both a biomedical and psychosocial nature, but were less patient-centered in their visit communication than were Dutch physicians. Cluster analysis revealed similar proportions of exam-centered (with especially long physical exam segments) and biopsychosocial visits in the 2 countries; however, 48% of the U.S. visits were biomedically intensive, while only 18% of the Dutch visits were of this type. Fifty percent of the Dutch visits were socioemotional, while this was true for only 10% of the U.S. visits. CONCLUSIONS: U.S. and Dutch primary care visits showed substantial differences in communication patterns and visit length. These differences may reflect country distinctions in medical training and philosophy, health care system characteristics, and cultural values and expectations relevant to the delivery and receipt of medical services.

Bensing JM, Sluijs EM. Evaluation of an interview training course for general practitioners. Soc Sci Med. 1985; 20(7):737-44.
(Communications Skills Training, Primary Care, Netherlands)
This article describes the evaluation of an experimental training in doctor-patient communication for general practitioners. The training was based on Rogerian theory and accommodated to the specific situation of the general practitioner. The main concept of this theory is the notion of 'unconditional positive regard'. It was expected that doctors would change their communication behaviour and that as a result patients would talk more about their psychosocial problems. The training was restricted to the diagnostic process, no therapeutic interventions were taught. The effects of this training have been measured by comparing video-tapes of live doctor-patient consultations, before and 3 months after the training. The most important result of this evaluation study turned out to be the change of the doctor's behaviour in the expected direction, but surprisingly the outcome of the consultation did not change at all: the doctors were empathically listening, but the patients did not talk more about their problems. Creating room for patients is not sufficient to induce them to discuss their personal problems with their doctors. Perhaps they do not feel like discussing their personal problems with them at all.

Bensing JM, Tromp F, van Dulmen S, van den Brink-Muinen A, Verheul W, Schellevis FG. Shifts in doctor-patient communication between 1986 and 2002: a study of videotaped general practice consultations with hypertension patients. BMC Fam Pract. 2006 Oct 25; 7:62.
(Primary Care, Netherlands)
BACKGROUND: Departing from the hypotheses that over the past decades patients have become more active participants and physicians have become more task-oriented, this study tries to identify shifts in GP and patient communication patterns between 1986 and 2002. METHODS: A repeated cross-sectional observation study was carried out in 1986 and 2002, using the same methodology. From two existing datasets of videotaped routine General Practice consultations, a selection was made of consultations with hypertension patients (102 in 1986; 108 in 2002). GP and patient communication was coded with RIAS (Roter Interaction Analysis System). The data were analysed, using multilevel techniques. RESULTS: No gender or age differences were found between the patient groups in either study period. Contrary to expectations, patients were less active in recent consultations, talking less, asking fewer questions and showing less concerns or worries. GPs provided more medical information, but expressed also less often their concern about the patients' medical conditions. In addition, they were less involved in process-oriented behaviour and partnership building. Overall, these results suggest that consultations in 2002 were more task-oriented and businesslike than sixteen years earlier. CONCLUSION: The existence of a more equal relationship in General Practice, with patients as active and critical consumers, is not reflected in this sample of hypertension patients. The most important shift that could be observed over the years was a shift towards a more businesslike, task-oriented GP communication pattern, reflecting the recent emphasis on evidence-based medicine and protocolized care. The entrance of the computer in the consultation room could play a role. Some concerns may be raised about the effectiveness of modern medicine in helping patients to voice their worries.

Bernhardt BA, Geller G, Doksum T, Larson SM, Roter D, Holtzman NA. Prenatal genetic testing: content of discussions between obstetric providers and pregnant women. Obstet Gynecol 1998 May;91(5 Pt 1): 648-55.
(Patient Satisfaction, United States)
OBJECTIVE: To document the content and accuracy of discussions about prenatal genetic testing between obstetric providers and pregnant women. METHODS: The first prenatal visits of 169 pregnant women with 21 obstetricians and 19 certified nurse-midwives were audiotaped and analyzed for whether a discussion of family history or genetic testing took place and if so, its length, content, and accuracy. RESULTS: Family history was discussed in 60% of visits, maternal serum marker screening in 60%, second-trimester ultrasonography for fetal anomalies in 34%, and for women at least 35 years old, amniocentesis or chorionic villus sampling (CVS) in 98%. The length of discussions of genetic testing averaged 2.5 minutes for women younger than 35 years of age and 6.9 minutes for older women. Topics discussed most often were the practical details of testing, the purpose of testing, and the fact that testing is voluntary. Discussions seldom were comprehensive. Obstetricians were more likely to make a recommendation about testing than were nurse-midwives and were less likely to indicate that testing is voluntary. Most women were satisfied with the amount of information, and the majority of women of advanced maternal age had made a decision about amniocentesis or CVS by the end of the visit. CONCLUSION: The information about genetic testing provided in the first prenatal visit is inadequate for ensuring informed autonomous decision-making. Guidelines addressing the content of these discussions should be developed with input from obstetricians, nurse-midwives, genetic counselors, and pregnant women.

Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract 1991 Feb; 32(2):175-81.
(Patient Recall and Satisfaction, Primary Care, United States)
The results of previous studies on the relationship between patient satisfaction and specific interviewing behaviors have been difficult to generalize because most studies have examined small samples of patients at one clinical location, and have used initial or acute care visits where the patient and physician did not have an established relationship. The present collaborative study of medical interviewing provided an opportunity to collect interviews from 550 return visits to 127 different physicians at 11 sites across the country. Tape recordings were analyzed using the Roter Interaction Analysis System, and postvisit satisfaction questionnaires were administered to patients. A number of significant relationships were found between communication during the visit and the various dimensions of patient satisfaction. Physician question asking about biomedical topics (both open- and closed-ended questions) was negatively related to patient satisfaction; however, physician question asking about psychosocial topics was positively related. Physician counseling for psychosocial issues was also positively related to patient satisfaction. Similarly, patient talk about biomedical topics was negatively related to satisfaction, while patient talk regarding psychosocial topics was positively related. Furthermore, patients were less satisfied when physicians dominated the interview by talking more or when the emotional tone was characterized by physician dominance. The findings suggest that patients are most satisfied by interviews that encourage them to talk about psychosocial issues in an atmosphere that is characterized by the absence of physician domination.

Blanch DC, Hall JA, Roter DL, Frankel RM. Is it good to express uncertainty to a patient? Correlates and consequences for medical students in a standardized patient visit. Patient Educ Couns. 2009 Sep;76(3):300-6. Epub 2009 Jul 14.
(Medical Education, Gender, United States)
OBJECTIVE: To examine the consequences of expressions of uncertainty (EOUs) in medical student interactions, with a particular focus on the gender of the expressor. METHODS: EOUs were identified in 147 videotaped interactions between third-year medical students and standardized patients enacting four medical scenarios. The encounters were also analyzed using the Roter Interaction Analysis System (RIAS). A subset of these interactions was shown to 244 analogue patients who rated satisfaction, liking, and perceived competence and confidence. RESULTS: Female medical students used more EOUs but not when adjusted for total number of statements. The EOU rate varied across scenarios. A higher EOU rate was perceived as more affectively negative by both RIAS trained coders and analogue patients. EOU rate was inversely related to analogue patient satisfaction and liking and this relationship was stronger for males than females. Female student use of EOUs was more strongly associated with ratings of anxiety than was male EOU use. CONCLUSION: There was an overall negative perception of medical students who expressed uncertainty; however, the strength of the associations varied due to medical student gender. PRACTICE IMPLICATIONS: The implications for medical education are discussed.

Brink-Muinen A, van Dulmen S, Messerli-Rohrbach V, Bensing J. Do gender-dyads have different communication patterns? A comparative study in Western-European general practices. Patient Educ Couns. 2002 Dec; 48(3):253-64.
(Primary Care, Gender, Netherlands)
From the viewpoint of quality of care, doctor-patient communication has become more and more important. Gender is an important factor in communication. Besides, cultural norms and values are likely to influence doctor-patient communication as well. This study examined (1). whether or not communication patterns of gender-dyads in general practice consultations differ across and between Western-European countries, and (2). if so, whether these differences continue to exist when controlling for patient, GP and consultation characteristics. Doctor-patient communication was assessed in six Western-European countries by coding video taped consultations of 190 GPs and 2812 patients. Cluster analysis revealed three communication patterns: a biomedical, a biopsychosocial and a psychosocial pattern. Across countries, communication patterns of the female/female dyad differed from that of the other gender-dyads. Differences in communication patterns between countries could especially be explained by differences in consultations of male doctors, irrespective of the patients' gender. It is important to take into consideration differences between gender-dyads and between countries when studying gender effects on communication across countries or when comparing studies performed in different countries.

Brown LD, de Negri B, Hernandez O, Dominguez L, Sanchack JH, Roter D. An evaluation of the impact of training Honduran health care providers in interpersonal communication. Int J Qual Health Care 2000 Dec;12(6):495-501.
(Communications Skills Training, Satisfaction, Honduras)
OBJECTIVE: To evaluate the impact of interpersonal communication (IPC) training on practice and patient satisfaction and to determine the acceptability of this training to providers in a developing country. DESIGN: The study used a pre-post design with treatment and control groups. Data collection methods included interaction analysis of audio-taped clinical encounters, patient exit interviews, and a self-administered questionnaire for health providers. STUDY PARTICIPANTS: Interaction analysis was based on an experimental group of 24 doctors and a control group of eight with multiple observations for each provider). Exit interviews were carried out with 220 pre-test patients and 218 post-test patients. All 87 health providers who received training responded to the self-administered questionnaire. INTERVENTION: A brief in-service training programme on interpersonal communications was presented in three half-day sessions; these focused on overall socio-emotional communication, problem solving skills and counselling. MAIN OUTCOME MEASURES AND RESULTS: The IPC intervention was associated with more communication by trained providers (mean scores of 136.6 versus 94.4; P = 0.001), more positive talk (15.93 versus 7.99; P = 0.001), less negative talk (0.11 versus 0.59; P = 0.018), more emotional talk (15.7 versus 5.5; P = 0.021), and more medical counselling (17.3 versus 11.3; P = 0.026). Patients responded by communicating more (mean scores of 113.8 versus 79.6; P = 0.011) and disclosing more medical information (54.7 versus 41.7; P = 0.002). Patient satisfaction ratings were higher for providers who had received the training and providers reported training to be relevant and useful. CONCLUSIONS: Further validation of IPC skills and simplification of assessment methods are needed if IPC is to be an area for routine monitoring and quality improvement.

Brown TN, Ueno K, Smith CL, Austin NS, Bickman L. Communication patterns in medical encounters for the treatment of child psychosocial problems: does pediatrician-parent concordance matter? Health Commun. 2007; 21(3):247-56.
(Pediatrics, United States)
This study examined how pediatrician-parent social status concordance related to communication patterns in medical encounters during which children received treatment for psychosocial problems indicating attention deficit disorder or attention deficit hyperactivity disorder. Using data from 28 pediatric medical encounters occurring in a large southeastern metropolitan city during 2003, we focused on concordance according to race, gender, and education, and its relation to laughter, concern, self-disclosure, question asking, and information-giving utterances, and patient-centeredness. Results indicated that race-concordant pediatricians and parents frequently laughed, whereas parents asked many biomedical questions in gender-concordant encounters. Education-concordant pediatricians and parents expressed concern repeatedly, exchanged biomedical information freely, and shared communication control. Pediatricians also self-disclosed when interacting with college-educated parents.

Caris-Verhallen WM, de Gruijter IM, Kerkstra A, Bensing JM. Factors related to nurse communication with elderly people. J Adv Nurs 1999 Nov;30(5):1106-17.
(Nursing, Netherlands)
This study explores variables that might influence nurses' communication with elderly patients. Three groups of variables arise from the literature that seem to affect the quality or quantity of nurse-patient communication: variables related to nurses, to patients, and to the setting in which nursing care takes place. The study was conducted in two different care settings: a home for elderly people and a home care organization. In a sample of 181 video-taped nursing encounters, involving 47 nurses and 109 patients a study was made of nurse-patient communication. In addition, relevant data related to patients, nurses and situation were gathered by questionnaires and were combined with the results of observations of videotaped nurse-patient interactions. It was found that the educational level of nurses was related most strongly to the way nurses communicate with their elderly patients. Patient characteristics such as age, gender and subjective state of health appeared to play a minor role in the way nurses communicate.

Caris-Verhallen WM, Kerkstra A, Bensing JM. Non-verbal behaviour in nurse-elderly patient communication. J Adv Nurs. 1999 Apr;29(4):808-18.
(Nursing, Netherlands)
This study explores the occurrence of non-verbal communication in nurse-elderly patient interaction in two different care settings: home nursing and a home for the elderly. In a sample of 181 nursing encounters involving 47 nurses a study was made of videotaped nurse-patient communication. Six non-verbal behaviours were observed: patient-directed eye gaze, affirmative head nodding, smiling, forward leaning, affective touch and instrumental touch. With the exception of instrumental touch these non-verbal behaviours are important in establishing a good relationship with the patient. To study the relationship between non-verbal and verbal communication, verbal communication was observed using an adapted version of Roter's Interaction Analysis System, which distinguishes socio-emotional and task-related communication. Data were analysed in hierarchical linear models. The results demonstrated that nurses use mainly eye gaze, head nodding and smiling to establish a good relation with their patients. The use of affective touch is mainly attributable to nurses' personal style. Compared to nurses in the community, nurses in the home for the elderly more often display non-verbal behaviours such as patient-directed gaze and affective touch.

Caris-Verhallen WM, Kerkstra A, Bensing JM, Grypdonck MH. Effects of video interaction analysis training on nurse-patient communication in the care of the elderly. Patient Educ Couns. 2000 Jan;39(1):91-103.
(Nursing , Netherlands)
This paper describes an empirical evaluation of communication skills training for nurses in elderly care. The training programme was based on Video Interaction Analysis and aimed to improve nurses' communication skills such that they pay attention to patients' physical, social and emotional needs and support self care in elderly people. The effects of the training course were measured in an experimental and control group. They were rated by independent observers, by comparing videotapes of nursing encounters before and after training. Forty nurses participated in 316 videotaped nursing encounters. Multi-level analysis was used to take into account similarity among same nurse encounters. It was found that nurses who followed the training programme, provided the patients with more information about nursing and health topics. They also used more open-ended questions. In addition, they were rated as more involved, warmer and less patronizing. Due to limitations in the study design, it could not be demonstrated that these findings can entirely be ascribed to the training course. Further research, incorporating a randomized controlled design and larger sample sizes, is recommended to determine whether the results can be attributed to this specific type of training.

Caris-Verhallen WM, Kerkstra A, van der Heijden PG, Bensing JM. Nurse-elderly patient communication in home care and institutional care: an explorative study. Int J Nurs Stud. 1998 Feb-Apr;35(1-2):95-108.
(Nursing , Netherlands)
This study explores communication patterns between nurses and elderly patients in two different care settings. In a sample of 181 video-taped nursing encounters, involving 47 nurses and 109 patients, a study was made of nurse-patient communication. The video recordings were observed using an adapted version of Roter's Interaction Analysis System, which yields frequencies of 23 types of verbal behaviours. These data were analyzed using correspondence analysis, to reduce them to a smaller number of verbal categories, in which two socio-emotional categories and three categories with task-related communication, could be distinguished. For each encounter five summary statistics corresponding to these categories were calculated. Using analysis of variance, it was shown that the amount of socio-emotional interaction in both settings appeared to be higher than was reported in previous studies into nurse-patient communication. Compared with the home for the elderly, communication was more task-related in home care.

Caris-Verhallen W, Timmermans L, van Dulmen S. Observation of nurse-patient interaction in oncology: review of assessment instruments. Patient Educ Couns. 2004 Sep;54(3):307-20.
(Oncology, Nursing, Netherlands)
The aim of this review is to identify assessment instruments that can be used for analyzing sequences and can be applied to research into nurse-patient communication in cancer care. A systematic search of the literature revealed a variety of methods and instruments applicable to studies recording nurse-patient interaction. The studies that were qualitative in nature offered valuable information on observational research in general, on procedures relating to informed consent and observational arrangements in nursing practice. The quantitative studies provided an insight into the content and structure of the interaction by describing communication concepts or by frequency counts of previously determined behaviours. Systematic research into interaction sequences was not found. However, some of the quantitative instruments identified could be adapted for this purpose. The complexity and time-consuming nature of observational research highlight the need for efficiency. For instance a combination of quantitative and qualitative instruments could be considered. Copyright 2004 Elsevier Ireland Ltd.

Carter WB, Inui TS, Kukull WA, Haigh VH. Outcome-based doctor-patient interaction analysis: II.Identifying effective provider and patient behavior. Med Care 1982 Jun;20(6):550-66.
(Patient Recall or Satisfaction, Primary Care, United States)
Three interactional analysis (IA) systems (Bales', Roter’s modified Bales, and Stiles' "Verbal response modes") were used to characterize behavioral elements of provider-patient dialogues of 101 new-patient visits in a general medical clinic. In a previous article, the explanatory power of these IA systems was compared. In this article, specific provider and patient behaviors within segments of the encounter (introduction-history, physical examination and conclusion), which were shown to be related to encounter outcomes of knowledge, compliance and satisfaction, were examined. Review of interactional behaviors entering regression analysis with a significant F-to-enter (p less than or equal to 0.05) and supplementary contextual analyses suggested the importance of several categories of physician and patient behavior. Behaviors manifesting tension bear important and complex relationships to encounter outcomes. For example, patient and physician expressions of tension generally bear strong negative relationships to patient satisfaction, while patient expressions interpreted as tension release are positively related to both satisfaction and compliance. The timing of other behaviors appears to be critical to subsequent outcomes. If patient requests for medication occur early in the encounter, this behavior is positively related to subsequent patient satisfaction. However, if they occur in the concluding segment, a negative relationship results. Finally, several relationships taken together indicate that physician teaching in the concluding segment may be important. While useful observations may emerge from application of currently available IA techniques, the resulting information is best characterized as hypothesis-generating. These IA systems have many limitations, and research is needed to derived more clinically oriented systems that may permit more consistent demonstrations of critical process-outcome relationships.

Cené CW, Roter D, Carson KA, Miller ER 3rd, Cooper LA. The effect of patient race and blood pressure control on patient-physician communication. J Gen Intern Med. 2009 Sep;24(9):1057-64. Epub 2009 Jul 3.
(Primary Care, Racial Disparities, United States)
BACKGROUND: Racial disparities in hypertension control contribute to higher rates of cardiovascular mortality among blacks. Patient-physician communication quality is associated with better health outcomes, including blood pressure (BP) control. Both race/ethnicity and BP control may adversely affect communication. OBJECTIVE: To determine whether being black and having poor BP control interact to adversely affect patient-physician communication more than either condition alone, a situation referred to as "double jeopardy." DESIGN, SETTINGS, AND PATIENTS: Cross-sectional study of enrollment data from a randomized controlled trial of interventions to enhance patient adherence to therapy for hypertension. Participants included 226 hypertensive patients and 39 physicians from 15 primary care practices in Baltimore, MD. MEASUREMENTS: Communication behaviors and visit length from coding of audiotapes. RESULTS: After controlling for patient and physician characteristics, blacks with uncontrolled BP have shorter visits (B = -3.9 min, p < 0.01) with less biomedical (B = -24.0, p = 0.05), psychosocial (B = -19.4, p < 0.01), and rapport-building (B = -19.5, p = 0.01) statements than whites with controlled BP. Of all communication outcomes, blacks with uncontrolled BP are only in "double jeopardy" for a patient positive affect-coders give them lower ratings than all other patients. Blacks with controlled BP also experience shorter visits and less communication with physicians than whites with controlled BP. There are no significant communication differences between the visits of whites with uncontrolled versus controlled BP. CONCLUSIONS: This study reveals that patient race is associated with the quality of patient-physician communication to a greater extent than BP control. Interventions that improve patient-physician communication should be tested as a strategy to reduce racial disparities in hypertension care and outcomes.

Coe JB, Adams CL, Bonnett BN. Prevalence and nature of cost discussions during clinical appointments in companion animal practice. J Am Vet Med Assoc. 2009 Jun 1;234(11):1418-24.
(Veterinary Medicine, Canada)
OBJECTIVE: To determine prevalence and nature of cost discussions between veterinarians and pet owners during clinical appointments in companion animal practice. DESIGN: Cross-sectional descriptive study. SAMPLE POPULATION: 20 veterinarians in companion animal practice in eastern Ontario and 350 clients and their pets. PROCEDURES: 200 veterinarian-client-patient interactions were randomly selected from all videotaped interactions and analyzed with the Roter interaction analysis system. Additional proficiency codes and blocking functions were developed to capture the prevalence, nature, and context of cost discussions. RESULTS: 58 of the 200 (29%) appointments that were analyzed included a discussion of cost. During 38 of these 58 (66%) appointments, the discussion involved costs associated with the veterinarian's time or with services provided by the veterinarian. Overall, reference to a written estimate was made during only 28 of the 200 (14%) appointments. Cost discussions were most common during appointments in which a decision related to diagnostic testing or dentistry was made. Appointments were significantly longer when a cost discussion was included than when it was not. CONCLUSIONS AND CLINICAL RELEVANCE: Results of the present study suggested that discussions related to cost were relatively uncommon during clinical appointments in companion animal practice and that written estimates were infrequently used to aid these discussions. When discussions of cost did occur, veterinarians appeared to focus on explaining costs in terms of the veterinarian's time or services provided by the veterinarian, rather than on the medical information that could be obtained or the benefits to the future health or function of the pet.

Cooper LA, Roter DL, Bone LR, Larson SM, Miller ER 3rd, Barr MS, Carson KA, Levine DM. A randomized controlled trial of interventions to enhance patient-physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045. Implement Sci. 2009 Feb 19;4:7.
(Primary Care, Racial Disparities, United States)
ABSTRACT: BACKGROUND: Disparities in health and healthcare are extensively documented across clinical conditions, settings, and dimensions of healthcare quality. In particular, studies show that ethnic minorities and persons with low socioeconomic status receive poorer quality of interpersonal or patient-centered care than whites and persons with higher socioeconomic status. Strong evidence links patient-centered care to improvements in patient adherence and health outcomes; therefore, interventions that enhance this dimension of care are promising strategies to improve adherence and overcome disparities in outcomes for ethnic minorities and poor persons. OBJECTIVE: This paper describes the design of the Patient-Physician Partnership (Triple P) Study. The goal of the study is to compare the relative effectiveness of the patient and physician intensive interventions, separately, and in combination with one another, with the effectiveness of minimal interventions. The main hypothesis is that patients in the intensive intervention groups will have better adherence to appointments, medication, and lifestyle recommendations at three and twelve months than patients in minimal intervention groups. The study also examines other process and outcome measures, including patient-physician communication behaviors, patient ratings of care, health service utilization, and blood pressure control. METHODS: A total of 50 primary care physicians and 279 of their ethnic minority or poor patients with hypertension were recruited into a randomized controlled trial with a two by two factorial design. The study used a patient-centered, culturally tailored, education and activation intervention for patients with active follow-up delivered by a community health worker in the clinic. It also included a computerized, self-study communication skills training program for physicians, delivered via an interactive CD-ROM, with tailored feedback to address their individual communication skills needs. CONCLUSION: The Triple P study will provide new knowledge about how to improve patient adherence, quality of care, and cardiovascular outcomes, as well as how to reduce disparities in care and outcomes of ethnic minority and poor persons with hypertension.

Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003 Dec 2;139(11):907-15.
(Primary Care, Race-Concordance, Patient Satisfaction, United States)
BACKGROUND: African-American patients who visit physicians of the same race rate their medical visits as more satisfying and participatory than do those who see physicians of other races. Little research has investigated the communication process in race-concordant and race-discordant medical visits. Objectives: To compare patient-physician communication in race-concordant and race-discordant visits and examine whether communication behaviors explain differences in patient ratings of satisfaction and participatory decision making. DESIGN: Cohort study with follow-up using previsit and postvisit surveys and audiotape analysis. SETTING: 16 urban primary care practices. PATIENTS: 252 adults (142 African-American patients and 110 white patients) receiving care from 31 physicians (of whom 18 were African-American and 13 were white). MEASUREMENTS: Audiotape measures of patient-centeredness, patient ratings of physicians' participatory decision-making styles, and overall satisfaction. RESULTS: Race-concordant visits were longer (2.15 minutes [95% CI, 0.60 to 3.71]) and had higher ratings of patient positive affect (0.55 point, [95% CI, 0.04 to 1.05]) compared with race-discordant visits. Patients in race-concordant visits were more satisfied and rated their physicians as more participatory (8.42 points [95% CI, 3.23 to 13.60]). Audiotape measures of patient-centered communication behaviors did not explain differences in participatory decision making or satisfaction between race-concordant and race-discordant visits. CONCLUSIONS: Race-concordant visits are longer and characterized by more patient positive affect. Previous studies link similar communication findings to continuity of care. The association between race concordance and higher patient ratings of care is independent of patient-centered communication, suggesting that other factors, such as patient and physician attitudes, may mediate the relationship. Until more evidence is available regarding the mechanisms of this relationship and the effectiveness of intercultural communication skills programs, increasing ethnic diversity among physicians may be the most direct strategy to improve health care experiences for members of ethnic minority groups.

Cox ED, Smith MA, Brown RL, Fitzpatrick MA. Learning to participate: effect of child age and parental education on participation in pediatric visits. Health Commun. 2009 Apr;24(3):249-58.
(Pediatrics, United States)
Children's participation in health care improves outcomes, yet little is known about factors that affect participation. We examine how child age and parental education affect participation. Visit videotapes were coded to reflect key visit tasks: information giving, information gathering, and relationship building. Multivariable models were used to analyze how participation was associated with child age and parental education. For each year of child age, physicians did 3% more information gathering, incidence rate ratio (IRR) = 1.03, 95% confidence interval (95% CI) = 1.01-1.06, but reduced relationship building by 4%, IRR = 0.96, 95% CI = 0.94-0.97. Children of college-graduate parents spoke twice as much information-giving talk, IRR = 2.11, 95% CI = 1.07-4.17, and nearly 5 times as much relationship-building talk, IRR = 4.74, 95% CI = 1.45-15.52, as children with less educated parents. Results suggest physicians might attend to relationship building with older children and work to improve participation of children of less educated parents.

Cox ED, Smith MA, Brown RL, Fitzpatrick MA. Assessment of the physician-caregiver relationship scales (PCRS). Patient Educ Couns. 2008 Jan;70(1):69-78.
(Pediatrics, United States)
OBJECTIVE: The physician-caregiver relationship affects patients' health outcomes, but measures of this important relationship are lacking. We develop and validate the physician-caregiver relationship scales (PCRS), incorporating three relationship domains (liking, understanding, dominance). METHODS: Videotapes of 100 children's visits were coded for verbal and nonverbal communication. Roter interaction analysis system utterance categories (personal remarks, laughter, agreements, approvals, concerns, reassurances, back channels and empathy) and summary measures (physician proportion of total talk and of number of questions) along with nonverbal measures (touch initiations, upright postures and leaning toward a participant) were used as indicators. Model fit was evaluated with confirmatory factor analysis (CFA). Validity was evaluated by associations of the PCRS with visit characteristics and global affect ratings. RESULTS: PCRS domains incorporating verbal and nonverbal indicators demonstrated good model fit (RMSEA<0.05; SRMR<0.12; TLI and CFI>0.95). Construct and predictive validity were demonstrated with PCRS domains relating to visit characteristics and affect ratings as predicted. CONCLUSIONS: CFA supported the multi-dimensional PCRS with three domains-liking, understanding and dominance. Such measures are valuable tools for investigations of physician-caregiver relationships. PRACTICE IMPLICATIONS: Models suggest specific indicators of the physician-caregiver relationship and inform.

Cox ED, Smith MA, Brown RL, Fitzpatrick MA. Effect of gender and visit length on participation in pediatric visits. Patient Educ Couns. 2007 Mar;65(3):320-8.
(Pediatrics, United States)
OBJECTIVE: To examine the effect of child, physician and parent genders as well as visit length on participation. METHODS: We analyzed videotapes and sociodemographics from 100 pediatric visits. Using the Roter Interaction Analysis System, coded utterances were aggregated to reflect key visit tasks: information giving, information gathering and relationship building. Negative binomial models were used to analyze how participation was associated with participants' genders and visit length. RESULTS: After adjustment, girls did twice as much relationship building as boys (incidence rate ratio = 2.33, 95% confidence interval = 1.01-5.36) and their physicians did 34% more information gathering (1.34, 1.16-1.55). Female physicians did 29% less information giving (0.71, 0.54-0.94). Having the father accompany the child reduced child relationship building 76% (0.24, 0.08-0.69) and reduced physician information giving 14% (0.86, 0.75-0.995), compared to having mother accompany. After adjusting for participants' genders, longer visits were associated with more participation for all participants. CONCLUSION: Child participation was impacted by child gender and by the accompanying parent's gender as well as the visit length. PRACTICE IMPLICATIONS: Because gender-based patterns of participation are evident in childhood, interventions to facilitate participation might begin early in life. To improve participation, interventions might include advocating for policies to support longer visit lengths.

Dale J, Sandhu H, Lall R, Glucksman E. The patient, the doctor and the emergency department: a cross-sectional study of patient-centredness in 1990 and 2005. Patient Educ Couns. 2008 Aug;72(2):320-9.
(Emergency Medicine, United Kingdom)
OBJECTIVE: To compare and contrast the duration and content of physician-patient interaction for patients presenting to an emergency department with problems of low acuity in 1990 and 2005 treated by different grades of physician. METHODS: Observational study with data collection in May-July 1990 and May-July 2005. Patients identified at nurse triage as presenting with 'primary care' problems were allocated by time of arrival to senior house officers (1990, n=7; 2005, n=10), specialist registrars/staff grades (1990, n=4; 2005, n=7) or sessionally employed general practitioners (1990, n=8; 2005, n=12) randomly rostered to work in a consulting room that had a wall-mounted video camera. A stratified sample of 430 video-taped consultations (180 (42%) from 1990 and 250 (58%) from 2005) was analysed using the Roter Interaction Analysis System. Main outcome measures -- length of consultation; numbers of utterances of physician and patient talk related to building a relationship, data gathering, activating/partnering (i.e. actively encouraging the patient's involvement in decision-making), and patient education/counselling. RESULTS: On average consultation length was 251s (95% CI for difference: 185-316) longer in 2005 than in 1990. The difference was especially marked for senior house officers (mean duration 385s in 1990 and 778s in 2005; 95% CI of difference: 286-518). All groups of physician showed increased communication related to activating and partnering and building a therapeutic relationship with the patient. While senior house officers demonstrated a greatly increased focus on data gathering, only general practitioners substantially increased the amount of talk centred on patient education and counselling; compared to senior house officers, the odds ratio for the number of such utterances included in consultations was 2.8 (95% CI: 1.4, 5.3). CONCLUSION: Although patient-centredness together with consultation length increased for all three physician groups over the duration of this study, senior house officers and specialist registrars/staff grades continued to place less emphasis on advice-giving and counselling than did general practitioners. The extent to which these observed changes in practice were determined by policy, management and training initiatives, and their impact on patient outcome, needs further study. PRACTICE IMPLICATIONS: Video-recording consultations is feasible in an acute hospital setting, and could be used to support training and workforce development. General practitioners can make a distinctive contribution to the workforce of emergency departments. Their consulting style differs from that of hospital physicians and may benefit patient care through a greater focus on patient education and counselling.

Detmar SB, Muller MJ, Wever LD, Schornagel JH, Aaronson NK. The patient-physician relationship. Patient-physician communication during outpatient palliative treatment visits: an observational study. JAMA 2001 Mar 14;285(10):1351-7.
(Oncology, Netherlands)
CONTEXT: Improving health-related quality of life (HRQL) is an important goal of palliative treatment, but little is known about actual patient-physician communication regarding HRQL topics during palliative treatment. OBJECTIVES: To investigate the content of routine communication regarding 4 specific HRQL issues between oncologists and their patients and to identify patient-, physician-, and visit-specific factors significantly associated with discussion of such issues. DESIGN: Observational study conducted between June 1996 and January 1998. SETTING: Outpatient palliative chemotherapy clinic of a cancer hospital in the Netherlands. PARTICIPANTS: Ten oncologists and 240 of their patients (72% female; mean age, 55 years) who had incurable cancer and were receiving outpatient palliative chemotherapy. MAIN OUTCOME MEASURES: Patient and physician questionnaires and audiotape analysis of communication regarding daily activities, emotional functioning, pain, and fatigue during an outpatient consultation using the Roter Interaction Analysis System. RESULTS: Physicians devoted 64% of their conversation to medical/technical issues and 23% to HRQL issues. Patients' communication behavior was divided more equally between medical/technical issues (41%) and HRQL topics (48%). Of the independent variables investigated, patients' self-reported HRQL was the most powerful predictor of discussing HRQL issues. Nevertheless, in 20% to 54% of the consultations in which patients were experiencing serious HRQL problems, no time was devoted to discussion of those problems. In particular, these patients' emotional functioning and fatigue were unaddressed 54% and 48% of the time, respectively. Discussion of HRQL issues was not more frequent in consultations in which tumor response was evaluated. CONCLUSION: Despite increasing recognition of the importance of maintaining patients' HRQL as a goal of palliative treatment, the amount of patient-physician communication devoted to such issues remains limited and appears to make only a modest contribution, at least in an explicit sense, to the evaluation of treatment efficacy in daily clinical practice.

de Ridder DT, Theunissen NC, van Dulmen SM. Does training general practitioners to elicit patients' illness representations and action plans influence their communication as a whole? Patient Educ Couns. 2007 Jun;66(3):327-36.
(Communication Skills Training, Netherlands)
OBJECTIVE: To examine whether the discussion of illness representations and action plans during medical encounters affects the way patients and general practitioners (GPs) communicate. METHODS: In a quasi-experimental design, 10 GPs first performed care-as-usual conversations with patients. After a 6 h training they performed consultations either emphasizing patients' illness representations or action plans. Data were collected from 70 videotaped consultations with hypertensive patients, which were analyzed using the Roter Interaction Analysis System. RESULTS: Compared with care-as-usual consultations, communication in the action plan condition resulted in an increased discussion of lifestyle issues whereas communication in the illness representation condition resulted in more discussion of patient concerns. In both experimental conditions the proportion of affective GP utterances was higher while patients contributed more to the conversation. When GPs changed their communication style, patients did accordingly. CONCLUSION: The explicit address of illness representations or action plans during consultations results in more attention to patient concerns and lifestyle issues and an overall improvement in patient-GP communication in terms of affective atmosphere and patient involvement. PRACTICE IMPLICATIONS: These findings show that after a brief training GPs are able to change their communication style in a way that allows for a more thorough consideration of patient self-management.

Deveugele M, Derese A, De Bacquer D, van den Brink-Muinen A, Bensing J, De Maeseneer J. Consultation in general practice: a standard operating procedure? Patient Educ Couns. 2004 Aug;54(2):227-33
(Primary Care, Belgium)
The objectives of this study were to describe the features of consultation within general practice with special attention to the differences between short, moderate and long consultations. An analysis of 2801 videotaped consultations of 183 General Practitioners from six countries participating in the Eurocommunication Study was made. The communicative behaviour was gauged by means of the Roter Interaction Analysis System. The consultation can be seen as a "standard operating procedure" consisting of 8% social behaviour, 15% agreement, 4% rapport building, 10% partnership building, 11% giving directions, 28% giving information, 14% asking questions and 7% counselling. A short consultation can be described as an encounter with a little bit of social behaviour to set the contact, medical questioning, giving directions for the further consultation and advises in order to solve the problem(s) mentioned. In a long consultation doctors take more time for a social talk, they give more attention to the relation or contact with the patient, they listen more extensively, especially to psychosocial problems, and they give more information.

Deveugele M, Derese A, De Bacquer D, van den Brink-Muinen A, Bensing J, De Maeseneer J. Is the communicative behavior of GPs during the consultation related to the diagnosis? A cross-sectional study in six European countries. Patient Educ Couns. 2004 Sep;54(3):283-9.
(Primary Care, Belgium)
The objectives of this study were to describe the features of consultation within general practice with special attention to the differences between short, moderate, and long consultations. An analysis of 2801 videotaped consultations of 183 General Practitioners in six countries participating in the Eurocommunication Study was made. The communicative behaviour was gauged by means of the Roter Interaction Analysis System. The consultation can be seen as a “standard operating procedure” consisting of 8% social behaviour, 15% agreement, 4% rapport building, 10% partnership building, 11% giving directions, 28% giving information, 14% asking questions and 7% counseling. A short consultation can be described as an encounter with a little bit of social behavior to set the contact, medical questioning, and giving directions for the further consultation and advises in order to solve the problem(s) mentioned. In a long consultation doctors take more time for social talk, they give more attention to the relation or contact with the patient, they listen more extensively, especially in psychosocial problems, and they give more information.

Deveugele M, Derese A, De Maeseneer J. Is GP-patient communication related to their perceptions of illness severity, coping and social support? Soc Sci Med. 2002 Oct;55(7):1245-53.
(Primary Care, Belgium)
The aim of the study was to explore the relationship between the communicative behaviour of general practitioner and patient on the one hand and the perception of the coping behaviour of the patient, the severity of the complaint and the presence of social support on the other hand. From 20 general practitioners (GP), 15 consultations per GP were videotaped and analysed using the Roter Interaction Analysis System. Doctors and patients rated their perceptions on questionnaires. The finding was that doctors and patients used predominantly task-oriented (instrumental) behaviour, with some exceptions. With older patients and patients with low social support the GPs used more affective communication, mainly consisting of social talk and mutual agreement. In the case of complex problems, the GP paid special attention to the relationship with the patient. Within the domain of instrumental communication, some differences between doctor and patient were observed. Although doctors and patients exchanged a lot of information about medical issues, patients gave information about their lifestyle and emotions, which the doctors did not verbally explore. In consultations where the patient perceived the complaint as severe, he or she was more focussed on the medical content. When the GP considered psychosocial issues important, doctor and patient communicated about lifestyle, emotions and social relations. This doctor-patient correlation was not found when patients perceived their problem as psychosocial.

Eide H, Frankel R, Haaversen AC, Vaupel KA, Graugaard PK, Finset A. Listening for feelings: identifying and coding empathic and potential empathic opportunities in medical dialogues. Patient Educ. Couns. 2004 Sep;54(3):291-7.
(Oncology, Norway)
The objective of the study was to validate the model of empathic opportunity (EO) and potential empathic opportunity (PEO) using the Roter Interaction Analysis System (RIAS) in a sample of cancer patients. Thirty-nine audio taped consultations at an outpatient oncology clinic performed by four oncologists were previously coded with the Roter Interaction Analysis System for another purpose. These consultations were also coded by two raters with the empathic and potential empathic opportunity method (E-PE-O method). The reliability of EO and PEO coding was satisfactory. Most of the Eos was found within the RIAS category “showing concern”. The PEOs were found in both the socio-emotional and the instrumental categories of the RIAS. We conclude that the E-PE-O method is a good starting point for studying the empathy process in oncology consultations.

Eide H, Graugaard P, Holgersen K, Finset A. Physician communication in different phases of a consultation at an oncology outpatient clinic related to patient satisfaction. Patient Educ Couns. 2003 Nov;51(3):259-66.
(Oncology, Patient Satisfaction, Norway)
The aim of this study was to identify the relationship between content during the different phases of the consultation and overall patient satisfaction with regular follow-up consultations at a cancer outpatient clinic. Thirty-six consultations were analysed with Roter Interaction Analysis System (RIAS). In the statistical analysis, timed events of the RIAS categories were used. The regular follow-up consultations were rather short aiming at discussing medical and therapeutic aspects of the illness. There was a positive correlation between physician informal talk (IT) and patient satisfaction in the history-taking phase. Patients were found to be dissatisfied if the physician had focused on a great deal of psychosocial exchange (PE) during physical examination. Our study suggests that the physician should not initiate discussion of psychosocial topics during physical exam. This result should be studied further in other samples and designs.

Eide H, Quera V, Finset A. Exploring rare patient behaviour with sequential analysis: an illustration. Epidemiol Psichiatr Soc. 2003 Apr-Jun;12(2):109-14.
(Interaction Analysis, Oncology, Norway)
AIMS: To illustrate the application of sequence analysis to the study of rare patient behaviour in physician-patient dialogue. The rare behaviour in question here is patients' expression of emotional cues and concerns. We investigate which physician behaviours precede and follow such expressions. METHODS: Thirty-five cancer-patient consultations performed by four oncologists (two male and two female) were analysed. The consultations were coded with the Roter Interaction Analysis System (RIAS). Sequence analysis by means of Sequential Data Interchange Standard (SDIS) and the Generalized Sequential Querier (GSEQ) was applied to the coded data. Lag analysis (using RIAS categories) was applied to associate the given behaviour (patient 'concerns') with target behaviours (physician utterances). RESULTS: For female physicians the significantly associated behaviour before the patient's expression of concern was reassurance, while male physicians also applied facilitation behaviour. After patients' expression of concern both reassurance and facilitating behaviour were shown by physicians of both genders. CONCLUSIONS: Sequence analysis appears to be a clinically meaningful and statistically sound method for analysing are patient utterances and associated physician behaviour.

Eide H, Quera V, Graugaard P, Finset A. Physician-patient dialogue surrounding patients' expression of concern: applying sequence analysis to RIAS. Soc Sci Med. 2004 Jul; 59(1):145-55.
(Interaction Analysis, Oncology, Norway)
The aim of this study was to analyze with sequence analysis physician-patient dialogue surrounding patients' expression of emotional cues. Two samples, sample 1 consisting of 36 cancer patient consultations conducted by four oncologists, and sample 2 consisting 79 consultations of haematology patients conducted by nine specialists, were audiotaped and coded with the Roter Interaction Analysis System (RIAS). Sequence analysis by means of a generalized sequential querier (GSEQ) was applied to the coded data. Lag sequential analysis (analyzed using RIAS categories) showed that certain behaviors of physicians corresponded with patients' expressions of concern. Physicians in both samples used silence and minimal encouragers before patient concern. The oncologists also used optimistic and affirming responses. The most common physician responses to patients' concern were minimal encouragers or affirming and optimistic responses. Sequence analysis based on RIAS coding appears to be a promising method for the study of doctor-patient dialogue and should be utilized more in studies of the communication process in medical consultations.

Ellington L, Baty BJ, McDonald J, Venne V, Musters A, Roter D, Dudley W, Croyle RT. Exploring Genetic Counseling Communication Patterns: The Role of Teaching and Counseling Approaches. J Genet Couns. 2006 Jun 15(3):179-89.
(Genetics Counseling, United States)
The educational and counseling models are often touted as the two primary professional approaches to genetic counseling practice. Yet, research has not been conducted to examine how these approaches are used in practice. In the present study, we conducted quantitative communication analyses of BRCA1 genetic counseling sessions. We measured communication variables that represent content (e.g., a biomedical focus) and process (e.g., passive listening) to explore whether genetic counselor approaches are consistent with prevailing professional models. The Roter Interaction Analysis System (RIAS) was used to code 167 pre-test genetic counseling sessions of members of a large kindred with an identified BRCA1 mutation. Three experienced genetic counselors conducted the sessions. Creating composite categories from the RIAS codes, we found the sessions to be largely educational in nature with the counselors and clients devoting the majority of their dialogue to providing biomedical information (62 and 40%, respectively). We used cluster analytic techniques, entering the composite communication variables and identified four patterns of session communication: Client-focused psychosocial, biomedical question and answer, counselor-driven psychosocial, and client-focused biomedical. Moreover, we found that the counselors had unique styles in which they combined the use of education and counseling approaches. We discuss the importance of understanding the variation in counselor communication to advance the field and expand prevailing assumptions.

Ellington L, Matwin S, Jasti S, Williamson J, Crouch B, Caravati M, Dudley W. Poison control center communication and impact on patient adherence. Clin Toxicol (Phila). 2008 Feb;46(2):105-9.
(Poison Control, Telephone, United States)
OBJECTIVE: This project explored the communication processes associated with poison control center calls. METHODS: In this preliminary study, we adapted the Roter Interaction Analysis System to capture staff-caller dialogue. This involved case selection, wherein adherence and non-adherence cases were selected; call linkage to medical records, where case records were linked with voice recordings; and application of Roter Interaction Analysis System to calls. RESULTS: Results indicate that communications are predominantly provider-driven. Patient age and percentage of staff partnership statements were significantly associated with adherence at the 0.05 level. Increases in age were associated with decreases in adherence to recommendations (p < 0.001). Increases in percentage of staff partnership statements (over all staff talk) were associated with increases in adherence (p = 0.013). CONCLUSION: This line of research could lead to evidence-based guidelines for effective staff-caller communication, increased adherence rates, and improved health outcomes.

Ellington L, Maxwel A, Baty BJ, Roter D, Dudley WN, Kinney AY. Genetic counseling communication with an African American BRCA1 kindred. Soc Sci Med. 2007 Feb;64(3):724-34.
(Genetics Counseling, United States)
We studied communication in genetic counseling sessions conducted with an African American, Breast Cancer 1, Early Onset (BRCA1) kindred in the USA. The Roter Interaction Analysis System (RIAS) was used to code and compare two sessions of 46 participants (26 females and 20 males) before and after they underwent genetic testing. Three certified genetic counselors and one medical geneticist conducted the sessions. When compared to pre-test communication, most of the providers' post-test communication was devoted to the provision of biomedical information (including screening recommendations) with fewer questions and psychosocial statements. Clients contributed a similar proportion to the total session dialogue in pre- and post-test sessions (40%). A larger proportion of their post-test session was devoted to indicating receptiveness to provider information than in the pre-test session. We found when providers were informing clients that they were BRCA1 mutation carriers, they provided more biomedical and psychosocial information and asked more psychosocial questions than when talking with non-carriers. This study provides the first description of genetic counseling communication for pre- and post-test BRCA1 sessions with African American individuals.

Ellington L, Roter D, Dudley WN, Baty BJ, Upchurch R, Larson S, Wylie JE, Smith KR, Botkin JR. Communication analysis of BRCA1 genetic counseling. J Genet Couns. 2005 Oct;14(5):377-86.
(Genetics Counseling, United States)
In this study, we apply an existing medical communication coding system to BRCA1 genetic counseling sessions, describe the session dynamics, and explore variation in session communication. The sample was comprised of 167 members of an identified BRCA1 kindred whose pretest counseling session was audiotaped and coded using Roter's Interaction Analysis System (RIAS). Three certified genetic counselors followed a research protocol that dictated areas to be covered in the counseling session. We found that it was feasible to code long, protocol driven BRCA1 sessions in a quantitative manner without the use of transcripts and capture the dialogue of all session participants. These findings support the use of RIAS in genetic counseling research. Our results indicate that these BRCA1 sessions were predominantly educational in nature with minimal dialogue devoted to psychosocial issues. We found that participant gender, presence of a client companion, and counselor identity influence session communication.

Ellington L, Wiebe DJ. Neuroticism, symptom presentation, and medical decision making. Health Psychol 1999 Nov;18(6):634-43.
(Primary Care, United States)
In 2 studies, the authors explored whether neuroticism influences illness descriptions in a manner that affects medical decisions. In Study 1, 80 participants presented an imagined illness that was high or low in severity to a confederate medical student. Neuroticism was associated with more elaborate symptom presentations and, among high-severity participants, with more disclosures of psychosocial information. In Study 2, representative videotapes from Study 1 were selected as stimuli to be evaluated by 14 family practice residents. Residents were able to discriminate between severity conditions for low- but not for high-neuroticism participants. Residents also viewed high-neuroticism participants as less credible, less in need of medical treatment, and more in need of mental health treatment than low-neuroticism participants. Correlations suggest the report of psychosocial concerns by high-neuroticism participants contributed to these effects.

Farquharson L, Noble LM, Barker C, Behrens RH. Health beliefs and communication in the travel clinic consultation as predictors of adherence to malaria chemoprophylaxis. Br J Health Psychol. 2004 May;9(Pt 2):201-17.
(Communication Skills, Adherence, United Kingdom)
OBJECTIVES: The objectives were, first, to determine whether adherence to malaria prophylaxis could be predicted by (i) health beliefs specified by the Health Belief Model and the Theory of Planned Behaviour, and (ii) communication during the consultation in a travel clinic; and secondly, to examine the impact of the consultation in changing travellers' health beliefs. DESIGN: A prospective study using regression analysis. METHODS: The participants were 130 consecutive travellers attending a travel medicine clinic. Health beliefs were measured pre- and post-consultation. The consultations were coded from audiotape using the Roter Interaction Analysis System and a content analysis method recording discussion about malaria and prophylaxis. Adherence was assessed by a follow-up telephone interview. RESULTS: Perceived susceptibility to malaria, perceived benefits of medication and intentions to adhere increased significantly as a result of the consultation, and the perceived permanent nature of side effects reduced significantly. At follow-up (N = 107), 62% reported full adherence, 25% partial adherence and 12% poor/no adherence. A multinomial logistic regression analysis revealed that perceived benefits of medication, length of stay, health professional discussion about adherence and travellers' questions and statements independently predicted reported adherence. CONCLUSIONS: Health beliefs and communication significantly predicted adherence in this setting. The findings also suggested qualitative differences between travellers who adhered fully, partially or poorly. Although the clinic consultation had a positive impact, emphasizing benefits of medication and resolving potential barriers to adherence could improve adherence in the population.

Fassaert T, van Dulmen S, Schellevis F, Bensing J. Active listening in medical consultations: Development of the Active listening observation scale (ALOS-global). Patient Education and Counseling. 2007Nov;68(3):258-64.
(Communications Skills, Netherlands)
OBJECTIVE: Active listening is a prerequisite for a successful healthcare encounter, bearing potential therapeutic value especially in clinical situations that require no specific medical intervention. Although generally acknowledged as such, active listening has not been studied in depth. This paper describes the development of the Active Listening Observation Scale (ALOS-global), an observation instrument measuring active listening and its validation in a sample of general practice consultations for minor ailments. METHODS: Five hundred and twenty-four videotaped general practice consultations involving minor ailments were observed with the ALOS-global. Hypotheses were tested to determine validity, incorporating patients' perception of GPs' affective performance, GPs' verbal attention, patients' self-reported anxiety level and gender differences. RESULTS: The final 7-item ALOS-global had acceptable inter- and intra-observer agreement. Factor analysis revealed one homogeneous dimension. The scalescore was positively related to verbal attention measured by RIAS, to patients' perception of GPs' performance and to their pre-visit anxiety level. Female GPs received higher active listening scores. CONCLUSION: The results of this study are promising concerning the psychometric properties of the ALOS-global. More research is needed to confirm these preliminary findings. PRACTICE IMPLICATIONS: After establishing how active listening differentiates between health professionals, the ALOS-global may become a valuable tool in feedback and training aimed at increasing listening skills.

Finset A, Graugaard PK, Holgersen K. Salivary cortisol response after a medical interview: the impact of physician communication behaviour, depressed affect and alexithymia. Patient Educ Couns. 2006 Feb;60(2):115-24. Epub 2005 Dec 28.
(Communication Skills, Norway)
OBJECTIVE: To explore if - and possibly how - a medical interview may affect adrenocortical activity in musculo-skeletal pain patients with and without alexithymia. METHODS: Female patients (N = 54) recruited from a patient organization for fibromyalgia completed the Toronto Alexithymia Scale (TAS-20) and subgroups with, respectively, low and high scores were selected for participation. Seven physicians conducted consultations attempting to vary their communication in accordance with given guidelines. All consultations were videotaped and analysed by The Roter Interaction Analysis System (RIAS) to evaluate the actual content of the consultations. RESULTS: An increase in depressed affect from pre- to post-interview was associated with relatively high cortisol levels 24 h after the consultation, but only in patients with alexithymia. Psychosocial questions from the physician were associated with increased depressed affect immediately following the interview, but not with cortisol responses at any time. CONCLUSION: In patients with deficient affect regulation, increase in depressed affect after a medical interview may be associated with delayed effects in adrenocortical activity, possibly mediated by rumination. PRACTICE IMPLICATIONS: Providers should be sensitive to potential deficits of affect regulation in their patients.

Ford S, Fallowfield L, Lewis S. Doctor-patient interactions in oncology. Soc Sci Med 1996 Jun;42(11):1511-9.
(Oncology, United Kingdom)
Studies which apply content analysis techniques to the cancer consultation are few. This descriptive study examines the structure and content of the bad news cancer consultations of 117 outpatients newly referred to the Medical Oncology Department of a large London teaching hospital. From previous communication research three main hypotheses are formed: (i) the cancer consultation is clinician-dominated rather than patient-centred; (ii) the level of psychosocial discussion between clinicians and patients is low and (iii) patient characteristics such as sex, age and prognostic category influence clinician behaviours. Each patient had two consultations with one of 5 oncologists. Both these were audiotaped with the patients' consent. The tapes were content coded using the Roter Interaction Analysis System. Results showed that clinicians tended to use closed rather than open questions. Patients asked few questions and were seldom given space to initiate discussion. Thus, the level of patient-centredness was low. Despite the fact that consultations concerned life threatening disease and often contained information regarding toxic treatment which is known to provoke psychological dysfunction, the number of questions relating to patients' psychological health were few. The amount of discussion concerning medical topics from both parties was 2.5 times greater than the amount of psychosocial discussion. Although there was a suggestion in the data that 3 clinicians showed variations in behaviour according to patient age and prognostic group, the number of patients for each doctor was small. Patients were well informed about their diagnosis, prognosis and treatment options, but their emotional well-being was rarely probed.

Ford S, Hall A, Ratcliffe D, Fallowfield L. The Medical Interaction Process System (MIPS): an instrument for analyzing interviews of oncologists and patient with cancer. Soc Sci Med 2000, 50(4): 553-566.
(Oncology, United Kingdom)
The increase in communication skills training for doctors has led to the need for more effective means of evaluation. Analysis of video and audio taped consultation using systems of interaction analysis can provide the trainee with in-depth feedback about their communication skills. Most interaction process systems were designed for use in primary care and recent research has questioned the applicability of these systems in medical specialties such as oncology. We describe the development of a new instrument, the Medical Interaction Process System (MIPS) for use in teaching communication skills and empirical research in medical encounters, particularly, between doctors and patients with cancer. A comparison of the MIPS and comparable behavior categories of another widely used system (the Roter Interaction Analysis System) was made to test convergent validity. Pearson correlation coefficients suggested a good level of concurrence between the two systems. Intercoder reliability tests were carried out between two coders at two separate time periods. Both of these indicated good reliability for the majority of categories. The two major advantages of the MIPS over other coding systems are: (1) the system allows for sequential and parallel coding, thus avoiding major coding conflicts and (2) the design of the coding sheet results in a multidimensional view of the consultation without data loss. We believe that the MIPS yields useful information for teaching doctors communication skills and also provides an objective method for evaluating the effectiveness of communication skills courses.

Garcia de Alba-Garcia JE, Rubel AJ, Moore CC, Marquez-Amezcua M, Casasola S, Von Glascoe C. [Article in Spanish]. Gac Med Mex 2002 Mar-Apr;138(2):211-6.
(Primary Care, Mexico)
The present work has as its purpose a description of the information exchanged during doctor-patient encounters immediately following diagnosis of pulmonary tuberculosis. To accomplish this nine such encounters were audiotape at two public health clinics in Guadalajara, Mexico. Communication of information and affect was evaluated by adapting the Roter interactional process analysis. Results show that the physician instructed the patient to behave in ways to prevent disease transmission while assuring patient recovery. Virtually lacking from these recordings is evidence of physician concern with the struggle patients experience to incorporate this regimen of directly observed therapy in to their daily lives. Because these sessions are managed by clinicians to encourage a unidirectional flow of information from physician to patient, the former fail to attain either patient cultural understanding of his/her disease process or comprehensive understanding of how he is affected she by the illness.

Garroutte EM, Kunovich RM, Buchwald D, Goldberg J. Medical communication in older American Indians: variations by ethnic identity. J Applied Gerontology, 2006 Feb; 25(1):27S-43S.
(American Indian, Ethnicity, United States)
The authors analyzed audiotapes from 102 patients of American Indian race (>50 years) to explore how ethnic identity influences medical communication. A standardized interaction analysis system was used to classify patient utterances into categories: information-giving, questions, social talk, positive talk, negative talk. The authors identified patient subgroups distinguished by level of identification with American Indian and White identity and explored whether some subgroups devoted more communication to certain categories of talk. Patients highly affiliated with American Indian identity devoted a significantly greater percentage of communication to “positive talk” – including statements of optimism, reassurance, and agreement—than patients identifying at lower levels (p>.05). They devoted less communication to “negative talk,” including corrections, disagreements, and anxiety statements (p>.05). Effects persisted after adjustment for confounders, including health status. Patterns may encourage providers to underestimate distress and overestimate satisfaction and comprehension in patients highly affiliated with American Indian identity.

Ghods BK, Roter DL, Ford DE, Larson S, Arbelaez JJ, Cooper LA. Patient-physician communication in the primary care visits of African Americans and whites with depression. J Gen Intern Med. 2008 May;23(5):600-6. Epub 2008 Feb 9.
(Primary Care, Racial Disparities, Depression, United States)
BACKGROUND: Little research investigates the role of patient-physician communication in understanding racial disparities in depression treatment. OBJECTIVE: The objective of this study was to compare patient-physician communication patterns for African-American and white patients who have high levels of depressive symptoms. DESIGN, SETTING, AND PARTICIPANTS: This is a cross-sectional study of primary care visits of 108 adult patients (46 white, 62 African American) who had depressive symptoms measured by the Medical Outcomes Study-Short Form (SF-12) Mental Component Summary Score and were receiving care from one of 54 physicians in urban community-based practices. MAIN OUTCOMES: Communication behaviors, obtained from coding of audiotapes, and physician perceptions of patients' physical and emotional health status and stress levels were measured by post-visit surveys. RESULTS: African-American patients had fewer years of education and reported poorer physical health than whites. There were no racial differences in the level of depressive symptoms. Depression communication occurred in only 34% of visits. The average number of depression-related statements was much lower in the visits of African-American than white patients (10.8 vs. 38.4 statements, p = .02). African-American patients also experienced visits with less rapport building (20.7 vs. 29.7 statements, p = .009). Physicians rated a higher percentage of African-American than white patients as being in poor or fair physical health (69% vs. 40%, p = .006), and even in visits where depression communication occurred, a lower percentage of African-American than white patients were considered by their physicians to have significant emotional distress (67% vs. 93%, p = .07). CONCLUSIONS: This study reveals racial disparities in communication among primary care patients with high levels of depressive symptoms. Physician communication skills training programs that emphasize recognition and rapport building may help reduce racial disparities in depression care.

Gilbert DA, Hayes E. Communication and outcomes of visits between older patients and nurse practitioners. Nurs Res. 2009 Jul-Aug;58(4):283-93.

(Nursing, Geriatrics, United States)
BACKGROUND: Effective patient-clinician communication is at the heart of good healthcare and may be even more vital for older patients and their nurse practitioners (NPs). OBJECTIVES: The objectives of this study were to examine 1) contributions of older patients' and NPs' characteristics and the content and relationship components of their communication to patients' proximal outcomes (satisfaction and intention to adhere) and longer term outcomes (changes in presenting problems, physical health, and mental health), and 2) contributions of proximal outcomes to longer term outcomes. METHODS: Visits were video-recorded for a statewide sample of 31 NPs and 155 older patients. Patients' and NPs' communications during visits were measured using the Roter Interaction Analysis System for verbal activities, a check sheet for nonverbal activities, and an inventory of relationship dimension items. Proximal outcomes were measured with single items after visits. At 4 weeks, change in presenting problems was measured with a single item, and physical and mental health changes were measured with the SF-12 Version 2 Health Survey. Mixed-model regression with backward deletion was conducted until only predictors with p < or = .05 remained in the models. RESULTS: With the other variables in the models held constant, better outcomes were related to background characteristics of poorer baseline health, nonmanaged care settings, and more NP experience; to a content component of seeking and giving biomedical and psychosocial information; and to a relationship component of more positive talk and greater trust and receptivity and affection, depth, and similarity. Poorer outcomes were associated with higher rates of lifestyle discussion and NPs' rapport building that patients may have perceived to be patronizing. Greater intention to adhere was associated with greater improvement in presenting problems. DISCUSSION: Older patient-NP communication was effective regarding seeking and giving biomedical and psychosocial information other than that involving lifestyle. Studies of ways to improve older patient-NP lifestyle discussions and rapport building are needed.

Gordon GH, Joos SK, Byrne J. Physician expression of uncertainty during patient encounters. Patient Education and Counseling 2000;40:59-65.
(Primary Care, United States)
Uncertainty is inherent in clinical medicine and may contribute to variability in physician practice patterns, patient satisfaction, and exchange of information. However, research on physician disclosure of uncertainty to patients is sparse. We measured the frequency of physician expressions of uncertainty to patients using audiotapes of visits to 43 physicians by 216 continuity patients in a university-affiliated general medicine clinic. We also analyzed the audiotapes using Roter Interaction Analysis. Physicians completed Gerrity's Physician's Reaction to Uncertainty scale and patients completed the Kranz Health Opinion Survey and a standardized satisfaction questionnaire. Physicians made verbal expressions of uncertainty in 71% of clinic visits. Physicians with greater self-rated reluctance to disclose uncertainty to patients made fewer expressions. Physicians who made more uncertainty expressions also used more positive talk and partnership building, and gave more information to patients. Physicians also expressed more uncertainty to patients with more education, greater desire for information, and more questions. Physician uncertainty expression were associated with greater patient satisfaction, but not independently of other physician verbal behaviors that were also associated with satisfaction.

Graugaard PK, Eide H, Finset A. Interaction analysis of physician-patient communication: the influence of trait anxiety on communication and outcome. Patient Educ Couns. 2003 Feb;49(2):149-56.
(Communication Skills, Norway)
Little attention has been paid to how patients' personality traits interfere with the communication and the outcome of physician-patient interaction. We performed an experimental study with students with high and low trait anxiety as patients. One physician conducted a single consultation with 41 students applying two beforehand-specified consultation styles. Patients completed questionnaires concerning emotional state and satisfaction. The actual content of the consultations was analyzed by Roter interaction analysis system (RIAS). The physician gave more biomedical information to low-anxiety students than high-anxiety students. Students who provided a lot of biomedical information themselves were less tense after the consultation. However, students with high anxiety were more dependent on the physician actively asking biomedical questions for them to be able to deliver that same information. In contrast to low-anxiety students, those with high anxiety were less satisfied after consultations involving many psychosocial questions posed by the physician and a good deal of emotional talk on their own part. Compared to low-anxiety students, students with high anxiety were less satisfied and tenser after consultations with much positive emotional talk on the part of the physician. We conclude that physicians and educators should be aware that psychological and emotional communication may be experienced as intrusive and inappropriate by patients with high trait anxiety when they present minor somatic problems.

Graugaard PK, Holgersen K, Eide H, Finset A. Changes in physician-patient communication from initial to return visits: a prospective study in a haematology outpatient clinic. Patient Educ Couns. 2005 Apr;57(1):22-9.
(Communication Skills, Norway)
Limited research has investigated how physician-patient interaction changes over time. We have therefore examined physician-patient communication during the two initial, as well as the seventh (on average) patient visit to a haematology outpatient clinic. Consultations were audio taped and analyzed using the Roter interaction analysis system (RIAS). Patients completed the Impact of Events Scale (IES) before and a satisfaction questionnaire after each consultation. Consultations were generally physician dominated and task-focused. While the amount of task-focused communication was significantly reduced between the initial and the return visits, the amount of socio-emotional communication remained quite stable. In return visits (but not in the two initial visits), patients with more severe diagnoses were given longer consultations and they provided more task-focused information to a less verbally dominant physician. Patients were more satisfied in the second and return visits (but not in the first), if consultations contained greater levels of socio-emotional communication.

Graugaard PK, Holgersen K, Finset A. Communicating with alexithymic and non-alexithymic patients: an experimental study of the effect of psychosocial communication and empathy on patient satisfaction. Psychother Psychosom. 2004 Mar-Apr;73(2):92-100.
(Communication Skills, Norway)
BACKGROUND: Previous studies have shown that alexithymia is associated with a wide range of somatic and psychiatric conditions. The aim of this study was to investigate experimentally how psychosocial communication and empathic response from the physician affects satisfaction in alexithymic and non-alexithymic patients. METHOD: Seven physicians and 65 female patients from a fibromyalgia patient association participated in the study. The Toronto Alexithymia Scale (TAS-20) was used to categorise patients as alexithymic or non-alexithymic. Patients also completed questionnaires regarding trait anxiety and satisfaction with their consultation. Physicians were instructed to differentiate their communication in terms of both psychosocial matters and empathic response. The content of the consultation was analysed using the Roter Interactional Analysis System. RESULTS: Regression analyses revealed that alexithymic patients were significantly more satisfied when they received a greater empathic response from the physician. Non-alexithymic patients, however, were more satisfied when the consultation was of longer duration. Psychosocial communication did not have any statistically significant effect on satisfaction in either of the two subgroups. CONCLUSIONS: Verbalised empathic response from the physician may be crucial for the alexithymic patient's post-consultation satisfaction and may thereby become the basis for a solid treatment alliance. The validity of this hypothesis should be tested in different clinical settings and with different patient populations. Future research on alexithymic patients' response to psychosocial communication may benefit from determining to what extent this communication is concerned with general distress or more complex emotional phenomena.

Hall JA, Irish JT, Roter DL, Ehrlich CM, Miller LH. Gender in medical encounters: an analysis of physician and patient communication in a primary care setting. Health Psychol 1994 Sep;13(5):384-92.
(Primary Care, Gender and Patient Satisfaction, United States)
The relation of physician and patient gender to verbal and nonverbal communication was examined in 100 routine medical visits. Female physicians conducted longer visits, made more positive statements, made more partnership statements, asked more questions, made more back-channel responses, and smiled and nodded more. Patients made more partnership statements and gave more medical information to female physicians. The combinations of female physician-female patient and female physician-male patient received special attention in planned contrasts. These combinations showed distinctive patterns of physician and patient behavior, especially in nonverbal communication. We discuss the relation of the results to gender differences in nonclinical settings, role strains in medical visits, and current trends in medical education.

Hall JA, Irish JT, Roter DL, Ehrlich CM, Miller LH. Satisfaction, gender, and communication in medical visits. Med Care 1994 Dec;32(12):1216-31.
(Primary Care, Gender and Patient Satisfaction, United States)
The authors conducted two studies of routine medical visits, investigating the relation of physician gender, patient gender, and physician age to patient satisfaction, and the correlations between communication behaviors and satisfaction separately for different combinations of patient and physician gender. Study 1 was based on videotaped visits to a hospital-based internal medicine practice (n = 97 visits). Study 2 was based on audiotaped visits to 11 different community and hospital-based practices in the United States and Canada (n = 524 visits). In both studies, patients examined by younger physicians, especially younger female physicians, reported lower ratings of satisfaction. These findings were true for male and female patients; however, in both studies, the lowest satisfaction in absolute terms was among male patients examined by younger female physicians. The effects were not explained by patient and physician background characteristics or by measured communication during the visit. Correlations between verbal and nonverbal communication and satisfaction for different combinations of physician and patient gender suggested that gender-related values and expectations influence patients' reactions to physicians' behavior. There also was evidence that patient satisfaction is reflected in the patient's affective behavior during the visit.

Hall JA, Milburn MA, Roter DL, Daltroy LH. Why are sicker patients less satisfied with their care? Test of two explanatory models. Health Psychol 1998 Jan;17(1):70-5.
(Primary Care, United States)
Two explanations were tested for why patients who are less healthy tend to be less satisfied with their medical care than healthier patients. The explanations were (a) that poor health produces dissatisfaction directly and (b) that poor health produces dissatisfaction through the mediating effect of physicians' behavior. Two studies are presented that measured patients' health status, patients' satisfaction with care, and their physicians' communication as recorded on audiotape. In Study 1, 114 patients had first visits with rheumatologists; in Study 2, 649 patients had continuing-care visits with physicians in internal and family medicine. Causal modeling revealed that the first study supported the direct explanation. The second study also supported the direct explanation, as well as the mediation explanation with respect to the physician's use of social conversation.

Hall JA, Roter DL. Physicians' knowledge and self-reported compliance promotion as predictors of performance with simulated lung disease patients. Evaluation and The Health Professions 1988 Sept;11(2):306-3l7.
(Primary Care, Communication Skills Training, United States)
Scores on a test of knowledge of chronic lung disease and self-reports of actions to enhance compliance in chronic-disease patients were obtained from 42 primary-care pysicians. Two years later each physician was audiotaped during encounters with two simulated lung disease patients. Transcripts were used to score physician performance and to analyze communication. Audiotapes of the encounters were also played to role-playing subjects (N=252) to ascertain likely patient outcomes. More knowledgeable physicians displyed more clinical expertise, gave more patient education, engaged in less social-emotional talk, and induced more satisfaction and recall by role-playing subjects. Physicians who said they worked harder to achieve compliance were shown to be more likely to ask more appropriate open-ended questions; ask more questions; offer less patient education; give more directions and instructions; and make more utterances.

Hall JA, Roter DL. Patient gender and communication with physicians: results of a community-based study. Womens Health 1995 Spring;1(1):77-95
(Primary Care, Gender, United States)
An observational study of 648 routine medical visits with 69 physicians examined patient gender in relation to patient and physician communication, patient preference for the physician's communication style, patient satisfaction, and the physician's awareness of the patient's satisfaction. Data consisted of audiotapes as well as patient and physician questionnaires. Women appeared to be more actively engaged in the talk of medical visits--they sent and received more emotionally charged talk and were judged by independent raters as more anxious and interested both globally and in terms of voice quality than men. Consistent with the more emotional talk, women reported preferring a more "feeling-oriented" physician than male patients did. Mean levels of satisfaction with communication did not differ by gender, and communication predictors of satisfaction were similar for male and female patients, although they were stronger for male patients. Physicians were significantly less aware of some aspects of female patients' satisfaction compared to male patients' satisfaction. In light of the weaker correlations between patients' communication and their satisfaction for women, we suggest that women provided fewer obvious cues to their satisfaction. Training in communication skills may increase open discussion about feelings and emotions and may also produce greater physician sensitivity to patients' satisfaction, particularly with female patients.

Hall JA, Roter DL, Katz NR. Task versus socioemotional behaviors in physicians. Med Care. 1987 May;25(5):399-412.
(Primary Care, United States)
This paper investigates associations among physicians' task-oriented and socioemotional behaviors during the medical encounter. The study is an analogue, using as source data the audiotapes and transcripts of two standardized patient cases presented by trained patient simulators to 43 primary care practitioners. Transcripts were scored for physician proficiency and were content-analyzed to assess the process of communication and information content. Physicians' speech errors were counted, and vocal affect ratings were made of filtered audiotape excerpts. Physician communications reflected by these measures were classified as task-oriented or socioemotional. Findings indicated: 1) Most aspects of physician style were reliable across visits. 2) Physicians adopted either a patient-oriented or a physician-oriented approach to task performance, as characterized by giving information and counseling versus giving directions and asking questions, respectively. 3) Verbal and nonverbal socioemotional measures were not related. 4) Physicians tended to adopt either a style characterized by information-giving and proficiency or a social orientation with patients. 5) Physicians who were more medically informative had more interested and anxious voices compared with the less informative physicians. Thus, although the more medically informative physicians spent less time making socioemotional utterances, they had a voice quality that may compensate for that neglect.

Hall JA, Roter DL, Milburn MA, Daltroy LH. Patients' health as a predictor of physician and patient behavior in medical visits: A synthesis of four studies. Med Care 1996 Dec;34(12):1205-18.
(Primary Care, United States)
OBJECTIVES: Although some patient characteristics are known to be related to physician and patient communication in medical encounters, very little is known about the impact of patients' health status on communication processes. The authors assess relations of patients' physical and emotional health status to verbal and nonverbal communication between physicians and patients in four original studies, and combine results across the four studies using meta-analytic procedures. METHODS: In four original studies of routine outpatient visits (consisting of more than 250 physicians and more than 1,300 patients), health status was measured and audiotape or videotape records were coded for verbal content and nonverbal cues indicating task-related behavior and affective reactions on the part of both the physician and the patient. Both physical and mental health data were obtained, using physicians and/or patients as sources; in two studies, physicians' satisfaction with the visit also was measured. All available background characteristics for both physicians and patients were controlled via partial correlations. The meta-analytic procedures used were the unweighted and weighted (by sample size) average partial correlations, the combined P across studies (Stouffer method), and the test of effect size heterogeneity. RESULTS: Physicians showed signs of negative response to sicker or more emotionally distressed patients, both in their behavior and in their ratings of satisfaction with the visit. Sicker patients also behaved more negatively than healthier patients. However, physicians also engaged in a variety of positive and professionally appropriate behaviors with the sicker or more distressed patients. This mixed pattern of responses is discussed in terms of alternative frameworks: the physician's goals, reciprocation of affect, and ambivalence on the part of the physician. CONCLUSIONS: The patient's health status appears to influence physician-patient communication. In clinical practice, increased attention by physicians to their own and their patients' behavior may enhance diagnosis and prevent misunderstandings.

Hall JA, Roter DL, Rand CS. Communication of affect between patient and physician. J Health Soc Behav 1981 Mar;22(1):18-30.
(Primary Care, United States)
The purpose of this research was to identify patterns of patient-provider communication, in particular combinations of verbal and nonverbal (vocal) expression during the medical visit, that are associated with patient contentment with the visit and appointment-keeping. The data used in the analyses were tape recordings of 50 patient-physician interactions during routine medical visits for chronic disease. The interactions, which were rated by 144 judges, were assessed in three conditions: electronically filtered speech (voice only), original speech (voice and words), and transcripts (words only). Among the affective aspects rated were anger, anxiety, dominance, sympathy, assertiveness, and businesslike manner. Findings indicate that the patient's contentment with the medical visit is related to the ratings of the physician's communication, but that the relationship for the physician's verbal communication is opposite that for the physician's nonverbal communication. When the physician sounds (in filtered speech) more negative--more angry, more anxious, and less as though the patient would return--the patients are more content. But when the physician utters words (judged in transcripts) that are less anxious and more sympathetic, patients are more content. The patient's return for subsequent appointments is also associated with the physician's expression of anger and anxiety in original (unfiltered) speech. Patients who return for appointments express mixed affects in the different conditions--more satisfied and less anxious in words and original speech, but less satisfied in voice tone. Since affect, in this study, appears to be reciprocated, we suggest that negative physican affect expressed in voice tone with positive affect communicated through words is interpreted by patients in an overall positive manner, as probably reflecting perceived seriousness and concern on the part of the physician.

Hampson SE, McKay HG, Glasgow RE. Patient-physician interactions in diabetes management: consistencies and variation in the structure and content of two consultations. Patient Educ Couns 1996 Oct;29(1):49-58.
(Primary Care, United Kingdom)
The structure and content of medical consultations concerning diabetes were examined in two, successive quarterly medical consultations between two physicians and their diabetes patients (N = 44). The consultations were audio-taped and coded for structure (e.g. question asking, information giving) using a modified version of the Roter Interactional Analysis System (inter-coder correlations typically exceeded 0.90 for the composite variables derived from the coding system). The tapes were also coded for content by monitoring the topics discussed (e.g. diet, medication, exercise). The majority of the interactions consisted primarily of information giving and positive talk on the part of both patients and providers. Nutrition-related issued, blood glucose monitoring, medication and exercise were addressed in the majority of interactions, but other regimen areas such as foot care, smoking habits, and alcohol were seldom discussed. There was little stability across the two consultations in terms of either structure (median test-retest correlation = 0.24) or content (majority of test-retest correlations were below 0.30). The importance of studying more than one patient-physician encounter when studying interaction style and content is discussed, as is the need for investigation of interactions between non-physician health care providers and patients with chronic disease.

Helitzer DL, Lanoue M, Wilson B, de Hernandez BU, Warner T, Roter D. A randomized controlled trial of communication training with primary care providers to improve patient-centeredness and health risk communication. Patient Educ Couns. 2011 Jan;82(1):21-9. Epub 2010 Mar 12.
(Communication Skills Training, Primary Care, United States)
OBJECTIVE: To determine the efficacy and effectiveness of training to improve primary care providers' patient-centered communication skills and proficiency in discussing their patients' health risks. METHODS: Twenty-eight primary care providers participated in a baseline simulated patient interaction and were subsequently randomized into intervention and control groups. Intervention providers participated in training focused on patient-centered communication about behavioral risk factors. Immediate efficacy of training was evaluated by comparing the two groups. Over the next 3 years, all providers participated in two more sets of interactions with patients. Longer term effectiveness was assessed using the interaction data collected at 6 and 18 months post-training. RESULTS: The intervention providers significantly improved in patient-centered communication and communication proficiencies immediately post-training and at both follow-up time points. CONCLUSIONS: This study suggests that the brief training produced significant and large differences in the intervention group providers which persisted 2 years after the training. PRACTICE IMPLICATIONS: The results of this study suggest that primary care providers can be trained to achieve and maintain gains in patient-centered communication, communication skills and discussion of adverse childhood events as root causes of chronic disease.

Hunfeld JA, Leurs A, De Jong M, Oberstein ML, Tibben A, Wladimiroff JW, Wildschut HI, Passchier J. Prenatal consultation after a fetal anomaly scan: videotaped exploration of physician's attitude and patient's satisfaction. Prenat Diagn. 1999 Nov;19(11):1043-7.
(Prenatal Consultation, Satisfaction and Recall, Netherlands)
The main aim of the study was to evaluate the relationship between the physician's attitude (using the non-verbal Global Affective Measure of the Roter Analaysis System and the Counselor Rating Form-short version) and the satisfaction of the pregnant women with the prenatal consultation. A secondary aim was to evaluate the women's recall of essential information (i.e. location, severity, prognosis and cause of the anomaly). To this end, 24 prenatal consultations (pregnant women, partners and physicians) were videotaped following a fetal anomaly scan, and a few days later, the pregnant women completed questionnaires to assess their perception of the physician's attitude and their satisfaction with the consultation and the extent to which they could recall the essentials of the information given about the fetal anomaly. In descending order, the physician's dominance/assertiveness (i.e. being self-confident and decisive) (assessment of the videotapes by two psychologists), trustworthiness (women's report) and expertise were significantly positively associated with the women's overall satisfaction, i.e. satisfaction with the information given and affective behaviour on the part of the physician during the prenatal consultation. All the women (n=24) recalled the essentials of the information given about the location of the fetal anomaly. The majority of them correctly reproduced the severity, the prognosis and the cause of the anomaly. Our findings indicate that women in whom a fetal anomaly has been detected derive particular benefit from a self-confident, decisive, expert and trustworthy physician.

Hunfeld JA, Leurs A, De Jong M, Oberstein ML, Tibben A, Wladimiroff JW, Wildschut HI, Passchier J. Prenatal consultation after a fetal anomaly scan: videotaped exploration of physician's attitude and patient's satisfaction. Prenat Diagn 1999 Nov;19(11):1043-7.
(Patient Satisfaction, Netherlands)
The main aim of the study was to evaluate the relationship between the physician's attitude (using the non-verbal Global Affective Measure of the Roter Analysis System and the Counselor Rating Form-short version) and the satisfaction of the pregnant women with the prenatal consultation. A secondary aim was to evaluate the women's recall of essential information (i.e. location, severity, prognosis and cause of the anomaly). To this end, 24 prenatal consultations (pregnant women, partners and physicians) were videotaped following a fetal anomaly scan, and a few days later, the pregnant women completed questionnaires to assess their perception of the physician's attitude and their satisfaction with the consultation and the extent to which they could recall the essentials of the information given about the fetal anomaly. In descending order, the physician's dominance/assertiveness (i.e. being self-confident and decisive) (assessment of the videotapes by two psychologists), trustworthiness (women's report) and expertise were significantly positively associated with the women's overall satisfaction, i.e. satisfaction with the information given and affective behaviour on the part of the physician during the prenatal consultation. All the women (n=24) recalled the essentials of the information given about the location of the fetal anomaly. The majority of them correctly reproduced the severity, the prognosis and the cause of the anomaly. Our findings indicate that women in whom a fetal anomaly has been detected derive particular benefit from a self-confident, decisive, expert and trustworthy physician.

Innes M, Skelton J, Greenfield S. A profile of communication in primary care physician telephone consultations: application of the Roter Interaction Analysis System. Br J Gen Pract. 2006 May;56(526):363-8.
(Telephone Consultations, United Kingdom)
BACKGROUND: Telephone consultations are a part of everyday practice, there is surprisingly little research on the subject. AIM: To describe the variation of consulting skills within a body of telephone consultations in primary care, highlighting the performance of one method of assessing the process of the consultation-- the Roter Interaction Analysis System-- with telephone consultations. DESIGN OF STUDY: Cross sectional study of 43 recordings of telephone consultations with GPs. SETTING: One rural county in the Midlands. METHOD: Recordings were made of 8 GPs, purposively selected for maximum variance in one region of the UK. Forty-three consultations were coded using the Roter Interaction Analysis System. From the descriptive categories, six composite categories were compiled reflecting a number of domains of interaction in a consultation: rapport, data gathering, patient education and counselling, partnership building, doctor dominance and patient-centredness. Analysis of variance was undertaken to explain variations between consultations for the different domains. Comparison was made to findings from similar work for face-to-face consultations. RESULTS: These telephone consultations feature more biomedical information exchange than psychosocial or affective communication. Length of interaction accounts for much of the variation seen between consultations in the domains of rapport, data gathering, patient education and counselling and partnership. Male doctors are more patient centred in this study. There is the suggestion of more doctor dominance and a less patient-centred approach when comparisons are made with previous work on face-to-face consultations. CONCLUSIONS: Although the telephone is increasingly being used to provide care, this study highlights the fact that telephone consultations cannot be taken as equivalent to those conducted face to face. More work needs to be done to delineate the features of telephone consultations.

Inui TS, Carter WB, Kukull WA, Haigh VH. Outcome-based doctor-patient interaction analysis: I Comparison of techniques. Med Care 1982 Jun;20(6):535-49.
(Patient Recall or Satisfaction, United States)
Interactional analysis (IA) systems have been devised and applied to doctor-patient dialogues to describe encounters and to relate process to outcomes. Prior work in this area has been typified by the use of a single taxonomy for classifying verbal behaviors and limited outcomes (compliance and/or satisfaction). We applied three different IA systems (Bales, Roter's modified Bales with affective ratings, and Stiles' "Verbal Response Modes") to 101 new-patient visits to a general medical clinic for which multiple outcomes had been determined: several measures of patient knowledge of problems at conclusion of visit; patient compliance with drugs (over the ensuing three months); and patient satisfaction with the visit (perceived technical, interpersonal and communication quality). Within IA systems, cross tabulations and multiple regressions were performed to relate encounter events to outcomes. Across IA systems, multiple regression R2 and R2 adjusted (R2a) for the number of independent variables entering were used to characterize strength of relationships. Roter's IA system showed stronger relationships to outcomes of knowledge (41% R2, 27% R2a) and compliance (44% R2, 28% R2a) than did Bales' or Stiles' systems. R2 for patient satisfaction was identical for Bales and Roter (35%), and greater than R2 for Stiles (14%). We conclude that choice of IA system for research or teaching purposes should be based on behaviors and outcomes of particular interest and importance to the user. Based on audioreview of tapes, Roter's approach is less time-consuming and may perform as well as more complex systems requiring transcript analysis.

Ishikawa H, Hashimoto H, Roter DL, Yamazaki Y, Takayama T, Yano E. Patient contribution to the medical dialogue and perceived patient-centeredness. An observational study in Japanese geriatric consultations. J Gen Intern Med. 2005 Oct;20(10):906-10.
(Geriatrics, Companions, Japan)
BACKGROUND: Relatively few studies have directly addressed the interaction dynamics and consequences of a companion's presence in the medical visit, and their findings have been contradictory. OBJECTIVES: To examine how patient's contribution to the medical dialogue, with or without the presence of a visit companion, is related to the perception of the medical visit as patient-centered. DESIGN: Observational study using pre- and postvisit questionnaires and audiotape recording of medical visits. PARTICIPANTS: One hundred and fifty-five patients aged 65 or over; 63 in medical visits that included the presence of a companion and 82 in visits that did not include a companion. MAIN OUTCOME MEASURE: Patient ratings of visit patient-centeredness. RESULTS: Long visits (greater than 10 minutes long) and visits in which patients were verbally active were rated as more patient-centered by patients than other visits. Since patients were generally less verbally active in visits that included a companion, accompanied visits, especially if they were less than 10 minutes long, received lower patient-centered ratings than others. The presence of a companion was not related to length of the visit, suggesting that the verbal activity of the companion was off-set by decreased verbal activity of the patient. CONCLUSIONS: Our results have suggested that patients are more likely to perceive their physician and visit as patient-centered when they have an opportunity to engage directly in the medical dialogue. A minimal amount of "talk-time" for patients themselves should be safeguarded even in a short visit, when a companion is present.

Ishikawa H, Roter DL, Yamazaki Y, Hashimoto H, Yano E. Patients' perceptions of visit companions' helpfulness during Japanese geriatric medical visits. Patient Educ Couns. 2006 Apr;61(1):80-6.
(Geriatrics, Companions, Japan)
OBJECTIVE: Elderly patients are often accompanied during medical visits by a companion, usually a family member. This study explores the association between patients' expectations regarding the communication role of their companions, and the role intended and taken by companions during the medical visits, on patient perceptions of companion helpfulness. METHODS: Participants included 63 patients aged 65 or over who were under continuous care of nine attending physicians at a university-affiliated geriatric clinic in Tokyo, and their companions during the medical visit. These medical visits were audiotape recorded and coded using a Japanese translation of the Roter Interaction Analysis System (RIAS). RESULTS: The discrepancy between what patients expected of their companions, and what companions intended and actually did during the visit, predicted patient ratings of companion helpfulness. It was especially noteworthy that the highest ratings of companion helpfulness occurred when patients expected their companion to be actively involved in communication and they were. However, if the patient anticipated only a limited companion role, the companion was not viewed as very helpful regardless of the role they played. DISCUSSION: There would be a largely unexploited potential for improving communication effectiveness through the optimal engagement of companions in visit communication.

Ishikawa H, Roter DL, Yamazaki Y, Takayama T. Physician-elderly patient-companion communication and roles of companions in Japanese geriatric encounters. Soc Sci Med. 2005 May;60(10):2307-20.
(Geriatrics, Companions, Japan)
Although the triadic encounter of physician, patient, and an accompanying family member is a common phenomenon in geriatrics, previous research on the communication in medical encounters has primarily focused on dyadic interactions between physician and patient. This study aimed to explore the triadic communication and communication roles of patient companions in Japanese geriatric encounters. Among elderly patients aged 65 or over who were under continuous care of nine attending physicians at a university affiliated geriatric clinic in Tokyo, 63 accompanied patients and 82 unaccompanied patients were included for this study. The consultation was audiotape recorded and analyzed using the Roter Interaction Analysis System (RIAS) with additional categories developed to code aspects of companion communication. In dyadic encounters, the average proportions of physician's talk and patient's talk were 54% and 46%, respectively, while in triadic encounters the average talk proportions of physician, patient, and companion were 49%, 29%, and 22%. Companions made a significant contribution to the communication during the visit by providing information and asking the physician questions, as well as facilitating patient's talk. The companion's communication may influence not only the patient's but also the physician's communication. The patient's expectation of the companion's role during the visit and the companion's intention regarding their role were generally related to one another, and had positive associations with the companion's actual behavior during the visit. Nevertheless, companions often anticipated playing a more direct communication role during the visit, including the provision of information and asking of questions, than patients expected of them. Further investigation is needed to explore the communication dynamics in triads and dyads, and its relation to patient outcomes.

Ishikawa H, Takayama T, Yamazaki Y, Seki Y, Katsumata N. Physician-patient communication and patient satisfaction in Japanese cancer consultations. Soc Sci Med 2002;55:301-311.
(Oncology, Japan)
Over the past few decades, physician-patient communication has been intensively studied in western countries, because of its importance for the physician-patient relationship and patient health outcomes. Although various concepts and models of this relationship have recently been introduced in Japan, there are few studies on Japanese physician-patient interaction. The purpose of this study is to describe characteristics of physician-patent communication in a Japanese cancer consultation, and to examine the relation of this interaction with patient satisfaction. One hundred and forty cancer outpatients and twelve physicians were included. The Roter Interaction Analysis System (RIAS), one of the most frequently used systems for analyzing physician-patient interaction, was applied. Physicians made more utterances directing the interaction than patients did, and their discussion was largely focused on biomedical topics. It can be concluded that the structure of the physician-patient interaction in our study was basically similar to those in previous western studies, although some differences were also found. The relation between physician-patient communication and patient satisfaction was generally consistent with previous studies. Patients were more satisfied with consultations in which the physician used more open-ended questions. On the other hand, physician direction and encouragement was negatively associated with patient satisfaction. Also, patients who asked more questions were less satisfied with the consultation.

Ishikawa H, Takayama T, Yamazaki Y, Seki Y, Katsumata N, Aoki Y. The interaction between physician and patient communications in Japanese cancer consultations and the influence of personal and consultation characteristics. Patient Educ Couns 2002 Apr;46(4):277-85.
(Oncology, Japan)
The communications of physician and patient vary with the characteristics of patient and consultation, as well as the communications of the counterpart. The purpose of this study is to explore the interaction between physician and patient communications in Japanese cancer consultation in view of the influence of patient and consultation characteristics. One hundred and forty cancer outpatients and 12 physicians were included in this study. The Roter Interaction Analysis System (RIAS) was used to analyze the physician-patient interaction. Patient information giving was positively related to physician facilitation, while patient question asking and emotional expression were associated with the warm and empathetic attitude of the physician. On the other hand, the encouraging statements of the physician were greater in shorter consultations, which implies physicians might have interrupted patients with encouragement before thoroughly listening to the patients concern. Further investigation is needed to confirm the causal relationships of these interactions.

Ishikawa H, Yano E, Fujimori S, Kinoshita M, Yamanouchi T, Yoshikawa M, Yamazaki Y, Teramoto T. Patient health literacy and patient-physician information exchange during a visit. Fam Pract. 2009 Oct 7.
(Health Literacy, Japan)
BACKGROUND: Health literacy (HL), the capacity of individuals to access, understand and use health information to make informed and appropriate health-related decisions, is recognized as an important concept in patient education and disease management. OBJECTIVE: To examine the relation of three levels of HL (i.e. functional, communicative and critical HL) to patient-physician information exchange during a visit. METHODS: Participants were 134 outpatients with type 2 diabetes who were under continuous care by four attending physicians at a university-affiliated hospital. The visit communication was recorded and analysed using the Roter Interaction Analysis System. Patient HL was measured through a self-reported questionnaire using newly developed self-rated scales of functional, communicative and critical HL. Sociodemographic and clinical characteristics and patient's perception of the information exchange were assessed for each patient through self-reported questionnaires and review of electronic medical records. RESULTS: Patient HL levels were related to the information exchange process during the visit. Among the three HL scales, communicative HL (the capacity to extract information, derive meaning from different forms of communication and apply new information to changing circumstances) was related to patient's perceptions of the information exchange. Further, patient communicative HL had a modifying effect on the relationship between physician's information giving and patient's perception of it, suggesting that physician's communication may be perceived differently depending on the patient's HL. CONCLUSION: The exploration of patient HL may provide a better understanding of potential barriers to patient-physician communication and patient's self-management of disease.

Johnson KB, Serwint JR, Fagan LA, Thompson RE, Wilson ME, Roter D. Computer-based documentation: effects on parent-provider communication during pediatric health maintenance encounters. Pediatrics, 2008 Sep:122(3):590-8.
(Computer Use, Pediatrics, United States)
OBJECTIVE: The goal was to investigate the impact of a computer-based documentation tool on parent-health care provider communication during a pediatric health maintenance encounter. METHODS: We used a quasiexperimental study design to compare communication dynamics between clinicians and parents/children in health maintenance visits before and after implementation of the ClicTate system. Before ClicTate use, paper forms were used to create visit notes. The children examined were < / =18 months of age. All encounters were audiotaped or videotaped. A team of research assistants blinded to group assignment reviewed the audio portion of each encounter. Data from all recordings were analyzed, by using the Roter Interaction Analysis System, for differences in the open/closed question ratio, the extent of information provided by parents and providers, and other aspects of spoken and nonverbal communication (videotaped encounters). RESULTS: Computer-based documentation visits were slightly longer than control visits (32 vs 27 minutes). With controlling for visit length, the amounts of conversation were similar during control and computer-based documentation visits. Computer-based documentation visits were associated with a greater proportion of open-ended questions (28% vs 21%), more use of partnership strategies, greater proportions of social and positive talk, and a more patient-centered interaction style but fewer orienting and transition phrases. CONCLUSIONS: The introduction of ClicTate into the health maintenance encounter positively affected several aspects of parent-clinician communication in a pediatric clinic setting. These results support the integration of computer-based documentation into primary care pediatric visits.

Joos SK, Hickman DH, Gordon GH, Baker LH. Effects of a physician communication intervention on patient care outcomes. J Gen Intern Med 1995;11:147-155.
(Communication Skills Training, United States)
OBJECTIVE. To determine whether an intervention designed to improve patient-physician communication increases the frequency with which physicians elicit patients' concerns, changes other communication behaviors, and improves health care outcomes. DESIGN. Pretest-posttest design with random assignment of physicians to intervention or control groups. SETTING. General medicine clinics of a university-affiliated Veterans Affairs Hospital. PATIENTS/PARTICIPANTS. Forty-two physicians and 348 continuity care patients taking prescription medications for chronic medical conditions. INTERVENTIONS. Intervention group physicians received 4.5 hours of training on eliciting and responding to patients' concerns and requests, and their patients filled out the Patient Requests for Services Questionnaire prior to a subsequent clinic visit. Control group physicians received 4.5 hours of training in medical decision-making. MEASUREMENTS AND MAIN RESULTS. The frequency with which physicians elicited all of a patient's concerns increased in the intervention group as compared with the control group (p = .032). Patients perceptions of the amount of information received from the physician did increase significantly (p < .05), but the actual magnitude of change was small. A measure of patient satisfaction with the physicians was high at baseline and also showed no significant change after the intervention. Likewise, the intervention was not associated with changes in patient compliance with medications or appointments, nor were there any effects on outpatient utilization. CONCLUSIONS. A low-intensity intervention changed physician behavior but had no effect on patient outcomes such as satisfaction, compliance, or utilization. Interventions may need to focus on physicians and patients to have the greatest effect.

Kalet A, Earp JA, Kowlowitz V. How well do faculty evaluate the interviewing skills of medical students? J Gen Intern Med 1992 Sep-Oct;7(5):499-505.
(Communication Skills Evaluation, United States)
OBJECTIVE: To study the reliability and validity of using medical school faculty in the evaluation of the interviewing skills of medical students. DESIGN: All second-year University of North Carolina medical students (n = 159) were observed interviewing standardized patients for 5 minutes by one of eight experienced clinical faculty. Interview quality was assessed by a faculty checklist covering questioning style, facilitative behaviors, and specific content. Twenty-one randomly chosen students were videotaped and rated: by the original rater as well as four other raters; by two nationally recognized experts; and according to Roter's coding dimensions, which have been found to correlate strongly with patient compliance and satisfaction. SETTING: Medical school at a state university in the southeastern United States. PARTICIPANTS: Faculty members who volunteered to evaluate second-year medical students during an annual Objective Structured Clinical Exam. INTERVENTIONS: Interrater reliability and intrarater reliability were tested using videotapes of medical students interviewing a standardized patient. Validity was tested by comparing the faculty judgment with both an analysis using the Roter Interactional Analysis System and an assessment made by expert interviewers. MEASUREMENTS AND MAIN RESULTS: Faculty mean checklist score was 80% (range 41-100%). Intrarater reliability was poor for assessment of skills and behaviors as compared with that for content obtained. Interrater reliability was also poor as measured by intraclass correlation coefficients ranging from 0.11 to 0.37. When compared with the experts, faculty raters had a sensitivity of 80% but a specificity of 45% in identifying students with adequate skills. The predictive value of faculty assessment was 12%. Analysis using Roter's coding scheme suggests that faculty scored students on the basis of likability rather than specific behavioral skills, limiting their ability to provide behaviorally specific feedback. CONCLUSIONS: To accurately evaluate clinical interviewing skills we must enhance rater consistency, particularly in assessing those skills that both satisfy patients and yield crucial data.

Katz MG, Jacobson TA, Veledar E, Kripalani S. Patient literacy and question-asking behavior during the medical encounter; a mix methods analysis. J Gen Intern Med 2007 Jun; 22(6): 782-6.
(Literacy, United States)
BACKGROUND: Although patient participation in the medical encounter confers significant benefits, many patients are reluctant to ask questions of their physicians. Patients' literacy level may affect their level of participation and question-asking behaviors. OBJECTIVE: To examine the effect of literacy on the number and types of questions asked by patients during primary care office visits. DESIGN: Convenience sample recruited between April and November 2004. Physician-patient visits were audiotaped, and patient questions from complete encounters (N = 57) were coded using an adaptation of the Roter Interaction Analysis System. PATIENTS: Participants were predominantly middle-aged (mean age = 56.7 years), female (75.4%), and African American (94.7%). Low literacy skills (< or = 6th grade reading level) were present in 38.6%. MEASUREMENTS: We hypothesized prospectively that low-literacy patients would ask fewer total questions and fewer questions about key aspects of their medical care. RESULTS: Low-literacy adults asked significantly fewer questions about medical care issues (median = 4 vs 6 among patients with higher literacy levels, p = .014). They also tended to ask fewer questions overall (median = 7 vs 10, p = .070). Low-literacy patients were more likely to ask the physician to repeat something (p = .013), indicating an initial lack of understanding. They were less likely to use medical terminology, refer to medications by name, request additional services, or seek new information. Question-asking behavior was not significantly related to patient gender, age, years of education, or physician-patient gender concordance. CONCLUSIONS: Literacy level appears to be an important determinant of patients' participation in the medical encounter. Low-literacy patients ask fewer questions about their medical care, and this may affect their ability to learn about their medical conditions and treatments.

Kim EJ. [Emergency nurse-patient interaction behavior][Article in Korean] Taehan Kanho Hakhoe Chi. 2005 Oct;35(6):1004-13.
(Emergency Medicine, Nursing, Korea)
PURPOSE: The main purpose of this study was to explore nurse-patient interaction behaviors and patient satisfaction with the interaction in the emergency department. METHOD: This study used video technology to record complete conversations between the nurse and patient, thus obtaining the interactions naturally occurring in a clinical setting. The participants were 28 nurses and 63 patients in the emergency department at one university hospital located in Seoul. The data was collected from November, 2002 to April, 2003. The video recordings were observed for 4 hours for each case and coded using an adapted version of Roter's Interaction Analysis System (RIAS), which yields frequencies of thirty-six types of interaction behaviors. RESULT: The information exchange related to therapeutic items including medications, simple orientation, and situational positive talk were characterized in the nurses' interaction behaviors. Giving information about one's own condition, questions about therapeutic regimen, and showing worry were characterized in patient interaction behaviors. The patients' satisfaction with the interaction was 37.75.9 (range 9-45). CONCLUSION: The emergency nurse-patient interaction behavior was task-related. The results suggest that identification of effective interaction behavior in the Emergency department and an interaction skill training program could increase patient satisfaction.

Kim YM, Figueroa ME, Martin A, Silva R, Acosta SF, Hurtado M, Richardson P, Kols A. Impact of supervision and self-assessment on doctor-patient communication in rural Mexico. Int J Qual Health Care. 2002 Oct;14(5):359-67.
(Primary Care, Communication Skills, Mexico)
OBJECTIVE: To determine whether supervision and self-assessment activities can improve doctor-patient communication. SETTING AND PARTICIPANTS: Six supervisors, 60 doctors in their last year of training, and 232 primary health care patients at rural health clinics in Michoacan, Mexico. DESIGN: The main evaluation compared post-intervention measures in control and intervention groups. A small panel study also examined changes from baseline to post-intervention rounds in both groups. INTERVENTION: Over a 4-month period, specially trained supervisors added 1 hour of supervision on interpersonal communication and counseling (IPC/C) to regular site visits. Doctors, who had received prior IPC/C training, periodically audiotaped and assessed their own consultations. MAIN OUTCOME MEASURES: These comprised frequency of doctors' facilitative communication, doctors' biomedical information-giving, and patients' active communication. RESULTS: The performance of all doctors improved markedly over the study period, but gains in facilitative communication and information-giving were significantly greater in the intervention than the control group. No single component of the intervention was responsible for the improvement; it resulted from the combination of activities. The doctors appreciated the more supportive relationship with supervisors that resulted from the intervention and found listening to themselves on audiotape a powerful, although initially stressful, experience. CONCLUSION: Supportive supervision and self-assessment activities can reinforce IPC/C training, prompt reflection and learning, and help novice doctors improve their interpersonal communication skills.

Kim YM, Kols A, Bonnin C, Richardson P, Roter D. Client communication behaviors with health care providers in Indonesia. Patient Educ Couns 2001 Oct;45(1):59-68.
(Decision-making, Indonesia)
Patient participation in health care consultations can improve the quality of decision making and increase patients' commitment to the treatment plan. This study examines client participation, operationally defined as client active communication, during family planning consultations in Indonesia. Data were collected on 1203 consultations in the provinces of East Java and Lampung. Sessions were audiotaped and the conversation coded using an adaptation of the roter interaction analysis system (RIAS). Culturally acceptable ways for Indonesian clients to participate in consultations include asking questions, requesting clarification, stating opinions, and expressing concerns. Factors significantly associated with client active communication were, in order of importance, providers' information giving, providers' facilitative communication, providers' expressions of negative emotion, client educational level, and province. The latter suggests the influence of culture on client participation. The results suggest that a combination of provider training and client education on key communication skills could increase client participation in health care consultations.

Kim YM, Kols A, Mwarogo P, Awasum D. Differences in counseling men and women: family planning in Kenya. Patient Educ Couns. 2000 Jan;39(1):37-47
(Gender, Family Planning, Kenya)
A comparison of family planning sessions with male and female clients in Kenya found distinct gender differences. Most men came for information, while women wanted to adopt, continue, or change contraceptive methods. Consultations with men and couples were more than twice as long as consultations with women. Men communicated actively (for example, by volunteering extra information, asking questions, and expressing worries) during 66% of their turns to speak, compared with 27% for women. Providers offered men more detailed information than women, asked them fewer questions, issued fewer instructions, and responded more supportively. These communication patterns may be seen as a reflection of Kenyan gender roles and men's and women's different reasons for seeking family planning services. Kenyan providers need to improve the quality of their interactions with women. They also need to anticipate men's outspokenness and understand the male agenda if they are to counsel men effectively. PIP: This study analyzes and compares transcripts of family planning consultations collected from two different family planning associations in Kenya to explore the possible differences in counseling women and men. A comparison of 358 family planning sessions at 25 service delivery sites in urban and rural areas found distinct gender differences. Most men came for information, while women opted to adopt, continue, or change contraceptive methods. Men participated more actively in the sessions during 66% of their turns to speak, compared with 27% for women. Men were offered more detailed information than women, were asked fewer questions, were issued fewer instructions, and were given more support by the providers. Such communication patterns may be seen as a reflection of Kenyan gender roles and men's and women's different reasons for seeking family planning services. The findings indicate that Kenyan providers need to improve the quality of their interactions with women, and that they also need to anticipate men's outspokenness and understand the male agenda for effective counseling.

Kim YM, Kols A, Prammawat S, Rinehart W. Sequence analysis: responsiveness of doctors to patient cues during family planning consultations in Mexico. Patient Educ Couns. 2005 Jul;58(1):114-7.
(Interaction Analysis, Family Planning, Mexico)
(Abstract not available.)

Kim YM, Putjuk F, Basuki E, Kols A. Increasing patient participation in reproductive health consultations: an evaluation of "Smart Patient" coaching in Indonesia. Patient Educ Couns. 2003 Jun;50(2):113-22.
(Patient Education, Indonesia)
Paternalistic models of health care, social distance between patients and providers, and cultural norms discourage patients from playing an active role in health consultations. This study tested whether individual coaching can give family planning patients the confidence and communication skills to talk more openly and more vigorously with providers. Educators met with 384 Indonesian women in clinic waiting rooms and coached them on asking questions, expressing concerns, and seeking clarification. An analysis of audiotaped consultations found that patients who received coaching articulated significantly more questions and concerns than others. Coaching narrowed differentials in active communication by patient type, age, and assertiveness, but it widened differentials by patient education and socioeconomic class. The discontinuation rate at 8 months was lower in the intervention than the control condition, but the difference was only marginally significant.

Kindler CH, Szirt L, Sommer D, Hausler R, Langewitz W. A quantitative analysis of anaesthetist-patient communication during the pre-operative visit. Anaesthesia. 2005 Jan; 60(1):53-9.
(Communication Skills, Anesthesia, Switzerland)
Previous communication research in general medical practice has shown that effective communication enhances patient compliance, satisfaction and medical outcome. It is expected that communication is equally important in anaesthesia, since patients often suffer from anxiety and lack of knowledge about anaesthetic procedures. However, little is known about the nature of communication during routine anaesthetic visits. The present study of 57 authentic anaesthetic visits provides the first results on the structure and content of communication in the pre-operative setting using the Roter Interaction Analysis System (RIAS). Patient-centred communication behaviours of anaesthetists and the extent of patient involvement were particularly investigated. From the 57 pre-operative visits, 18 267 utterances were coded. The mean (SD) [range] duration of the visit was 16.1 (7.8) [3.7-42.7] min. Anaesthetists provided 169 (68) and patients 153 (82) utterances per visit (53.5% vs. 46.5%). Physician and patient gender had no impact on the distribution of utterances and the duration of the visit. Conversation mainly focussed on biomedical issues with little psychosocial discussion (< 0.1% of all anaesthetist utterances). However, anaesthetists quite frequently used emotional comments toward patients (7%) and involved them in the conversation. The use of facilitators, open questions and emotional statements by the anaesthetist correlated with high patient involvement. The amount of patient participation in anaesthetic decisions was assessed with the Observing Patient Involvement Scale (OPTION). Compared with general practitioners, anaesthetists offered more opportunities to discuss treatment options (mean (SD) OPTION score 26.8 (16.8) vs. 16.8 (7.7)).

Kirimlioglu N, Elcioglu O, Yildiz Z. Client participation and provider communication in family planning counselling and the sample study from Turkey. Eur. J Contracept. Reprod. Health Care. 2005 Jun;10(2):131-141.
(Family Planning, Turkey)
Background The family planning program in Turkey was established in 1965 to curb the rapid increase in population growth. The last Demographic and Health Survey showed that about 64 % of married women in Turkey used contraception. OBJECTIVES: This study examines of behavior of family planning clients and provider in Eskisehir/Turkey, to see whether they can achieve this ideal partnership. METHODS: Consultation between 83 physicians, 222 nurses and 324 clients requesting family planning methods were audio-taped and analyzed for physicians and nurses communication style. Data were collected from 3 hospital and 14 small health units that give services in Eskisehir. The audio-taped consultations were coded using an adaptation of the RIAS which has been used extensively in both developed and developing countries and in statistical analyzing chi(2) and t test were utilized. RESULTS AND CONCLUSIONS: The single strongest factor was providers giving biomedical and technical information. The qualitative analysis of audiotapes found that most of clients' questions concern contraceptive side effects and symptoms. The next category social talk, consisted largely of greetings. Most of the providers (87.6 %) are women. The results show that providers dominate most counseling session and clients rarely take on active role.

Koerber A, Gajendra S, Fulford RL, BeGole E, Evans CA. An exploratory study of orthodontic resident communication by patient race and ethnicity. J Dent Educ. 2004 May;68(5):553-62.
(Race, Dentistry, United States)
Race has been shown to affect the quality of physician-patient relations. In view of this, dentistry must consider whether race also affects dentist-patient relations. The purpose of this study was to explore whether orthodontic residents showed more social connection and concern for European ancestry patients, were more negative to minority patients, and appropriately used interventions designed to overcome cultural differences. Communications in sixty-eight dentist-patient encounters were analyzed using the Roter Interaction Analysis System (RIAS). The frequencies of each type of utterance were examined according to the patient's race/ethnicity. The race/ethnic groups were European (nineteen), African American (eleven), Latino (thirty-four), and Asian (four). In 90 percent of the sessions, the resident and the patient were of different ethnicity. Residents used social connection utterances more with European ancestry patients, but used personal utterances more with Latino patients. Residents did not use open-ended questions or probes for patient understanding more with minority patients. The communication patterns observed in this study were similar to those reported in the literature. This study has limitations, but additional research may confirm that residents communicate differently with patients by race and could use more appropriate methods of dealing with cross-cultural situations. More research on cross-cultural communication is needed.

Kruijver IP, Kerkstra A, Bensing JM, van de Wiel HB. Communication skills of nurses during interactions with simulated cancer patients. J Adv Nurs. 2001 Jun;34(6):772-9.
(Oncology, Netherlands)
AIM: In this paper the balance of affective and instrumental communication employed by nurses during the admission interview with recently diagnosed cancer patients was investigated. RATIONALE: The balance of affective and instrumental communication employed by nurses appears to be important, especially during the admission interview with cancer patients. METHODS: For this purpose, admission interviews between 53 ward nurses and simulated cancer patients were videotaped and analysed using the Roter Interaction Analysis system, in which a distinction is made between instrumental and affective communication. RESULTS: The results reveal that more than 60% of nurses' utterances were of an instrumental nature. Affective communication occurred, but was more related to global affect ratings like giving agreements and paraphrases than to discussing and exploring actively patients feelings by showing empathy, showing concern and optimism. CONCLUSION: In future, nurses should be systematically provided with (continuing) training programmes, in which they learn how to communicate effectively in relation to patients' emotions and feelings, and how to integrate emotional care with practical and medical tasks.

Kruijver IP, Kerkstra A, Francke AL, Bensing JM, van de Wiel HB. Evaluation of communication training programs in nursing care: a review of the literature. Patient Educ Couns. 2000 Jan;39(1):129-45.
(Nursing, Netherlands)
An important aspect of nursing care is communication with patients. Nurses' major communication tasks are not only to inform the patient about his/her disease and treatment, but also to create a therapeutically effective relationship by assessing patients' concerns, showing understanding, empathy, and providing comfort and support. In this review, 14 studies, which focus on the evaluation of the effects of communication training programs for nurses, have been evaluated. The selected studies were screened on several independent, process and outcome variables as described by Francke et al. [8]. In this way not only is the training program taken into account as a variable which may be responsible for nurses' behavioural change and for changes in patient outcomes, but also a range of other variables which can give more nuanced explanations for a training program's degree of effectiveness. On the whole, the studies reviewed showed limited or no effects on nurses' skills, on nurses' behavioural changes in practice, and on patient outcomes. Finally, the majority of the studies had a weak design. The use of experimental research designs should be pursued in future studies in order to eliminate the influence of confounding variables.

Krupat E, Frankel R, Stein T, Irish J. The Four Habits Coding Scheme: Validation of an instrument to assess clinicians' communication behavior. Patient Educ. Couns. 2006 Jul;62(1):38-45.
(Communication Skills, United States)
OBJECTIVE: To present preliminary evidence for the reliability and validity of the Four Habits Coding Scheme (4HCS), an instrument based on a teaching model used widely throughout Kaiser Permanente to improve clinicians' communication skills. METHODS: One hundred videotaped primary care visits were coded using the 4HCS, and the data were assessed against a previously available data set for these visits, including the Roter Interaction Analysis System (RIAS), back channel responses, measures of nonverbal behavior, length of visit, and patients' post-visit assessments. RESULTS: Levels of inter-rater reliability were acceptable, and the distribution of ratings across items indicated that physicians' modal responses varied widely. Correlations between 4HCS ratings, RIAS, back channel responses, and non-verbal measures provided evidence of the instrument's construct validity. CONCLUSIONS: The Four Habits Coding Scheme, an instrument that combines both evaluative and descriptive elements of physician communication behavior and is derived from a conceptually based teaching model, has the potential to be of utility to researchers and evaluators as well as educators and clinicians. PRACTICE IMPLICATIONS: The Four Habits Coding Scheme provides a template for both guiding and measuring physician communication behaviors.

Labhardt ND, Schiess K, Manga E, Langewitz W. Provider-patient interaction in rural Cameroon-How it relates to the patient's understanding of diagnosis and prescribed drugs, the patient's concept of illness, and access to therapy. Patient Educ Couns. 2009 Jan 23.[Epub ahead of print]
(Primary Care, Cameroon)
OBJECTIVE: This cross-sectional survey examines the relation between provider-patient interaction and several patient-outcomes in a rural health district in Cameroon. METHODS: We used structured patient interviews and the Roter Interaction Analysis System (RIAS) for analysis of audio-recorded consultations. RESULTS: Data from 130 primary care consultations with 13 health-care providers were analysed. 51% of patients correctly named their diagnoses after the consultation; in 47% of prescribed drugs patients explained correctly the purpose. Patients' ability to recall diagnoses was related to the extent of clarity a provider used in mentioning it during consultation (recall rates: 87.5% if mentioned explicitly, 56.7% if mentioned indirectly and 19.2% if not mentioned at all; p< 0.001). Two thirds of patients were able to describe their concept of illness before the consultation, but only 47% of them mentioned it during consultations. On average patients who mentioned their disease concept were faced with more remarks of disapproval from providers (1.73 vs 0.63 per consultation; p< 0.01). Although 41% of patients admitted problems with financial resources to buy prescribed drugs, discussion about financial issues was very rare during consultations. Providers issued financial questions in 32%, patients in 21% of consultations. CONCLUSION: This study shows that provider-patient interaction in primary health care in a rural Cameroon district deserves more attention. It might improve the patients' knowledge about their health condition and support them in beneficial health behaviour. PRACTICE IMPLICATIONS: Our findings should encourage providers to give more medical explanation, to discuss patients' health beliefs in a non-judgemental manner, and to consider financial issues more carefully.

Lamiani G, Furey A. Teaching nurses how to teach: An evaluation of a workshop on patient education. Patient Educ Couns. 2009 May;75(2):270-3.
(Nursing, United States)
OBJECTIVE: To evaluate the effects of a patient education workshop on nurses: (1) communication skills; (2) Knowledge of patient-centered model, patient education process, and sense of preparedness to provide patient education. METHODS: Fourteen nurses attended a 2-day workshop on patient education based on a patient-centered model. Data on communication skills were collected by means of pre-/post-written dialogues and analyzed with the Roter Interaction Analysis System (RIAS). Data of nurses' knowledge and sense of preparedness were collected through a post questionnaire comprised of 5-point Likert scale items. RESULTS: Post-dialogues showed an increase in patient talking (P< 0.001) and in patient-centered communication as indicated by the increase in Psychosocial exchanges (P=0.003) and Process exchanges (P=0.001). Nurses reported that the workshop increased "very much" their knowledge of the patient-centered model (mean=4.19) and patient education process (mean=4.69), and their sense of preparedness to provide patient education (P=0.001). CONCLUSIONS: Data suggest the efficacy of the workshop in developing patient-centered communication skills and improving nurses' knowledge and preparedness to deliver patient education. PRACTICE IMPLICATIONS: Trainings based on a patient-centered model and interactive learning methods should be implemented for nurses to improve their ability to deliver effective patient education.

Lamiani G, Meyer EC, Browning DM, Brodsky D, Todres ID. Analysis of enacted difficult conversations in neonatal intensive care. J Perinatol. 2009 Apr;29(4):310-6.
(Intensive Care, United States)
OBJECTIVE: To analyze the communicative contributions of interdisciplinary professionals and family members in enacted difficult conversations in neonatal intensive care. STUDY DESIGN: Physicians, nurses, social workers, and chaplains (n=50) who attended the Program to Enhance Relational and Communication Skills, participated in a scenario of a preterm infant with severe complications enacted by actors portraying family members. Twenty-four family meetings were videotaped and analyzed with the Roter Interaction Analysis System (RIAS). RESULT: Practitioners talked more than actor-family members (70 vs 30%). Physicians provided more biomedical information than psychosocial professionals (P< 0.001), and less psychosocial information than nurses, and social workers and chaplains (P< 0.05; P< 0.001). Social workers and chaplains asked more psychosocial questions than physicians and nurses (MD=P< 0.005; RN=P< 0.05), focused more on family's opinion and understanding (MD=P< 0.01; RN=P< 0.001), and more frequently expressed agreement and approval than physicians (P< 0.05). No differences were found across disciplines in providing emotional support. CONCLUSION: Findings suggest the importance of an interdisciplinary approach and highlight areas for improvement such as using silence, asking psychosocial questions and eliciting family perspectives that are associated with family satisfaction.

Langewitz WA, Loeb Y, Nübling M, Hunziker S. From patient talk to physician notes-Comparing the content of medical interviews with medical records in a sample of outpatients in Internal Medicine. Patient Educ Couns. 2009 Sep;76(3):336-40. Epub 2009 Jun 26.
(Primary Care, Medical Records, Decision-making, Switzerland)
OBJECTIVES: An increasing number of consultations are delivered in group practices, where a stable 1:1 relationship between patient and physician cannot be guaranteed. Therefore, correct documentation of the content of a consultation is crucial to hand over information from one health care professional to the next. METHODS: We randomly selected 20 interviews from a series of 56 videotaped consultations with patients requesting a general check-up exam in the outpatient department of Internal Medicine at the University Hospital Basel. All patients actively denied having any symptoms or specific health concerns at the time they made their appointment. Videotapes were analysed with the Roter Interaction Analysis System (RIAS). Corresponding physician notes were analysed with a category check-list that contained the information related items from RIAS. RESULTS: Interviews contained a total of 9.002 utterances and lasted between 15 and 53min (mean duration: 37min). Patient-centred communication (Waiting, Echoing, Mirroring, Summarising) in the videos significantly correlated with the amount of information presented by patients: medical information (r=.57; p=.009), therapeutic information (r=.50; p=.03), psychosocial information (r=.41; p=.07), life style information (r=.52; p=.02), and with the sum of patient information (r=.64; p=.003). Even though there was a significant correlation between the amount of information from the video and information in physician's notes in some categories (patient gives medical information; Pearson's r=.45; p=.05, patient gives psychosocial information; Pearson's r=.49; p=.03), an inspection of the regression lines shows that a large extent of patient information is omitted from the charts. Physicians never discussed with patients whether information should be documented in the charts or omitted. CONCLUSIONS: The use of typical patient-centred techniques increases information gathered from patients. Physicians document only a small percentage of patient information in the charts, their 'condensing heuristic' is not shared with patients. PRACTICE IMPLICATIONS: Patient involvement should be advocated not only to medical decision making but also to the way physicians document the content of a consultation. It is a joint responsibility of patient and health care professional to decide, which information should be kept and thus be communicated to another health care professional in future consultations.

Langewitz W, Nubling M, Weber H. A theory-based approach to analysing conversation sequences. Epidemiol Psichiatr Soc. 2003 Apr-Jun;12(2):103-8.
(Interaction Analysis, Switzerland)
AIMS: To assess the quality of communication generally two procedures are used: one defines categories of utterances and counts their frequency, the other uses global observer ratings. We investigated whether a sequence analysis of utterances yields results which more precisely reflect the process of a conversation. METHODS: We re-examined data from a randomised controlled intervention study in which residents' interviews with simulated patients were analysed with the Maastricht History and Advice Checklist (MAAS-R) and the Roter Interaction Analysis System (RIAS). Using the U-file of the RIAS we studied the effect of different types of physician questions (open, closed questions, facilitators, other physician actions) on the length of uninterrupted patients' speech and content of utterances. We investigated also whether reciprocity indices improve after a communication skills training, and whether they correlate with global scores form MAAS-R. RESULTS: Patients respond to a closed question with a mean of 1.78 (+/- 1.49) utterances as compared to 2.75 (+/- 2.72) utterances after an open question. The likelihood of a concern was more than 10 fold higher after an open question compared to closed questions. Reciprocal sequences make up less than 2 percent of the conversation, Still, they correlate with global items form MAAS-R. The 'empathy index' improves after the training.

Levinson W, Dull VT, Roter DL, Chaumeton N, Frankel RM. Recruiting physicians for office-based research. Med Care 1998 Jun;36(6):934-7.
(Physician Satisfaction, United States)
OBJECTIVES: Research conducted in community outpatient offices can provide insight into the common experiences of patients and physicians. However, recruiting physicians to participate in office-based research is challenging and few descriptions of methods that have been used to successfully recruit random samples of physicians are available. This article describes recruitment strategies utilized in a project that achieved high rates of participation from community-based primary care physicians and surgeons. METHODS: Recruitment methods included the use of advisory boards to identify potential barriers to participation, use of respected members of the medical community as recruiters, and obtaining endorsements from physician organizations and prominent members of the medical community. RESULTS: Overall, 81% of physicians contacted from a sample frame agreed to participate in the project. Participating physicians most frequently reported that they participated because the project could provide them with feedback about their interviewing style. CONCLUSIONS: The recruitment methods described here can be generalized to other types of investigations.

Levinson W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med 1993 Jun;8(6):318-24.
(Primary Care, Communication Skills Training, United States)
PURPOSE: To evaluate and compare the effects of two types of continuing medical education (CME) programs on the communication skills of practicing primary care physicians. PARTICIPANTS: Fifty-three community-based general internists and family practitioners practicing in the Portland, Oregon, metropolitan area and 473 of their patients. METHOD: For the short program (a 4 1/2-hour workshop), 31 physicians were randomized to either the intervention or the control group. In the long program (a 2 1/2-day course), 20 physicians participated with no randomization. A research assistant visited all physicians' offices both one month before and one month after the CME program and audiotaped five sequential visits each time. Data were based on analysis of the content and the affect of the interviews, using the Roter Interactional Analysis Scheme. RESULTS: Based on both t-test analysis and analysis of covariance, no effect on communication was evident from the short program. The physicians enrolled in the long program asked more open-ended questions, more frequently asked patients' opinions, and gave more biomedical information than did the physicians in the short program. Patients of the physicians who attended the long program tended to disclose more biomedical and psychosocial information to their physicians. In addition, there was a decrease in negative affect for both patient and physician, and patients tended to demonstrate fewer signs of outward distress during the visit. CONCLUSION: This study demonstrates some potentially important changes in physicians' and patients' communication after a 2 1/2-day CME program. The changes demonstrated in both content and affect may have important influences on both biologic outcome and physician and patient satisfaction.

Levinson W, Roter DL. Physician’ psychosocial beliefs correlate with their patient communication skills. J Gen Intern Med 1995, 10: 375-379.
(Primary Care, United States)
To assess the relationship between physicians’ beliefs about the psychosocial aspects of patient care and their routine communication with patients. Fifty community primary care physicians participating in a continuing medical education program and 473 of their patients in Portland, Oregon participated. Routine office visits were audio taped and analyzed for communication behaviors and emotional using the Roter Interaction Analysis System (RIAS). Physician beliefs about psychosocial aspects with a five-point Likert scale. Attitudes were correlated with communication behaviors using the Pearson correlation coefficient. Physician beliefs about psychosocial aspects of patient care are associated with their communication with patients in routine office visits. Patients of physicians with more positive attitudes have more psychosocial discussions in visits than do patients of physicians with less positive attitudes. They also appear more involved as partners in their care. These findings have implications for medical educators, teachers, and practicing physicians.

Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997 Feb 19;277(7):553-9.
(Physicians' Malpractice History, United States)
OBJECTIVE: To identify specific communication behaviors associated with malpractice history in primary care physicians and surgeons. DESIGN: Comparison of communication behaviors of "claims" vs "no-claims" physicians using audiotapes of 10 routine office visits per physician. SETTINGS: One hundred twenty-four physician offices in Oregon and Colorado. PARTICIPANTS: Fifty-nine primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons and their patients. Physicians were classified into no-claims or claims (> or =2 lifetime claims) groups based on insurance company records and were stratified by years in practice and specialty. MAIN OUTCOME MEASURES: Audiotape analysis using the Roter Interaction Analysis System. RESULTS: Significant differences in communication behaviors of no-claims and claims physicians were identified in primary care physicians but not in surgeons. Compared with claims primary care physicians, no-claims primary care physicians used more statements of orientation (educating patients about what to expect and the flow of a visit), laughed and used humor more, and tended to use more facilitation (soliciting patients' opinions, checking understanding, and encouraging patients to talk). No-claims primary care physicians spent longer in routine visits than claims primary care physicians (mean, 18.3 vs 15.0 minutes), and the length of the visit had an independent effect in predicting claims status. The multivariable model for primary care improved the prediction of claims status by 57% above chance (90% confidence interval, 33%-73%). Multivariable models did not significantly improve prediction of claims status for surgeons. CONCLUSIONS: Routine physician-patient communication differs in primary care physicians with vs without prior malpractice claims. In contrast, the study did not find communication behaviors to distinguish between claims vs no-claims surgeons. The study identifies specific and teachable communication behaviors associated with fewer malpractice claims for primary care physicians. Physicians can use these findings as they seek to improve communication and decrease malpractice risk. Malpractice insurers can use this information to guide malpractice risk prevention and education for primary care physicians but should not assume that it is appropriate to teach similar behaviors to other specialty groups.

Liu CC, Wissow LS. Residents who stay late at hospital and how they perform the follow day. Med Educ. 2008 Jan; 42 (1): 74-81.
(Pediatric Residents, Taiwan)
Context The limits imposed on the official working hours of paediatric residents do not necessarily reduce the amount of time they spend at work. Fatigue and stress can result from staying late voluntarily, and this in turn can alter clinical performance, much as long obligatory hours did in the past. Methods A cross-sectional analysis was made of a systematic sample of 243 primary care visits conducted in 1990 by 52 paediatric residents at a teaching hospital. The paediatric residents reported on their work responsibilities the night before each primary care visit and their communication style during the visit was analysed from recordings made on audiotapes using the Roter Interactional Analysis System (RIAS). Results Paediatric residents who care for critically ill children were more likely to stay late even if they were not on call. During primary care visits the next day, those paediatric residents who stayed late were more verbally dominant - their verbal input, as a proportion of the total, was: 0.67 (stayed late) versus 0.62 (on call), P = 0.007; 0.67 (stayed late) versus 0.64 (left on time), P = 0.02. Paediatric residents who stayed late displayed less patient-centredness: patient-centred talk as a proportion of total 0.31 (stayed late) versus 0.36 (on call), P = 0.02; 0.31(stayed late) versus 0.34 (left on time), P = 0.03. Compared with paediatric residents who left on time, those who stayed late reported feeling less fulfilled; if their clinic was in the afternoon, they also reported more fatigue. Conclusions The care of critically ill children may make paediatric residents more liable to remain at work after the end of their shift. The clinical interactions of such residents were more dominant and less patient-centred. Helping paediatric residents to learn to manage their work while under clinical stress could promote better adherence to guidelines on working hours and have a positive impact on patient care.

Margalit RS, Roter D, Dunevant MA, Larson S, Reis S. Electronic medical record use and physician-patient communication: an observational study of Israeli primary care encounters. Patient Educ Couns. 2006 Apr;61(1):134-41
(Electronic Medical Records, Primary Care, Israel)
OBJECTIVES: Within the context of medical care there is no greater reflection of the information revolution than the electronic medical record (EMR). Current estimates suggest that EMR use by Israeli physicians is now so high as to represent an almost fully immersed environment. This study examines the relationships between the extent of electronic medical record use and physician-patient communication within the context of Israeli primary care. METHODS: Based on videotapes of 3 Israeli primary care physicians and 30 of their patients, the extent of computer use was measured as number of seconds gazing at the computer screen and 3 levels of active keyboarding. Communication dynamics were analyzed through the application of a new Hebrew translation and adaptation of the Roter Interaction Analysis System (RIAS). RESULTS: Physicians spent close to one-quarter of visit time gazing at the computer screen, and in some cases as much as 42%; heavy keyboarding throughout the visit was evident in 24% of studied visits. Screen gaze and levels of keyboarding were both positively correlated with length of visit (r = .51, p < .001 and F(2,27) = 2.83, p < .08, respectively); however, keyboarding was inversely related to the amount of visit dialogue contributed by the physician (F(2,27) = 4.22, p < .02) or the patient (F(2,27) = 3.85, p < .05). Specific effects of screen gaze were inhibition of physician engagement in psychosocial question asking (r = -.39, p < .02) and emotional responsiveness (r = -.30, p < .10), while keyboarding increased biomedical exchange, including more questions about therapeutic regimen (F(2,27) = 4.78, p < .02) and more patient education and counseling (F(2,27) = 10.38, p < .001), as well as increased patient disclosure of medical information to the physician (F(2,27) =3.40, p < .05). A summary score reflecting overall patient-centered communication during the visit was negatively correlated with both screen gaze and keyboarding (r = -.33, p < .08 and F(2,27) = 3.19, p < .06, respectively). DISCUSSION: The computer has become a 'party' in the visit that demanded a significant portion of visit time. Gazing at the monitor was inversely related to physician engagement in psychosocial questioning and emotional responsiveness and to patient limited socio-emotional and psychosocial exchange during the visit. Keyboarding activity was inversely related to both physician and patient contribution to the medical dialogue. Patients may regard physicians' engrossment in the tasks of computing as disinterested or disengaged. Increase in visit length associated with EMR use may be attributed to keyboarding and computer gazing. CONCLUSIONS: This study suggests that the way in which physicians use computers in the examination room can negatively affect patient-centered practice by diminishing dialogue, particularly in the psychosocial and emotional realm. Screen gaze appears particularly disruptive to psychosocial inquiry and emotional responsiveness, suggesting that visual attentiveness to the monitor rather than eye contact with the patient may inhibit sensitive or full patient disclosure. PRACTICAL IMPLICATIONS: We believe that training can help physicians optimize interpersonal and educationally effective use of the EMR. This training can assist physicians in overcoming the interpersonal distancing, both verbally and non-verbally, with which computer use is associated. Collaborative reading of the EMR can contribute to improved quality of care, enhance the decision-making process, and empower patients to participate in their own care.

Mead N, Bower P, Hann M. The impact of general practitioners’ patient-centredness on patients’ post-consultation satisfaction and enablement. Soc Sci Med 2002:55:283-299.
(Primary Care, United Kingdom)
The concept of patient-centredness is complex, but is generally seen as an approach that emphasizes, on the part of the health profession, attention to patients’ psychosocial (as well as physical) needs, the use of psychotherapeutic behaviours to convey a sense of partnership and positive regard, and active facilitation of patients’ involvement in decision-making about their care. To date, there is little consistent evidence that doctors’ use of a “patient-centred” consulting style leads to better patient outcomes. However, previous studies have been limited by a lack of conceptual clarity and methodological consensus, and by the absence of a clear theoretical framework linking patient-centredness to outcomes. In this study, three specific, conceptually distinct dimensions of a patient-centred consulting style were operationalised: the “biopsychosocial perspective”, “sharing power and responsibility” and the “therapeutic alliance”. These dimensions were measured in terms of three “socio-emotional” and two “task-relevant” general practitioner (GP) behaviours, using in-depth observational techniques applied to 173 videotaped GP consultations. Theoretically-derived hypotheses were tested concerning relationships between these patient-centred behaviours and two different consultation outcomes: patient satisfaction and enablement. Multivariate regression showed that GPs’ patient-centred behaviours did not predict either outcome. The robustness of these findings is considered within the context of study strengths and weaknesses, and implications for future research are discussed.

Meeuwesen L, Bensing J, van den Brink-Muinen A. Communicating fatigue in general practice and the role of gender. Patient Educ Couns. 2002 Dec;48(3):233-42.
(Primary Care, Gender, Netherlands)
The aim of this study has been to obtain more insight into the health condition of fatigued patients, their expectations when visiting the general practitioner (GP), the way they communicate, and possible gender differences. Data consisted of 579 patient questionnaires and 440 video-observations of these patients and 31 GPs. Results showed that fatigue is a common health problem but seldom on the agenda in general practice. More women indicated symptoms of fatigue than men did. Fatigued patients' health was worse than that of non-fatigued patients, and they expected more biomedical and especially psychosocial communication. Furthermore, male fatigued patients expected more biomedical communication than fatigued female patients did. While the GPs accommodated their verbal behavior to fatigued patients by giving more psychosocial information and more counseling, they were not more affective towards the fatigued than towards the non-fatigued patients. Female GPs were more affective than their male colleagues, and they used gender-specific communication strategies to explore the patient's agenda. It seems necessary to use a gender-sensitive approach in communication research.

Meeuwesen L, Harmsen JA, Bernsen RM, Bruijnzeels MA. Do Dutch doctors communicate differently with immigrant patients than with Dutch patients? Soc Sci Med. 2006 Nov;63(9):2407-17.
(Cross-Cultural, Netherlands)
The aim of this study was to gain deeper insight into relational aspects of the medical communication pattern in intercultural consultations at GP practices in the Netherlands. We ask whether there are differences in the verbal interaction of Dutch GPs with immigrant and Dutch patients. Data were drawn from 144 adult patient interviews and video observations of consultations between the patients and 31 Dutch GPs. The patient group consisted of 61 non-Western immigrants (Turkish, Moroccan, Surinamese, Antillean, Cape Verdian) and 83 Dutch participants. Affective and instrumental aspects of verbal communication were assessed using Roter's Interaction Analysis System (RIAS). Patients' cultural background was assessed by ethnicity, language proficiency, level of education, religiosity and cultural views (in terms of being more traditional or more modern). Consultations with the non-Western immigrant patients (especially those from Turkey and Morocco) were well over 2 min shorter, and the power distance between GPs and these patients was greater when compared to the Dutch patients. Major differences in verbal interaction were observed on the affective behavior dimensions, but not on the instrumental dimensions. Doctors invested more in trying to understand the immigrant patients, while in the case of Dutch patients they showed more involvement and empathy. Dutch patients seemed to be more assertive in the medical conversation. The differences are discussed in terms of patients' ethnic background, cultural views (e.g. practicing a religion) and linguistic barriers. It is concluded that attention to cultural diversity does matter, as this leads to different medical communication patterns. A two-way strategy is recommended for improving medical communication, with implications for both doctor and patient behavior.

Meeuwesen L, van den Brink-Muinen A, Hofstede G. Can dimensions of national culture predict cross-national differences in medical communication? Patient Educ Couns 2009 Apr;75(1):58-66.
(Cross-Cultural, Netherlands)
OBJECTIVE: This study investigated at a country level how cross-national differences in medical communication can be understood from the first four of Hofstede's cultural dimensions, i.e. power distance, uncertainty avoidance, individualism/collectivism and masculinity/femininity, together with national wealth. METHODS: A total of 307 general practitioners (GPs) and 5820 patients from Belgium, Estonia, Germany, Great Britain, the Netherlands, Poland, Romania, Spain, Sweden and Switzerland participated in the study. Medical communication was videotaped and assessed using Roter's interaction analysis system (RIAS). Additional context information of physicians (gender, job satisfaction, risk-taking and belief of psychological influence on diseases) and patients (gender, health condition, diagnosis and medical encounter expectations) was gathered by using questionnaires. RESULTS: Countries differ considerably form each other in terms of culture dimensions. The larger a nation's power distance, the less room there is for unexpected information exchange and the shorter the consultations are. Roles are clearly described and fixed. The higher the level of uncertainty avoidance, the less attention is given to rapport building, e.g. less eye contact. In 'masculine' countries there is less instrumental communication in the medical interaction, which was contrary to expectations. In wealthy countries, more attention is given to psychosocial communication. CONCLUSION: The four culture dimensions, together with countries' wealth, contribute importantly to the understanding of differences in European countries' styles of medical communication. Their predictive power reaches much further than explanations along the north/south or east/west division of Europe. PRACTICE IMPLICATIONS: The understanding of these cross-national differences is a precondition for the prevention of intercultural miscommunication. Improved understanding may occur at microlevel in the medical encounter, as well as on macrolevel in pursuing more effective cooperation and integration of European health care policies.

Meredith LS, Mazel RM. Counseling for depression by primary care providers. Int J Psychiatry Med 2000;30(4):343-65.
(Primary Care, United States)
OBJECTIVE: Primary care providers (PCPs) deliver a significant amount of depression care, yet little is known about the content of clinical encounters with depressed patients. We describe the extent to which PCP's encounters with depressed and non-depressed patients involve psychotherapeutic counseling relative to other types of counseling during primary care visits. METHOD: Cross-sectional evaluation of audiotaped office visits between October 1997 and September 1998 with 154 patients of 27 PCPs at three Veterans' Health Administration clinics in California. Using the Roter Interaction Analysis System, we coded conversation into mutually exclusive talk categories and developed specific measures of depression counseling coded for sequences of depression talk. Analysis of variance and covariance was used to evaluate differences in counseling by depression type adjusted for encounter length, previous depression treatment, patient characteristics, and provider clustering. RESULTS: PCPs delivered significantly more depression care (assessed using coded audiotapes of patient visits) to their patients with major depression compared with patients who had no depression or symptoms but no disorder. However, counseling using psychotherapeutic techniques did not differ by depression level and was equivalent for patients with major depression and subthreshold relative to non-depressed. Encounters with patients who had major depression included more talk about depression, devoted more time to discussing depression, and included more depression talk per minute. PCP encounters with depressed patients also included less biomedical talk compared to other groups. CONCLUSIONS: Findings suggest that PCPs do provide depression counseling to their patients who need it the most. Whether counseling is associated with appropriate treatment and subsequent outcomes will require additional research.

Miller EA, Nelson EL. Modifying the Roter Interaction Analysis System to study provider-patient communication in telemedicine: promises, pitfalls, insights, and recommendations. Telemed J E Health. 2005 Feb;11(1):44-55.
(Telemedicine, United States)
This paper suggests modifications to the Roter Interaction Analysis System (RIAS)--the most widely used measure for assessing provider-patient communication during conventional face-to-face consultations--for use in telemedicine. The RIAS, which describes and categorizes communication behaviors, is used to quantify communication events, which may then be correlated with patient, provider, and system attributes and health outcomes. Most of the changes suggested here add new coding subcategories to characterize technology-related utterances and to provide opportunities for global assessments of the overall technology environment within which provider-patient interactions took place. There are also general issues raised that interaction analysis researchers should consider when studying provider-patient communication in a telemedicine context. These relate to nonverbal behavior, multiple participants, missing information, and validity and reliability. In addition to comparing telemedicine to in person consultations, a modified RIAS could be used to compare televideo consultations to each other, across different specialties and technical specifications. A modified RIAS would accommodate not only differences in the current technology environment, but also changes in the way providers and patients communicate over time. The more we know about what interaction patterns lead to best outcomes, the more emphasis can be placed on developing training programs and other interventions to enhance patient-provider interactions in telemedicine.

Mjaaland TA, Finset A. Frequency of GP communication addressing the patient's resources and coping strategies in medical interviews: a video-based observational study. BMC Fam Pract. 2009 Jul 1;10:49.
(Primary Care, Communication Skills, Norway)
BACKGROUND: There is increasing focus on patient-centred communicative approaches in medical consultations, but few studies have shown the extent to which patients' positive coping strategies and psychological assets are addressed by general practitioners (GPs) on a regular day at the office. This study measures the frequency of GPs' use of questions and comments addressing their patients' coping strategies or resources. METHODS: Twenty-four GPs were video-recorded in 145 consultations. The consultations were coded using a modified version of the Roter Interaction Analysis System. In this study, we also developed four additional coding categories based on cognitive therapy and solution-focused therapy: attribution, resources, coping, and solution-focused techniques. The reliability between coders was established, a factor analysis was applied to test the relationship between the communication categories, and a tentative validating exercise was performed by reversed coding. RESULTS: Cohen's kappa was 0.52 between coders. Only 2% of the utterances could be categorized as resource or coping oriented. Six GPs contributed 59% of these utterances. The factor analysis identified two factors, one task oriented and one patient oriented. CONCLUSION: The frequency of communication about coping and resources was very low. Communication skills training for GPs in this field is required. Further validating studies of this kind of measurement tool are warranted.

Mjaaland TA, Finset A. Communication skills training for general practitioners to promote patient coping: the GRIP approach. Patient Educ Couns. 2009 Jul;76(1):84-90. Epub 2009 Jan 9.
(Primary Care, Communication Skills Training, Norway)
OBJECTIVE: To develop, perform and test the effects of a communication skills training program for general practitioners (GPs). The program specifically addresses the patients' coping and resources despite more or less severe psychological or physical illness. METHODS: A training model was developed, based on cognitive therapy and solution-focused therapy. The training was given the acronym GRIP after its main content: Get a measure of the patient's subjective complaints and illness attributions. Respond to the patient's understanding of the complaints. Identify resources and solutions. Promote positive coping. The study involved a quasi-experimental design in which 266 consultations with 25 GPs were video recorded. Forty hours of communication skills training were given to the intervention group. RESULTS: Consultation duration, patient age and distress determined the frequency of the GRIP communication. There was a significant effect of training on four particular subcategories of the GRIP techniques. The effect of the training was most evident in a subgroup of GPs who used little or no resource-oriented communication before training. CONCLUSION: This pilot training model may help change the GPs' communicative pattern with patients in some situations. PRACTICE IMPLICATION: Communication skills training programmes that emphasize patient attributions and personal resources should be developed further and tested in general practice settings with an aim to promote patient coping.

Neal RD, Ali N, Atkin K, Allgar VL, Ali S, Coleman T. Communication between South Asian patients and GP’s: comparative study using the Roter Interactional Analysis System. Br. J Gen Pract. 2006 Nov; 56 (532): 869-75.
(Cross-Cultural, United Kingdom)
BACKGROUND: The UK South Asian population has poorer health outcomes. Little is known about their process of care in general practice, or in particular the process of communication with GPs. AIM: To compare the ways in which white and South Asian patients communicate with white GPs. DESIGN OF STUDY: Observational study of video-recorded consultations using the Roter Interactional Analysis System (RIAS). SETTING: West Yorkshire, UK. METHOD: One hundred and eighty-three consultations with 11 GPs in West Yorkshire, UK were video-recorded and analysed. RESULTS: Main outcome measures were consultation length, verbal domination, 16 individual abridged RIAS categories, and three composite RIAS categories; with comparisons between white patients, South Asian patients fluent in English and South Asian patients nonfluent in English. South Asians fluent in English had the shortest consultations and South Asians non-fluent in English the longest consultations (one-way ANOVA F = 7.173, P = 0.001). There were no significant differences in verbal domination scores between the three groups. White patients had more affective (emotional) consultations than South Asian patients, and played a more active role in their consultations, as did their GPs. GPs spent less time giving information to South Asian patients who were not fluent in English and more time asking questions. GPs spent less time giving information to South Asian patients fluent in English compared with white patients. CONCLUSIONS: These findings were expected between patients fluent and non-fluent in English but do demonstrate their nature. The differences between white patients and South Asian patients fluent in English warrant further explanation. How much of this was due to systematic differences in behaviour by the GPs, or was in response to patients' differing needs and expectations is unknown. These differences may contribute to differences in health outcomes.

Nelson EL, Miller EA, Larson KA. Reliability associated with the Roter Interaction Analysis System (RIAS) adapted for the telemedicine context. Patient Educ Couns. 2009 May 16.[Epub ahead of print]
(Telemedicine, United States)
OBJECTIVE: This study's purpose was to adapt the Roter Interaction Analysis System (RIAS) for telemedicine clinics and to investigate the adapted measure's reliability. The study also sought to better understand the volume of technology-related utterance in established telemedicine clinics and the feasibility of using the measure within the telemedicine setting. This initial evaluation is a first step before broadly using the adapted measure across technologies and raters. METHODS: An expert panel adapted the RIAS for the telemedicine context. This involved accounting for all consultation participants (patient, provider, presenter, family) and adding technology-specific subcategories. Ten new and 36 follow-up telemedicine encounters were videotaped and double coded using the adapted RIAS. These consisted primarily of follow-up visits (78.0%) involving patients, providers, presenters, and other parties. Reliability was calculated for those categories with 15 or more utterances. RESULTS: Traditional RIAS categories related to socioemotional and task-focused clusters had fair to excellent levels of reliability in the telemedicine setting. Although there were too few utterances to calculate the reliability of the specific technology-related subcategories, the summary technology-related category proved reliable for patients, providers, and presenters. Overall patterns seen in traditional patient-provider interactions were observed, with the number of provider utterances far exceeding patient, presenter, and family utterances, and few technology-specific utterances. CONCLUSION: The traditional RIAS is reliable when applied across multiple participants in the telemedicine context. Reliability of technology-related subcategories could not be evaluated; however, the aggregate technology-related cluster was found to be reliable and may be especially relevant in understanding communication patterns with patients new to the telemedicine setting. Use of the RIAS instrument is encouraged to facilitate comparison between traditional, face-to-face clinics and telemedicine; among diverse consultation mediums and technologies; and across different specialties. Future research is necessary to further investigate the reliability and validity of adding technology-related subcategories to the RIAS. The limited number of technology-related utterances, however, implies a certain degree of comfort with two-way interactive video consultation among study participants. PRACTICE IMPLICATIONS: Telemedicine continues to increase access to healthcare. The technology-related categories of the adapted RIAS were reliable when aggregated, thereby providing a tool to better understand how telemedicine affects provider-patient communication and outcomes.

Nelson EL, Spaulding R. Adapting the Roter interaction analysis system for telemedicine: lessons from four specialty clinics. J Telemed Telecare. 2005;11 Suppl 1:105-7.
(Telemedicine, United States)
Four specialists (a child psychiatrist, an oncologist, a cardiologist and a rheumatologist) conducted telemedicine clinics using videoconferencing at a bandwidth of 128-384 kbit/s. The consultations were video recorded. The coded interactions from the first two patients recruited from each of the four telemedicine clinics were analyzed. Tapes were coded by two raters. We adapted the Roter interaction analysis system (RIAS) for the telemedicine context. Utterances were coded into socio-emotional and task-focused categories. There were 1055 utterances in total. Providers generated significantly more utterances across categories than patients. In the patient-provider interactions, only 2% of the total utterances related to the technology. The predominance of socio-emotional utterances compared with task-focused utterances for providers was contrary to our expectations. Further studies are required to establish the reliability of the adapted RIAS measure and to increase understanding of telemedicine communication patterns.

Newes-Adeyi G, Heliter DL, Roter DL, Caulfield LE. Improving client-provider communication: evaluation of a training program for women, infants and children (WIC) professionals in New York State. Patient Educ Couns 2004 Nov;55(2):210-7.
(Communication Skills Training, United States)
Results are presented from evaluation of an intensive 1 day training program to improve the growth monitoring counseling skills of Special Supplemental Nutrition Program for Women, Infant and Children (WIC) providers. The training was framed by the patient-centered approach, and focused on a seven-step technique that emphasized eliciting client perspective on the child’s health and negotiating follow-up strategies. Changes in skill were assessed during audio taped mock counseling sessions with simulated clients. Observed intervention effects were moderate but encouraging for future training programs. After the training, more providers elicited client perspective, and provider level of engagement in negotiating with the client increased. At post-test providers asked more open-ended questions that at pre-test, and provider-to-client talk ratio decreased. Increases in provider total and competence-related satisfaction paralleled improvements in counseling proficiency. Study results suggest that counseling skills of non-physician health providers can change after a 1 day focused training: providers were more client-centered in their discussions.

Odone L, Mauri E, Vegni E, Moja EA. Breaking unexpected bad news: pilot study on communication style of physicians. [Article in Italian] Recenti Prog Med. 2005 Dec;96(12):594-8.
(Bad News Delivery, Standardized Patients, Italy)
The aim of this study was to explore the physician's communication pattern when breaking a bad unexpected news. 30 videotaped consultations (VRM) were collected in which the physicians met an actress as a patient. The doctors received the x-ray report in which an apical mass was detected before (condition A) or during (condition B) the consultation. The VRM were analysed through the Roter Interaction Analysis System (RIAS). Data suggested in condition B a significant decrease in "process", "counselling" and "emotional" categories. In consultation where a bad unexpected news is communicated doctors seem to be less directive in the content and more emotionally defended.

Ong LM, Visser MR, Kruiyver IP, Bensing JM, van den Brink-Muinen A, Stouthard JM, Lammes FB, deHaes JC. The Roter Interaction Analysis System (RIAS) in oncological consultations: psychometric properties. Psychooncology 1998 Sep-Oct;7(5):387-401.
(Oncology, Netherlands)
One of the most frequently used systems to analyse doctor-patient communication is the Roter Interaction Analysis System (RIAS). However, it has mostly been applied and evaluated in primary care settings. Two studies are presented in which the psychometric properties of the RIAS are investigated in an oncological setting. In the first study (N = 25) the feasibility, inter-rater reliability and content validity of the RIAS was investigated. In the second study, we evaluated the discriminant validity of the RIAS. Results of the first study showed that coding of tapes was more time consuming than indicated by the Roter manual. The inter-rater reliability proved to be high for both physician communication (0.68-1) and patient communication (0.60-1). The content validity proved to be acceptable: all utterances could be classified. However, coding dilemmas regarding affective communication occurred. The RIAS provided no option to classify communication of a third person present. Some communication categories were never or rarely used. Results of the second study indicate that the RIAS was able to discriminate between communicative behaviors in oncological consultations (N = 60) and three different GP-samples (random-GP sample N = 329, hypertension sample N = 103, gynaecology sample N = 65). To conclude, the psychometric properties of the RIAS are satisfactory in an oncological setting.

Ong LM, Visser MR, Lammes FB, de Haes JC. Doctor-patient communication and cancer patients’ quality of life and satisfaction. Patient Education and Counseling 2000;41: 145-156.
(Oncology, Netherlands)
In this study, the relationship between (a) doctors' and patients' communication and (b) doctors' patient-centredness during the oncological consultation and patients' quality of life and satisfaction was examined. Consultations of 96 consecutive cancer patients were recorded and content-analysed by means of the Roter Interaction Analysis System. Data collection (mailed questionnaires) took place after 1 week and after 3 months. Oncologists' behaviours were unrelated to patients' quality of life. Their socio-emotional behaviours related to both patients' visit-specific and global satisfaction. Patients' behaviours related to both patient outcomes although mostly to satisfaction. Multiple regression analyses showed that patients' quality of life and satisfaction were most clearly predicted by the affective quality of the consultation. Surprisingly, oncologists' patient-centredness was negatively related to patients' global satisfaction after 3 months. In summary, doctor-patient communication during the oncological consultation is related to patients' quality of life and satisfaction. The affective quality of the consultation seems to be the most important factor in determining these outcomes.

Ong LM, Visser MR, van Zuuren FJ, Rietbroek RC, Lammes FB, de Haes JC. Cancer patients’ coping styles and doctor-patient communication. Psychooncology 1999 Mar-Apr;8(2):155-66.
(Oncology, Netherlands)
Monitoring and blunting styles have become relevant concepts regarding their potential impact on patients' and doctors' behaviors. The present study aimed at investigating the relation between cancer patients' coping styles and doctor-patient communication and global affect. Coping styles were assessed by means of the Threatening Medical Situations Inventory (TMSI). Since a shortened version of the TMSI was used, the validity of this instrument was also evaluated. First, it was examined whether the two factor structure of the original TMSI could be confirmed in our version. Then, the relation between coping style and patients' preferences for information and participation in decision-making was evaluated. Second, the relation between monitoring and blunting and patients' age, sex, education, quality of life and prognosis was investigated. Finally, the relation between patients' coping styles and communicative behaviors and global affect of both patients and physicians during the initial oncological consultation was examined. Patients (N = 123) visited their gynaecologist or medical oncologist for an initial discussion of possible treatment. Patients' coping styles, socio-demographics, preference for information and participation in decision-making, quality of life and prognosis were assessed by postal questionnaire prior to the visit to the outpatient clinic. The consultation was audiotaped and analysed according to Roter's Interaction Analysis System, to identify instrumental and affective communicative behaviors of both patients and physicians. The two factor structure of the TMSI could be confirmed. A monitoring style was related to a preference for detailed information (r = 0.23) and participation in medical decision-making (r = 0.23). A monitoring style was also related to patient question-asking (r = 0.25) and patient dominance (r = 0.23). To conclude, the validity of the shortened TMSI is satisfactory. Also, cancer patients' coping styles are not related to other personal and disease characteristics. Further, a monitoring style seems to have an impact on patients' question-asking and dominance during the oncological consultation.

Paasche-Orlow M, Roter D. The communication patterns of internal medicine and family practice physicians. J Am Board Fam Pract. 2003 Nov-Dec;16(6):485-93.
(Primary Care, United States)
BACKGROUND: Although differences between Internal Medicine (IM) and Family Practice (FP) physicians have been examined in terms of care outcomes and cost, there have been few studies of specialty differences in physician-patient communication. METHODS: In 1995, 277 clinical encounters with 29 full-time, community-based FP physicians and 287 clinical encounters with 30 full-time, community based IM physicians were audiotaped. Communication was evaluated with the Roter Interaction Analysis System to reflect data gathering, patient education and counseling, rapport building, partnership building, verbal dominance, and patient-centeredness. Patient satisfaction was measured with an exit questionnaire. RESULTS: IM clinicians ask more biomedical questions (P =.02). FP clinicians engage in more psychosocial discussion (P =.02) and tend to engage in more emotionally supportive exchanges such as empathy and reassurance (P =.06). Significant interaction effects show differential treatment of patient subgroups by specialty; FP physicians were more verbally dominant with female patients (P < .01) and more patient-centered in their communication style with minority patients (P =.03). Although patient satisfaction was similar for IM and FP, satisfaction was more closely linked to measures of rapport and patient-centeredness for patients of FP physicians than for patients of internists. CONCLUSIONS: The current work adds insight into FP and IM differences in both physician-patient communication and predictors of patient satisfaction.

Pahal JS, Li HZ. The dynamics of resident-patient communication: data from Canada. Commun Med. 2006;3(2):161-70.
(Resident Training, Canada)
The objectives of this study were to examine patterns of resident-patient communication and the relationship between resident patterns of speech with patient satisfaction. Forty consultations, ten in each of the four gender combinations (male resident/male patient, male resident/female patient, female resident/female patient, female resident/male patient) were audiotaped and microanalyzed using the Roter Interaction Analysis System. Several findings depart significantly from previous studies with physician-only or physician-resident-mixed samples. First, the average length of the 40 consultations was 19.5 minutes, 11.3 minutes longer than consultations in a physician-only sample drawn in the same clinic previously. Second, male residents engaged in twice as much psychosocial talk as female residents and conducted longer consultations. Third, residents asked 80% of the total questions while patients asked 20% of the questions. Previous studies with physician-only or physician-resident-mixed samples reported that physicians ask 89-99% of the total questions. Finally, patients' overall satisfaction and communication satisfaction were negatively correlated with residents' positive talk, which constitutes 31% of a given resident's total utterances. In the study conducted in the same clinic with a physician-only sample, physician positive talk was 26% and physician positive talk was not correlated with patient satisfaction. Is this a signal that residents should reduce the amount of positive talk? Apparently more studies with resident-only samples are needed to answer this and other unanswered questions in the field to offer directives to resident training.

Pieterse AH, van Dulmen AM, Ausems MG, Beemer FA, Bensing JM. Communication in cancer genetic counselling: does it reflect counselees' previsit needs and preferences? Br J Cancer. 2005 May 9;92(9):1671-8.
(Oncology, Genetics Counseling, Netherlands)
This study sought to describe counsellor-counselee interaction during initial cancer genetic counselling consultations and to examine whether the communication reflects counselees' previsit needs. A total of 130 consecutive counselees, referred mainly for breast or colon cancer, completed a questionnaire before their first appointment at a genetic clinic. Their visit was videotaped. Counselee and counsellor verbal communications were analysed and initiative to discuss 11 genetics-specific conversational topics was assessed. The content of the visit appeared relatively standard. Overall, counselees had a stronger psychosocial focus than counsellors. Counsellors directed the communication more and initiated the discussion of most of the topics assessed. Counselees did not appear to communicate readily in a manner that reflected their previsit needs. Counsellors provided more psychosocial information to counselees in higher need for emotional support, yet did not enquire more about counselees' specific concerns. New counselees may be helped by receiving more information on the counselling procedure prior to their visit, and may be advised to prepare the visit more thoroughly so as to help them verbalise more their queries during the visit.

Pieterse AH, van Dulmen AM, Beemer FA, Bensing JM, Ausems MG. Cancer genetic counseling: communication and counselees' post-visit satisfaction, cognitions, anxiety, and needs fulfillment. J Genet Couns. 2007 Feb;16(1):85-96.
(Cancer, Genetics Counseling, Netherlands)
Little is known about the relation between communication during cancer genetic counseling and outcome. We assessed associations between counselor-counselee communication and counselee satisfaction, cognitions, anxiety, and fulfillment of major needs, corrected for pre-visit levels as appropriate. In total 171 consecutive new counselees, mainly referred for breast or colon cancer, received pre- and post-visit questionnaires assessing needs/fulfillment, knowledge, perceived control (PPC), anxiety (STAI), and satisfaction. Initial visits were videotaped and counselor eye gaze was recorded. Verbal communication was rated by Roter Interaction Analysis System (RIAS). Asking more medical questions was associated with lower satisfaction levels. Receiving more medical information was related to higher correct knowledge scores, higher reported fulfillment of some needs, and unrelated to perceptions of control. Receiving more psychosocial information and longer counselor eye gaze were related to higher anxiety scores. Longer visits were related to higher correct knowledge scores. Providing medical information appears the most powerful communication aspect to increase counselee satisfaction and address needs. More research is needed on how to address adequately (emotional) needs and increase feelings of control.

Pieterse AH, van Dulmen AM, Beemer FA, Ausems MG, Bensing JM. Tailoring communication in cancer genetic counseling through individual video-supported feedback: A controlled pretest-posttest design. Patient Educ Couns. 2006 Mar;60(3):326-35.
(Genetics Counseling, Netherlands)
OBJECTIVES: To assess the influence of a 1-day individual video-feedback training for cancer genetic counselors on the interaction during initial visits. Feedback was intended to help counselors make counselees' needs more explicit and increase counselors' sensitivity to these. METHODS: In total 158 counselees, mainly referred for breast or colon cancer and visiting 1 of 10 counselors, received a pre- and post-visit questionnaire assessing needs (fulfillment). Visits were videotaped, counselor eye gaze was assessed, and verbal communication was analyzed by Roter Interaction Analysis System (RIAS) adapted to the genetic setting. Halfway the study, five counselors were trained. RESULTS: Trained counselors provided more psychosocial information, and with trained counselors emotional consequences of DNA-testing was more often discussed. Counselees seen by a trained counselor considered their need for explanations on (emotional) consequences of counseling as better fulfilled. Unexpectedly, counselees' contribution to the interaction was smaller with trained counselors. CONCLUSION: Feedback appeared to result in greater emphasis on psychosocial issues, without lengthening the visit. However, counselors did not become more verbally supportive in other ways than by providing information. PRACTICE IMPLICATIONS: A 1 day individual training appears effective to some extend; increased opportunities for watching and practicing behavioral alternatives and arranging consolidating sessions may improve training results.

Price EG, Windish DM, Magaziner J, Cooper LA. Assessing validity of standardized patient ratings of medical students' communication behavior using the Roter interaction analysis system. Patient Educ Couns. 2008 Jan;70(1):3-9.
(Standardized Patients, United States)
OBJECTIVE: The primary objective of this study is to examine concurrent validity of standardized patient (SP) ratings of second year medical students' communication skills with the Roter interaction analysis system (RIAS). METHODS: We designed An Integrated Medical Encounter (AIME), to teach second year medical students the link between communication and clinical reasoning with emphasis placed on understanding the connection between biomedical and psychosocial aspects of patient care. We randomized 120 students to intervention (AIME) and control groups (non-AIME). Students completed two post-intervention SP encounters which were videotaped and coded using RIAS. SPs used a 30-item checklist to rate students' communication behaviors. RESULTS: There were no differences between AIME and non-AIME students in age, ethnicity, gender, or college major; however, more AIME students reported prior health professional work. SPs rated AIME students' rapport-building skills higher (mean [S.E.]: 4.1 [0.15] vs. 3.9 [0.15], p=0.05); however, there were no differences in data gathering, patient education/counseling. RIAS demonstrated that AIME students more frequently used rapport-building statements (60.4 [2.7] vs. 52.1 [2.8], p=0.03). CONCLUSION: The RIAS confirmed SP ratings of differences in AIME and non-AIME students' rapport-building skills. PRACTICE IMPLICATIONS: Future studies in medical education should further examine the minimum number of SP ratings needed to effectively evaluate communication skills curricula when resources are limited.

Ratanawongsa N, Roter D, Beach MC, Laird SL, Larson SM, Carson KA, Cooper LA. Physician burnout and patient-physician communication during primary care encounters. J Gen Intern Med. 2008 Oct;23(10):1581-8.
(Primary Care, United States)
BACKGROUND: Although previous studies suggest an association between provider burnout and suboptimal self-reported communication, no studies relate physician burnout to observed patient-physician communication behaviors. OBJECTIVE: To investigate the relationship between physician burnout and observed patient-physician communication outcomes in patient-physician encounters. DESIGN: Longitudinal study of enrollment data from a trial of interventions to improve patient adherence to hypertension treatment. SETTING: Fifteen urban community-based clinics in Baltimore, MD. PARTICIPANTS: Forty physicians and 235 of their adult hypertensive patients, with oversampling of ethnic minorities and poor persons. Fifty-three percent of physicians were women, and the average practice experience was 11.2 years. Among the 235 patients, 66% were women, 60% were African-American, and 90% were insured. MEASUREMENTS: Audiotape analysis of communication during outpatient encounters (one per patient) using the Roter Interaction Analysis System and patients' ratings of satisfaction with and trust and confidence in the physician. RESULTS: The median time between the physician burnout assessment and the patient encounter was 15.1 months (range 5.6-30). Multivariate analyses revealed no significant differences in physician communication based on physician burnout. However, compared with patients of low-burnout physicians, patients of high-burnout physicians gave twice as many negative rapport-building statements (incident risk ratio 2.06, 95% CI 1.58-2.86, p < 0.001). Physician burnout was not significantly associated with physician or patient affect, patient-centeredness, verbal dominance, or length of the encounter. Physician burnout was also not significantly associated with patients' ratings of their satisfaction, confidence, or trust. CONCLUSIONS: Physician burnout was not associated with physician communication behaviors nor with most measures of patient-centered communication. However, patients engaged in more rapport-building behaviors. These findings suggest a complex relationship between physician burnout and patient-physician communication, which should be investigated and linked to patient outcomes in future research.

Richard C, Lussier MT. MEDICODE: an instrument to describe and evaluate exchanges on medications that occur during medical encounters. Patient Educ Couns. 2006 Dec;64(1-3):197-206.
(Primary Care, United States)
OBJECTIVE: To examine the psychometric properties of MEDICODE, a coding instrument developed to assess medication discussions during medical consultations. METHODS: Inter-coder reliability, test-retest stability, and concurrent validity with the Roter Interaction Analysis System (RIAS) and predictive validity with the Medical Interview Satisfaction Scale (MISS) were calculated. RESULTS: Inter-coder reliability and test-retest stability for medication class and status were both very good. Inter-coder agreement and test-retest stability for theme identification were mostly over 90%. Kappa values for theme identification varied from acceptable to excellent for 21 of the 29 and for 26 of the 37 Kappa coefficients that could be calculated. The mean percent agreement between MEDICODE and RIAS for medication class was of 96.8% and the mean Kappa value was 0.83. Although the mean percent agreement for the presence of a theme in MEDICODE and RIAS was 81%, the average Kappa coefficients were lower at 0.40. However, each of the four broad theme categories had its share of themes with robust Kappa values. We found significant positive correlations (p < 0.05) between discussions of medication main effects and instructions with patient satisfaction. CONCLUSION: With a reasonable amount of training, the coders were able to produce reliable and valid measures of discussions of medications during medical consultations. PRACTICAL IMPLICATIONS: MEDICODE will facilitate the study of the impact of the nature and intensity of discussions about medications during consultations on patient medication knowledge, medication recall and compliance.

Rost K, Roter D. Predictors of recall of medication regimens and recommendations for lifestyle change in elderly patients. Gerontologist. 1987 Aug;27(4):510-5.
(Primary Care, United States)
Post-visit recall of medication regimens and lifestyle recommendations was explored among 83 elderly patients making visits to a clinic which specialized in care of the elderly. Recall was problematic, with the average elderly patient failing to recall 46% of the medications recorded in the chart. Of the 42 patients receiving lifestyle recommendations, 52% failed to recall them post-visit. Patterns of communication during the visit were more strongly related to recall than patients' ages, affective state or cognitive functioning.

Rost K, Roter D, Bertakis K, Quill T. Physician-patient familiarity and patient recall of medication changes. The Collaborative Study Group of the SGIM Task Force on the Doctor and Patient. Fam Med. 1990 Nov-Dec;22(6):453-7.
(Primary Care, Patient Recall and Satisfaction, United States)
Although patients regularly see the same physicain for medical care, little is known about the effects of physician-patient familiarity on important visit outcomes. In a study of visits made to 79 physicians in 11 primary care settings, investigators sought to determine: 1) whether patient recall of prescription medication changes improved as physician-patient familiarity increased, and 2) whether characteristics which predicted recall for newer patients also predicted recall for intermediate and established patients. Sixty-six percent of patients recalled all medication changes recommended during the visit. While recall did not improve as physician-patient familiarity increased, predictors of recall did differ. Generally, the more drug information the physician gave during the concluding segment of the visit, the fewer drug changes the patient remembered. However, this relationship reversed as physician-patient familiarity increased. Elderly patients demonstrated diminished recall regardless of the number of previous visits. The findings suggest that the lengthy provision of drug information actually succeeds in heightening medication recall only when the physician and patient have a well-established relationship. In earlier stages, asking patients to restate recommendations may be a more effective strategy to enhance patient recall.

Rost K, Roter D, Quill T, Bertakis K. Capacity to remember prescription drug changes: deficits associated with diabetes. Collaborative Study Group of the Task Force on the Medical Interview. Diabetes Res Clin Pract. 1990 Oct;10(2):183-7.
(Primary Care, Patient Recall and Satisfaction, United States)
This study compared the capacity of 44 diabetes patients and 131 non-diabetic patients to remember prescription medication recommendations made during return visits to primary care clinics. Diabetes patients were 1.6-times less likely to remember all medication recommendations immediately after the visit than non-diabetic patients, a discrepancy which remained significant after controlling for sociodemographic, health status and treatment differences between the two groups. The results suggest that the cognitive deficits that diabetes patients demonstrate in laboratory testing may be severe enough to diminish their ability to learn treatment recommendations made in primary care settings. Further research is needed to determine whether recall is problematic for diabetes patients in general, or primarily for those in poor metabolic control. Clinicians who treat diabetes patients need to incorporate readily implemented strategies to promote patient recall for substantial numbers of diabetes patients to benefit from pharmacological treatment.

Roter DL. Patient participation in the patient-provider interaction: the effects of patient question asking on the quality of interaction, satisfaction, and compliance. Health Educ Monogr. 1977 Winter;5(4):281-315
(Primary Care, Patient Recall or Satisfaction, United States)
The purpose of this study was to investigate the effectiveness, dynamics, and consequences of a health education intervention designed to increase patient question asking during the patient's medical visit. Data were collected at a Baltimore family and community health center which provides outpatient services to a low income, predominantly black and female population. The majority of the study participants were, in addition, elderly and chronically ill. A total of 294 patients and 3 providers took part in the study. The study design included random assignment of patients to experimental and placebo groups with two non-equivalent (non-randomized) control groups. Findings included: (1) The experimental group patients asked more direct questions and fewer indirect questions than did placebo group patients. (2) The experimental group patient-provider interaction was characterized by negative affect, anxiety, and anger, while the placebo group patient-provider interaction was characterized as mutually sympathetic. (3) The experimental group patients were less satisfied with care received in the clinic on the day of their visit than were placebo patients. (4) The experimental group patients demonstrated higher appointment-keeping ratios (an average number of appointments kept divided by an average number of appointments made) during a four-month prospective monitoring period.

Roter DL. Patient question asking in physician-patient interaction. Health Psychol. 1984;3(5):395-409.
(Primary Care, United States)
Patient question asking may be regarded as not only a method of information seeking but as a mechanism of patient participation in the medical dialogue. As such, the study of question asking behavior provides insight into the physician-patient communication process. Presented is an analysis of data gathered as part of an experimental intervention designed to increase patient question asking during routine medical visits. Audiotape recordings of two physicians in 123 medical visits were content analyzed to identify the number, content, and form of patient questions, as well as a variety of other interaction variables. These measures were then related to patient satisfaction with care. Findings indicate that the experimental intervention had significant effect on increasing the number of direct questions asked and that these were asked outside of their usual interaction pattern. Further, the relationship between question asking and satisfaction differed in the two groups. The study contributes to our understanding of physician-patient communication dynamics and the information seeking process.

Roter DL. Elderly patient-physician communication: A descriptive study of content and affect during the medical encounter. Advances in Health Education. 1991;3:179-190.
(Primary Care, United States)
This paper investigates the communication dynamics between elderly patients and their physicians during the medical encounter with a special focus on physicians' perception and response to patients' emotional state during the visit. The study was conducted in the outpatient facilities of a large teaching hospital and included observations of 83 patient encounters with 3 physicians. Each encounter was audiotaped and followed with patient and physician exit questionnaires. Physicians were quite sensitive to the emotional state of their patients, as measured by objective coders and standardized tests. Moreover, communication between patients and physicians was considerably different in medical visits for patients rated by their physician as psychologically distressed than for patients rated as nondistressed. Physicians were more likely to use open-ended questions regarding feelings and emotions, and provide reassurance and comfort to patients they rated as anxious, demented, depressed, emotionally dependent, or irritated. These patients were also less likely to receive medical information about their medical condition.

Roter DL, Cole KA, Kern DE, Barker LR, Grayson M. An evaluation of residency training in interviewing skills and the psychosocial domain of medical practice. J Gen Intern Med. 1990 Jul-Aug;5(4):347-54.
(Primary Care, Communication Skills Training, United States)
Competent use of interviewing skills is important for the care of all patients but is especially critical, and frequently deficient, in meeting the needs of patients experiencing emotional distress. This study presents an evaluation of a curriculum in communication and psychosocial skills taught to first-year medical residents. A randomized experimental design compared trained and untrained residents' (n = 48) performances with a simulated patient presenting with atypical chest pain and psychosocial distress. Evaluation was based on analysis of videotapes, simulated patient report of residents' behaviors, and chart notation. Trained compared with untrained residents asked more open-ended questions and fewer leading questions, summarized main points more frequently, did more psychosocial counseling, and were rated as having better communication skills by the simulated patient. The use of more focused and psychosocially directed questions, and fewer leading and grab-bag questions, was associated with more accurate diagnoses and management recorded in the medical chart. However, no significant difference was found in the charting practices of trained versus untrained residents.

Roter D, Ellington L, Erby LH, Larson S, Dudley W. The Genetic Counseling Video Project (GCVP): models of practice. Am J Med Genet C Semin Med Genet. 2006 Nov 15;142(4):209-20.
(Genetic Counseling, United States)
Genetic counseling is conceptualized as having both "teaching" and "counseling" functions; however, little is known about how these functions are articulated in routine practice. This study addresses the question by documenting, on videotape, the practices of a national sample of prenatal and cancer genetic counselors (GCs) providing routine pre-test counseling to simulated clients (SCs). One hundred and seventy-seven GCs recruited at two annual conferences of the National Society of Genetic Counselors (NSGC) were randomly assigned to counsel one of six female SCs of varying ethnicity, with or without a spouse, in their specialty. One hundred and fifty-two videotapes were coded with the Roter Interaction Analysis System (RIAS) and both GCs and SCs completed evaluative questionnaires. Two teaching and two counseling patterns of practice emerged from cluster analysis. The teaching patterns included: (1) clinical teaching (31%) characterized by low psychosocial, emotional and facilitative talk, high levels of clinical exchange, and high verbal dominance; and (2) psycho-educational teaching (27%) characterized by high levels of both clinical and psychosocial exchange, low levels of emotional and facilitative talk, and higher verbal dominance. The counseling patterns included: (1) supportive counseling (33%) characterized by low psychosocial and clinical exchange, high levels of emotional and facilitative talk, and low verbal dominance; and (2) psychosocial counseling (9%) with high emotional and facilitative talk, low clinical and high psychosocial exchange, and the lowest verbal dominance. SCs ratings of satisfaction with communication, the counselor's affective demeanor, and the counselor's use of non-verbal skills were highest for the counseling model sessions. Both the teaching and counseling models seem to be represented in routine practice and predict variation in client satisfaction, affective demeanor, and nonverbal effectiveness.

Roter DL, Erby L, Larson S, Ellington L. Oral literacy demand of prenatal genetic counseling dialogue: Predictors of learning. Patient Educ Couns. 2009 Jun;75(3):392-7. Epub 2009 Feb 27.
(Health Literacy, Genetic Counseling, United States)
OBJECTIVE: To assess the relationship between the oral literacy demand of genetic counseling sessions and the ability of low literate subjects to learn genetics-related information. METHODS: Ninety-six simulated genetic counseling sessions were videotaped and shown to 312 subjects recruited to imagine themselves as the session's client. Study measures included oral literacy demand, operationalized as: (1) use of key genetics terms; (2) informational context; (3) general language complexity; and (4) structural characteristics of dialogue interactivity. The study outcome was learning of genetics-related information. RESULTS: Subjects with restricted literacy (below 8th grade level) learned more when viewing sessions with greater dialogue interactivity and more personally contextualized information. Subjects with adequate literacy skills, however, tended to learn less in low literacy demand sessions. CONCLUSION: The oral literacy demand of medical dialogue represents a learning obstacle to low literate subjects. However, this may not be the case for those with greater literacy skills who can understand the complex language and process the dense informational load of high demand sessions. PRACTICE IMPLICATIONS: In order to meet the educational needs of all patients, clinicians must attend to both the informativeness and the oral literacy demand of their communication.

Roter DL, Erby LH, Larson S, Ellington L. Assessing oral literacy demand in genetic counseling dialogue: preliminary test of a conceptual framework. Soc Sci Med. 2007 Oct;65(7):1442-57. Epub 2007 Jul 5.
(Health Literacy, Genetic Counseling, United States)
Health literacy deficits affect half the American patient population and are linked to poor health, ineffective disease management and high rates of hospitalization. Restricted literacy has also been linked with less satisfying medical visits and communication difficulties, particularly in terms of the interpersonal and informational aspects of care. Despite growing attention to these issues by researchers and policy makers, few studies have attempted to conceptualize and assess those aspects of dialogue that challenge persons with low literacy skills, i.e., the oral literacy demand within medical encounters. The current study uses videotapes and transcripts of 152 prenatal and cancer pretest genetic counseling sessions recorded with simulated clients to develop a conceptual framework to explore oral literacy demand and its consequences for medical interaction and related outcomes. Ninety-six prenatal and 81 cancer genetic counselors-broadly representative of the US National Society of Genetic Counselors-participated in the study. Key elements of the conceptual framework used to define oral literacy demand include: (1) use of unfamiliar technical terms; (2) general language complexity, reflected in the application of Microsoft Word grammar summary statistics to session transcripts; and, (3) structural characteristics of dialogue, including pacing, density, and interactivity. Genetic counselor outcomes include self-ratings of session satisfaction, informativeness, and development of rapport. The simulated clients rated their satisfaction with session communication, the counselor's effective use of nonverbal skills, and the counselor's affective demeanor during the session. Sessions with greater overall technical term use were longer and used more complex language reflected in readability indices and multi-syllabic vocabulary (measures averaging p < .05). Sessions with a high proportionate use of technical terms were characterized by shorter visits, high readability demand, slow speech speed, fewer and more dense counselor speaking turns and low interactivity (p < .05).The higher the use of technical terms, and the more dense and less interactive the dialogue, the less satisfied the simulated clients were and the lower their ratings were of counselors' nonverbal effectiveness and affective demeanor (all relationships p < .05). Counselors' self-ratings of informativeness were also inversely related to use of technical terms (p < .05). Just as print material can be made more reader-friendly and effective following established guidelines, the medical dialogue may also be made more patient-centered and meaningful by having providers monitor their vocabulary and language, as well as the structural characteristics of interaction, thereby lowering the literacy demand of routine medical dialogue. These consequences are important for all patients but may be even more so for patients with restricted literacy.

Roter DL, Ewart CK. Emotional inhibition in essential hypertension: obstacle to communication during medical visits? Health Psychol. 1992;11(3):163-9.
(Primary Care, Patient Emotional Distress, United States)
A substantial literature on the "hypertensive personality" links essential hypertension (EH) with the suppression of negative emotions, implying that suppression may elevate blood pressure. Yet affective inhibition might also impair communication with health care providers and exacerbate EH by limiting therapeutic collaboration. We studied 542 patient-physician interviews from a national sample to see if patients with EH (n = 203) were less likely to exhibit negative emotions than normotensive patients (n = 339) as rated by their physicians and independent observers. EH patients did not differ from others on self-rated emotional or physical health. However, physicians were less accurate in characterizing the emotional states of EH patients than those of normotensive patients, and they rated EH patients as exhibiting fewer signs of distress during the visit. Independent observers also judged the EH patients as less distressed than normotensives, thereby validating the physicians' appraisals. Content analysis disclosed that physicians paid less attention to psychosocial concerns and concentrated on biomedical matters to a greater degree with hypertensive patients than with their normotensive patients. EH patients, particularly those experiencing emotional distress, appear to have patterns of self-presentation that could present an obstacle to effective communication with their physicians, and this difficulty may be amplified by physicians' disinclination to probe for emotional difficulty.

Roter DL, Geller G, Bernhardt BA, Larson SM, Doksum T. Effects of obstetrician gender on communication and patient satisfaction. Obstet Gynecol. 1999 May;93(5 Pt 1):635-41.
(Outside Primary Care, United States)
OBJECTIVE: To describe patient-obstetrician communication during the first prenatal visit and its relationship to physician gender and patient satisfaction. METHODS: The first prenatal visit of 87 women with 21 obstetricians (11 male and ten female) was audiotaped and analyzed using the Roter Interaction Analysis System. Patient satisfaction was measured by postvisit questionnaire. RESULTS: Communication during first prenatal visits was largely biomedical, with little psychosocial or social discussion. Male physicians conducted longer visits than females (26 minutes versus 21.9 minutes, P < .05) and engaged in more facilitative communication (ie, making sure they were understood and providing direction and orientation) and explicit statements of concern and partnership (z > 1.96, P < .05). Female physicians devoted more communication to agreements, disagreements, and laughter than males (z > 1.96, P < .05). Satisfaction with physicians' emotional responsiveness and informational partnership was related to female physician gender and a variety of task-focused and affective communication variables. CONCLUSION: Communication and satisfaction between women and obstetricians during initial prenatal visits is related to physician gender and patient satisfaction. Male physicians conducted longer visits but women were more satisfied with female physicians.

Roter DL, Hall JA. Physician's interviewing styles and medical information obtained from patients. J Gen Intern Med. 1987 Sep-Oct;2(5):325-9.
(Primary Care, Communication Skills Training, United States)
This paper investigates the association between physicians' interviewing styles and medical information obtained during simulated patient encounters. The sources of data are audiotapes and transcripts of two standardized patient cases presented by trained patient simulators to 43 primary care practitioners. Transcripts were scored for physician proficiency using expert-generated criteria and were content-analyzed to assess the process of communication and information content. Relevant patient disclosure was also scored from the transcripts based on expert-generated criteria. Findings were: 1) On the whole, physicians elicited only slightly more than 50% of the medical information considered important according to expert consensus, with a range from 9% to 85%. 2) Both open and closed questions were substantially related to patient disclosure of medical information to the physician, but open questions were substantially more so (Pearson correlations of 0.37 and 0.72, respectively). 3) Patient education, particularly information regarding prognosis, cause, and prevention, was substantially related to patient disclosure of medical information to the physician (Pearson correlations of 0.44, 0.36, and 0.34, respectively). 5) Finally, clinical expertise was only weakly associated with patient disclosure of medical information to the physician (Pearson correlation of 0.16).

Roter DL, Hall JA, Katz NR. (1987). Relations between physicians' behaviors and patients' satisfaction, recall, and impressions: An analogue study. Med Care. 1987 May;25(5):437-51.
(Primary Care, Patient Recall and Satisfaction, United States)
This paper investigates associations between physicians' task-oriented and socioemotional behaviors, on the one hand, and analogue patients' satisfaction, recall of information, and global impressions. The study is based on role-playing subjects' responses to interactions between physicians and simulated patients. Audiotapes of two standardized patient cases presented by trained patient simulators to 43 primary care physicians were rated by role-playing patients (N = 258), and electronically filtered excerpts from the encounters were rated for vocal affect by 37 independent judges. Content analysis was made of the visits' transcripts to assess interaction process and to identify all medical information communicated. Finally, speech error rate was calculated from a combination of audiotape and transcript. Findings revealed that role-playing patients clearly distinguished task from socioemotional behaviors of the physicians, and a consistent pattern of association emerged between physicians' task behaviors and role-playing patients' satisfaction, recall, and impressions. Within the task domain, patient-centered skills (i.e., giving information and counseling) were consistently related to patient effects in a positive direction, but physician-centered behaviors (i.e., giving directions and asking questions) demonstrated the opposite relationship. A negative pattern of association was also evident between physicians' socioemotional behaviors and patient effects.

Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians' interviewing skills and reducing patients' emotional distress: A randomized clinical trial. Arch Intern Med 1995 Sep 25;155(17):1877-84.
(Primary Care, Communication Skills Training, Patient Emotional Distress, United States)
BACKGROUND: Despite high prevalence, emotional distress among primary care patients often goes unrecognized during routine medical encounters. OBJECTIVE: To explore the effect of communication-skills training on the process and outcome of care associated with patients' emotional distress. METHODS: A randomized, controlled field trial was conducted with 69 primary care physicians and 648 of their patients. Physicians were randomized to a no-training control group or one of two communication-skills training courses designed to help physicians address patients' emotional distress. The two training courses addressed communication through problem-defining skills or emotion-handling skills. All office visits of study physicians were audiotaped until five emotionally distressed and five nondistressed patients were enrolled based on patient response to the General Health Questionnaire. Physicians were also audiotaped interviewing a simulated patient to evaluate clinical proficiency. Telephone monitoring of distressed patients for utilization of medical services and General Health Questionnaire scores was conducted 2 weeks, 3 months, and 6 months after their audiotaped office visits. RESULTS: Audiotape analysis of actual and simulated patients showed that trained physicians used significantly more problem-defining and emotion-handling skills than did untrained physicians, without increasing the length of the visit. Trained physicians also reported more psychosocial problems, engaged in more strategies for managing emotional problems with actual patients, and scored higher in clinical proficiency with simulated patients. Patients of trained physicians reported reduction in emotional distress for as long as 6 months. CONCLUSIONS: Important changes in physicians' communication skills were evident after an 8-hour program. The training improved the process and outcome of care without lengthening the visits.

Roter DL, Knowles N, Somerfield M, Baldwin J. Routine communication in sexually transmitted disease clinics: an observational study. Am J Public Health 1990 May;80(5):605-6.
(Outside Primary Care, United States)
Sixty STD patients were followed during the course of their clinic visit which averaged 2.75 professional contacts. Based on audiotape analysis, virtually all patients received a diagnosis; however, 25 percent of the patients did not receive any information about treatment or prevention, and only 57 percent of patients were given complete information. Patient recall of the information they were given averaged about 43 percent. Patients not seen by a physician during their clinic visit achieved higher recall rates than patients seen by a physician.

Roter D, Larson S. The Roter interaction analysis system (RIAS): utility and flexibility for analysis of medical interactions. Patient Educ Couns 2002 Apr;46(4):243-51.
(Primary Care, United States)
The Roter interaction analysis system (RIAS), a method for coding medical dialogue, is widely used in the US and Europe and has been applied to medical exchanges in Asia, Africa, and Latin America. Contributing to its rapid dissemination and adoption is the system's ability to provide reasonable depth, sensitivity, and breadth while maintaining practicality, functional specificity, flexibility, reliability, and predictive validity to a variety of patient and provider outcomes. The purpose of this essay is two-fold. First, to broadly overview the RIAS and to present key capabilities and coding conventions, and secondly to address the extent to which the RIAS is consistent with, or complementary to, linguistic-based techniques of communication analysis.

Roter DL, Larson S. The relationship between residents’ and attending physicians’ communication during primary care visits: an illustrative use of the Roter Interaction Analysis System (RIAS). Health Commun 2001;13(1);33-48.
(Primary Care, United States)
This is a descriptive study of residents' and attending physicians' communication profiles during primary care encounters. A small study sample of 10 audiotapes of medical visits between patients and their medical residents was used to illustrate the application of the RIAS. In 8 of these visits, an attending physician was present and consulted with the resident about the case for varying periods of time. RIAS analysis was structured to explore the relationship between these residents and their attending physicians' communication. Differences in the communication profile distributions between residents and attendings were evident in all four of the visit functions—education and counseling, data-gathering, rapport-building, and providing procedural cues to the patient.

Roter DL, Larson SM, Beach MC, Cooper LA. Interactive and evaluative correlates of dialogue sequence: A simulation study applying the RIAS to turn taking structures. Patient Educ Couns. 2008 Apr;71(1):26-33.
(Interaction Analysis, United States)
OBJECTIVE: This study explores novel characterizations of turn taking structure and its interaction and evaluative correlates. METHODS: The Roter Interaction Analysis System (RIAS) was applied to videotapes of 51 physicians with a simulated patient (SP) to create a variety of novel turn taking measures including turn frequency, rate of interactivity, density, duration, and statement pacing. RESULTS: Visits averaged 52 speaker turns with an interactivity rate of 3.9 turns per visit minute. For physicians, turn duration averaged 13.7s with a turn density of 4.2 statements paced at one statement every 3s. For the SP, turn duration was 3s with a turn density of 1.4 statements paced at one statement every 2s. More turns, briefer turn duration and faster physician pacing were significantly related to positive ratings of affective demeanor, interpersonal satisfaction and collaborative decision-making. These measures, and interactivity, were also associated with a RIAS-based patient-centeredness score and more overall patient talk. CONCLUSION: Turn taking structures can be characterized in novel ways lending depth and richness to our understanding of dialogue, relationships to the patient-centeredness of a visit, and evaluative judgments of physician performance. PRACTICE IMPLICATIONS: The study findings suggest specificity to the interviewing admonishment "talk less and listen more" by enhancing the interactivity of the dialogue and guarding against doctors tendency toward long monologues.

Roter DL, Larson S, Fischer CS, Arnold RM, Tulsky, JA. Experts practice what they preach: A descriptive study of best and normative practices in end of life discussions. Arch Intern Med. 2000 Dec 11-25;160(22):3477-85.
(Primary Care, United States)
BACKGROUND: Advance directives (ADs) are widely regarded as the best available mechanism to ensure that patients' wishes about medical treatment at the end of life are respected. However, observational studies suggest that these discussions often fail to meet their stated goals. OBJECTIVES: To explore best practices by describing what physicians who are considered expert in the area of end of-life bioethics or medical communication do when discussing ADs with their patients and to explore the ways in which best practices of the expert group might differ in content or style from normative practice derived from primary care physicians' discussions of ADs with their patients collected as part of an earlier study. DESIGN: Nonexperimental, descriptive study of audiotaped discussions. SETTING: Outpatient primary care practices in the United States. PARTICIPANTS: Eighteen internists who have published articles in the areas of bioethics or communication and 48 of their patients. Fifty-six academic internists and 56 of their established patients in 5 practice sites in 2 locations-Durham, NC, and Pittsburgh, Pa. Eligible patients were at least 65 years old or suffered from serious medical illness and had not previously discussed ADs with their physician. Expert clinicians had discretion regarding patient selection, while the internists chose patients according to a predetermined protocol. MEASUREMENTS: Coders applied the Roter Interaction Analysis System (RIAS) to audiotapes of the medical visits to describe communication dynamics. In addition, the audiotapes were scored on 21 items reflecting physician performance in specific skills related to AD discussions. RESULTS: Experts spent close to twice as much time (14.7 vs 8.1 minutes, P < .001) and were less verbally dominant (P < .05) than other physicians during AD discussions. When length of visit was controlled statistically, the expert physicians gave less information about treatment procedures and biomedical issues (P < .05) and asked fewer related questions (P < . 05) but tended toward more psychosocial and lifestyle discussion and questions. Experts engaged in more partnership building (P < .05) with their patients. Patients of the expert physicians engaged in more psychosocial and lifestyle discussion (P < .001), and more positive talk (P < .05) than patients of community physicians. Expert physicians scored higher on the 21 items reflecting AD-specific skills (P < .001). CONCLUSIONS: Best practices as reflected in the performance of expert physicians reflect differences in measures of communication style and in specific AD-related proficiencies. Physician training in ADs must be broad enough to include both of these domains.

Roter DL, Larson S, Sands DZ, Ford DE, Houston T. Can e-mail messages between patients and physicians be patient-centered? Health Commun. 2008 Jan-Feb;23(1):80-6.
(e-mail Communication, United States)
This study explores the extent to which e-mail messages between patients and physicians mimic the communication dynamics of traditional medical dialogue and its fulfillment of communication functions. Eight volunteers drawn from a larger study of e-mail users agreed to supply copies of their last 5 e-mail messages with their physicians and the physician replies. Seventy-four e-mail messages (40 patient and 34 physician) were provided and coded using the Roter Interactive Analysis System. The study found that physicians' e-mails are shorter and more direct than those of patients, averaging half the number of statements (7 vs. 14; p < .02) and words (62 vs. 121; p < .02). Whereas 72% of physician and 59% of patient statements were devoted to information exchange, the remaining communication is characterized as expressing and responding to emotions and acting to build a therapeutic partnership. Comparisons between e-mail and with face-to-face communication show many similarities in the address of these tasks. The authors concluded that e-mail accomplishes informational tasks but is also a vehicle for emotional support and partnership. The patterns of e-mail exchange appear similar to those of in-person visits and can be used by physicians in a patient-centered manner. E-mail has the potential to support the doctor-patient relationship by providing a medium through which patients can express worries and concerns and physicians can be patient-centered in response.

Roter DL, Larson S, Shinitzky H, Chernoff R, Serwint JR, Adamo G, Wissow L. Use of an innovative video feedback technique to enhance communication skills training. Med Educ. 2004 Feb;38(2):145-57.
(Communication Skills Training, Video Feedback, Pediatrics, United States)
CONTEXT: Despite growing interest in medical communication by certification bodies, significant methodological and logistic challenges are evident in experiential methods of instruction. OBJECTIVE: There were three study objectives: 1) to explore the acceptability of an innovative video feedback programme to residents and faculty; 2) to evaluate a brief teaching intervention comprising the video feedback innovation when linked to a one-hour didactic and role-play teaching session on pediatric residents' communication with a simulated patient; and 3) to explore the impact of resident gender on communication change. DESIGN: Pre/post comparison of residents' performance in videotaped interviews with simulated patients before and after the teaching intervention. Individually tailored feedback on targeted communication skills was facilitated by embedding the Roter Interaction Analysis System (RIAS) within a software platform that presents a fully coded interview with instant search and review features. SETTING/PARTICIPANTS: 28 first year residents in a large, urban, pediatric residency programme. RESULTS: Communication changes following the teaching intervention were demonstrated through significant improvements in residents' performance with simulated patients pre and post teaching and feedback. Using paired t-tests, differences include: reduced verbal dominance; increased use of open-ended questions; increased use of empathy; and increased partnership building and problem solving for therapeutic regimen adherence. Female residents demonstrated greater communication change than males. CONCLUSIONS: The RIAS embedded CD-ROM provides a flexible structure for individually tailoring feedback of targeted communication skills that is effective in facilitating communication change as part of a very brief teaching intervention.

Roter D, Lipkin M Jr, Korsgaard A. Sex differences in patients' and physicians' communication during primary care medical visits. Med Care 1991 Nov;29(11):1083-93.
(Primary Care, Gender, Patient Satisfaction, United States)
This study reports on the analysis of audiotapes of 537 adult, chronic disease patients and their 127 physicians (101 men and 26 women) in a variety of primary care practice settings to explore differences attributable to the effects of the patient's and the physician's sex on the process of communication during medical visits. Compared to male physicians, women conducted longer medical visits (22.9 vs 20.3 minutes; F(1,515) = 7.9, P less than .005), with substantially more talk F(1,518) = 19.5, P less than .000. Differences were especially evident during the history segment of the visit when female physicians talked 40% more than male physicians (F(1,518) = 20.1, P less than .000) and when patients of female physicians talked 58% more than male physicians' patients (F(1,448) = 24.4, P less than .000). Compared to male physicians, female physicians engaged in more positive talk, partnership-building, question-asking, and information-giving. Similarly, when with female compared to male physicians, patients engaged in more positive talk, more partnership-building, question-asking, and information-givingrelated to both biomedical and psychosocial topics.

Roter DL, Rosenbaum J, deNegri B, Renaud D, DiPrete-Brown L, Hernandez O. The effects of a continuing medical education programme in interpersonal communication skills on doctor practice and patient satisfaction in Trinidad and Tobago. Med Educ 1998 Mar;32(2):181-9.
(Primary Care, Communication Skills Training, Trinidad and Tobago)
This study investigates the effects of a brief training programme on the communication skills of doctors in ambulatory care settings in Trinidad and Tobago. Evaluation of doctor performance is based on analysis of audiotapes of doctors with their patients during routine clinic visits and on patient satisfaction ratings. A pre-test/post-test quasi-experimental study design was used to evaluate the effects of exposure to the training programme. Doctors were assigned to groups based on voluntary participation in the programme. Audiotapes of the 15 participating doctors (nine trained and six control) with 75 patients at baseline and 71 patients at the post-training assessment were used in this analysis. The audiotapes were content-coded using the Roter Interaction Analysis System (RIAS). Doctors trained in communication skills used significantly more target skills post-training than their untrained colleagues. Trained doctors used more facilitations in their visits and more open-ended questions than other doctors. There was also a trend towards more emotional talk, and more close-ended questions. Patients of trained doctors talked more overall, gave more information to their doctors and tended to use more positive talk compared to other patients. Trained doctors were judged as sounding more interested and friendly, while patients of trained doctors were judged as sounding more dominant, responsive and friendly than patients of untrained doctors. Consistent with these communication differences, patient satisfaction tended to be higher in visits of trained doctors.

Roter DL, Roter HL, Feinstein M. Podiatrist-patient interaction during routine podiatry visits. J JAm Podiatry Assoc 1984 Nov;74(11):553-8.
(Outside Primary Care, United States)
The authors present an empirical description of the content of routine podiatry practice and its relationship to a number of patient effects. Tape recordings of a sampling of 20 patients from private podiatry practices were analyzed to determine typical interaction profiles. Elements of interaction were related to patients' questionnaire responses in such areas as recall of therapeutic recommendations, recall of discussion topcis, and patient satisfaction. Overall findings indicate that satisfaction among podiatry patients was high, with the most significant predictors of satisfaction being: 1) discussion of self-care and preventive activities, 2) short medical history segments, 3) interaction marked by laughter and joking, and 4) physician request for patient opinion on treatment or cause of the problem.

Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA 1997 Jan 22-29;277(4):350-6.
(Primary Care, Patient Recall or Satisfaction, Physician Satisfaction, United States)
OBJECTIVES: To use audiotape analysis to describe communication patterns in primary care, to relate these to ideal relationship types as described in the literature, and to explore the patterns' relationships with physician and patient characteristics and satisfaction. DESIGN: Description of routine communication in primary care based on audiotape analysis and patient and physician exit questionnaires. SETTING: A total of 11 ambulatory clinics and private practices. PARTICIPANTS: The participants were 127 physicians and 537 patients coping with ongoing problems related to disease. MAIN OUTCOMES MEASURES: Roter Interactional Analysis System (RIAS) and patient and physician exit satisfaction questionnaires. RESULTS: Cluster analysis revealed 5 distinct communication patterns: (1) "narrowly biomedical," characterized by closed-ended medical questions and biomedical talk occurring in 32% of visits; (2) "expanded biomedical," like the restricted pattern but with moderate levels of psychosocial discussion occurring in 33% of the visits; (3) "biopsychosocial," reflecting a balance of psychosocial and biomedical topics (20% of the visits); (4) "psychosocial," characterized by psychosocial exchange (8% of visits); and (5) "consumerist," characterized primarily by patient questions and physician information giving (8% of visits). Biomedically focused visits were used more often with more sick, older, and lower income patients by younger, male physicians. Physician satisfaction was lowest in the narrowly biomedical pattern and highest in the consumerist pattern, while patient satisfaction was highest in the psychosocial pattern. CONCLUSIONS: Primary care communication patterns range from narrowly biomedical to consumerist patterns and parallel the ideal forms of patient-physician relationships described in the literature.

Sala F, Krupat E, Roter D. Satisfaction and the use of humor by physicians and patients. Psychology and Health 2002:17(3):269-280.
(Patient Satisfaction, United States)
The current study investigated the extent to which various types of humor are associated with high- and low-satisfaction doctor visits and whether male and female physicians and patients differ in their use of humor. A humor coding scheme, capable of distinguishing three categories (negative, positive, and general) and ten sub-types of humor, was validated against 92 audiotaped physician-patient primary care visits, half rated high and half rated low in satisfaction. Results revealed that physicians and patients used more light humor, more humor that relieves tension, more self-effacing humor, and more positive-function humor in high satisfaction than in low-satisfaction visits. In addition, the patients of female physicians used more humor than the patients of male physicians across levels of satisfaction. The results indicate a strong association between humor and satisfaction, and suggest ways in which humor and laughter help to maintain rapport in the physician-patient relationship.

Sandhu H, Dale J, Stallard N, Crouch R, Glucksman E. Emergency nurse practitioners and doctors consulting with patients in an emergency department: a comparison of communication skills and satisfaction. Emerg Med J. 2009 Jun;26(6):400-4.
(Emergency Medicine, United Kingdom)
BACKGROUND: Emergency nurse practitioners (ENPs) play an increasingly important role in UK emergency departments (EDs), but there is limited evidence about how this affects patient care and outcome. A study was undertaken to compare the content of, and satisfaction with, consultations made with patients presenting with problems of low acuity to an ED. METHODS: Patients presenting with "primary care" problems were allocated to senior house officers (SHOs, n = 10), specialist registrars/staff grades (n = 7), sessionally-employed general practitioners (GPs, n = 12) or ENPs (n = 6) randomly rostered to work in a consulting room that had a wall-mounted video camera. At the end of each consultation the doctor/ENP and the patient were asked to complete the Physician/Patient Satisfaction Questionnaire. A stratified sample of videotaped consultations (n = 296) was analysed in depth using the Roter Interaction Analysis System. The main outcome measures were length of consultation; numbers of utterances of doctor/ENP and patient talk related to building a relationship, data gathering, activating/partnering, and patient education/counselling; doctor/ENP and patient consultation satisfaction scores. RESULTS: ENPs and GPs focused more on patient education and counselling about the medical condition or therapeutic regimen than did ED doctors. There were no significant differences in consultation length. ENPs had higher levels of overall self-satisfaction with their consultations than ED doctors. Patient satisfaction with how actively they participated in the consultation was significantly associated with the amount of talk relating to building a relationship and activating and partnering, and patient satisfaction with information giving in the consultation was significantly associated with the amount of talk relating to building a relationship. CONCLUSION: These findings suggest differences between ENP and ED doctor consultations which are associated with some aspects of patient satisfaction. In contrast to previous reports, consultation length was not greater for ENPs than for doctors. There is a need for further research to test the generalisability of these findings and their impact on clinical outcome.

Sandvik M, Eide H, Lind M, Graugaard PK, Torper J, Finset A. Analyzing medical dialogues: strength and weakness of Roter's interaction analysis system (RIAS). Patient Educ Couns 2002 Apr;46(4):235-41.
(Interaction Analysis, Norway)
Roter's interaction analysis system (RIAS) is analyzed in this article. Ground rules of linguistic interaction analysis, emphasizing meaning as a product of interaction and turn taking as a basic principle for the understanding of interaction are briefly introduced. Specific aspects of the application of RIAS are discussed and a number of adjustments and/or specifications suggested: (1) utterances should be defined in terms of content and turn taking criteria; (2) the recording system should allow for registering interruptions; (3) pauses or silences should be scored on the basis of functional criteria and not as demarcation in the communication; (4) clear distinctions should be made between the categories of "backchannel" and "agree"; (5) questions should be coded according to function rather than linguistic form; (6) some of the socioemotional categories may appear too narrow, others too wide; (7) crying should be included in the coding scheme as a separate category.

Schouten BC, Meeuwesen L. Cultural differences in medical communication: a review of the literature. Patient Educ Couns. 2006 Dec;64(1-3):21-34. Epub 2006 Jan 20.
(Intercultural Communication, Netherlands)
OBJECTIVE: Culture and ethnicity have often been cited as barriers in establishing an effective and satisfying doctor-patient relationship. The aim of this paper is to gain more insight in intercultural medical communication difficulties by reviewing observational studies on intercultural doctor-patient communication. In addition, a research model for studying this topic in future research is proposed. METHODS: A literature review using online databases (Pubmed, Psychlit) was performed. RESULTS: Findings reveal major differences in doctor-patient communication as a consequence of patients' ethnic backgrounds. Doctors behave less affectively when interacting with ethnic minority patients compared to White patients. Ethnic minority patients themselves are also less verbally expressive; they seem to be less assertive and affective during the medical encounter than White patients. CONCLUSION: Most reviewed studies did not relate communication behaviour to possible antecedent culture-related variables, nor did they assess the effect of cultural variations in doctor-patient communication on outcomes, leaving us in the dark about reasons for and consequences of differences in intercultural medical communication. Five key predictors of culture-related communication problems are identified in the literature: (1) cultural differences in explanatory models of health and illness; (2) differences in cultural values; (3) cultural differences in patients' preferences for doctor-patient relationships; (4) racism/perceptual biases; (5) linguistic barriers. It is concluded that by incorporating these variables into a research model future research on this topic can be enhanced, both from a theoretical and a methodological perspective. PRACTICE IMPLICATIONS: Using a cultural sensitive approach in medical communication is recommended.

Schouten BC, Meeuwesen L, Harmsen HA. The impact of an intervention in intercultural communication on doctor-patient interaction in The Netherlands. Patient Educ Couns. 2005 Sep;58(3):288-95.
(Intercultural Communication, Netherlands)
OBJECTIVE: Findings of scarcely available studies indicate that there are substantial gaps in intercultural doctor-patient communication. In order to improve intercultural communication in medical practice in The Netherlands, an educational intervention was developed. The aim of the present study was to examine the effects of this intervention on doctor-patient communication. METHODS: Participants (general practitioners: n=38; patients: n=124) were assigned at random to an intervention or a control group. GPs in the intervention group received 2.5 days training on intercultural communication. Patients in the intervention group were exposed to a videotaped instruction in the waiting room, right before the consultation. Data were collected through videotapes of visits of ethnic minority patients to their GP and home interviews with the patients after their medical visit. Communication behaviour was assessed using the Roter interaction analysis system (RIAS). Interview length was assessed as well. RESULTS: The length of the medical encounter increased significantly after having received the intervention. Total number of GP utterances increased significantly too. When comparing relative frequencies on affective and instrumental verbal behavior of both patients and doctors, no significant changes could be detected. CONCLUSION: It is concluded that there seems to be some change in doctor-patient interaction, but RIAS may not be suitable to detect subtle changes in the medical communication process. It is recommended to use other analysis methods to assess cultural differences in medical communication. PRACTICE IMPLICATIONS: Knowledge about possible antecedents of gaps in intercultural medical communication should be increased in order to be able to design effective interventions for intercultural doctor-patient communication.

Schouten BC, Meeuwesen L, Tromp F, Harmsen HA. Cultural diversity in patient participation: the influence of patients' characteristics and doctors’ communicative behaviour. Patient Educ Couns. 2007 Jul;67(1-2):214-23. Epub 2007 May 4.
(Intercultural Communication, Netherlands)
OBJECTIVE: The primary goal of this study was to examine the extent to which patient participation during medical visits is influenced by patients' ethnic background, patients' culture-related characteristics (e.g. acculturation, locus of control, cultural views) and features of doctors' communicative behaviour. Furthermore, the mutual influence between patients' participatory behaviour and doctors' communicative behaviour was investigated. An additional goal was to identify the independent contribution of these variables to the degree of patient satisfaction and mutual understanding between GP and patient. METHODS: Communicative behaviour of patients (n=103) and GPs (n=29) was analysed with Roter's Interaction Analysis System, frequency of patient questions and patients' assertive utterances (e.g. making requests, suggesting alternative treatment options). Additional data were gathered using GP and patient questionnaires after the consultations. RESULTS: Results show that non-Western ethnic minority patients display less participatory behaviour during medical consultations than Dutch patients. GPs' affective verbal behaviour had most effect on degree of patient participation and patient satisfaction. Regression analyses indicate a significant mutual influence between patients' verbal behaviour and GPs' verbal behaviour. CONCLUSION: Overall, results of this study show some important differences between Dutch and non-Western ethnic minority patients in degree of patient participation. Furthermore, our results indicate that patient participation encompasses several aspects that are not necessarily interrelated. PRACTICE IMPLICATIONS: The necessity for continued education of GPs' communicative skills, particularly when dealing with non-Western ethnic minority patients, is reflected in the strong influence of GP's affective verbal behaviour on both patient participation and their satisfaction with the medical encounter.

Shaw JR, Adams CL, Bonnett BN, Larson S, Roter DL. Veterinarian-client-patient communication during wellness appointments versus appointments related to a health problem in companion animal practice. J Am Vet Med Assoc. 2008 Nov 15;233(10):1576-86.
(Veterinary Medicine, Canada)
OBJECTIVE: To compare the clinical interview process, content of the medical dialog, and emotional tone of the veterinarian-client-patient interaction during wellness appointments and appointments related to a health problem in companion animal practice. DESIGN: Cross-sectional descriptive study. SAMPLE POPULATION: A random sample of 50 companion animal practitioners in southern Ontario and a convenience sample of 300 clients and their pets. PROCEDURE: For each practitioner, 6 clinical appointments (3 wellness appointments and 3 problem appointments) were videotaped. The Roter interaction analysis system was used to analyze the resulting 300 videotapes. RESULTS: Wellness appointments were characterized by a broad discussion of topics, with 50% of data-gathering statements and 27% of client education statements related to the pet's lifestyle activities and social interactions. Wellness appointments included twice as much verbal interaction with the pet as did problem appointments, and the emotional atmosphere of wellness appointments was generally relaxed. There were more social talk, laughter, statements of reassurance, and compliments directed toward the client and pet. In contrast, during problem appointments, 90% of the data gathering and client education focused on biomedical topics. Coders rated veterinarians as hurried during 30 of the 150 (20%) problem appointments; they rated clients as anxious during 39 (26%) problem appointments and as emotionally distressed during 21 (14%). Conclusions and CLINICAL RELEVANCE: Results suggested that veterinarian-client-patient communication differed between wellness and problem appointments. Owing to the emphasis on biomedical content during problem appointments, veterinarians may neglect lifestyle and social concerns that could impact patient management and outcomes, such as client satisfaction and adherence to veterinarian recommendations.

Shaw JR, Adams CL, Bonnett BN, Larson S, Roter DL. Use of the roter interaction analysis system to analyze veterinarian-client-patient communication in companion animal practice. J Am Vet Med Assoc. 2004 Jul 15;225(2):222-9.
(Veterinary Medicine, Canada)
OBJECTIVE: To identify specific components of veterinarian-client-patient communication during clinical appointments in companion animal practice. DESIGN: Cross-sectional descriptive study. SAMPLE POPULATION: A random sample of 50 companion animal practitioners in southern Ontario and a convenience sample of 300 clients and their pets. PROCEDURE: For each practitioner, 6 clinical appointments (3 wellness appointments and 3 appointments related to a health problem) were videotaped, and the Roter interaction analysis system (RIAS) was used to analyze the resulting 300 videotapes. Statements made during each appointment were classified by means of a communication framework reflecting the 4 essential tasks of the appointment (i.e. data gathering, education and counseling, relationship building, and activation and partnership). RESULTS: 57% of the veterinarians contacted (50/87) and 99% of the clients contacted agreed to participate in the study. Mean duration of the appointments was 13 minutes. Typically, veterinarians contributed 62% of the total conversation and clients contributed 38%. Fifty-four percent of the veterinarian interaction was with the client, and 8% was with the pet. Data gathering constituted 9% of the veterinarian-to-client communication and was primarily accomplished through closed-ended questioning; 48% of veterinarian-to-client communication involved client education and counseling, 30% involved relationship building, and 7% involved activation and partnership (the remaining 6% constituted orientation). CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that the RIAS was a reliable method of assessing the structure, process, and content of veterinarian-client-patient communication and that some veterinarians do not use all the tools needed for effective communication.

Shaw JR, Bonnett BN, Adams CL, Roter DL. Veterinarian-client-patient communication patterns used during clinical appointments in companion animal practice. J Am Vet Med Assoc. 2006 Mar 1;228(5):714-21.
(Veterinary Medicine, Canada)
OBJECTIVE: To identify communication patterns used by veterinarians during clinical appointments in companion animal practice. DESIGN: Cross-sectional descriptive study. SAMPLE POPULATION: A random sample of 50 companion animal practitioners in southern Ontario and a convenience sample of 300 clients and their pets. PROCEDURE: For each practitioner, 6 clinical appointments (3 wellness appointments and 3 appointments related to a health problem) were videotaped. The Roter interaction analysis system was used to analyze the resulting 300 videotapes, and cluster analysis was used to identify veterinarian communication patterns. RESULTS: 175 (58%) appointments were classified as having a biomedical communication pattern, and 125 (42%) were classified as having a biolifestyle-social communication pattern. None were classified as having a consumerist communication pattern. Twentythree (46%) veterinarians were classified as using a predominantly biomedical communication pattern, 19 (38%) were classified as using a mixed communication pattern, and 8 (16%) were classified as using a predominantly biolifestyle-social communication pattern. Pattern use was related to the type of appointment. Overall, 103 (69%) wellness appointments were classified as biolifestyle-social and 127 (85%) problem appointments were classified as biomedical. Appointments with a biomedical communication pattern (mean, 11.98 minutes) were significantly longer than appointments with a biolifestyle-social communication pattern (10.43 minutes). Median relationship-centered care score (ie, the ratio of client-centered talk to veterinarian-centered talk) was significantly higher during appointments with a biolifestyle-social communication pattern (1.10) than during appointments with a biomedical communication pattern (0.40). CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that veterinarians in companion animal practice use 2 distinct patterns of communication. Communication pattern was associated with duration of visit, type of appointment, and relationship-centeredness. Recognition of these communication patterns has implications for veterinary training and client and patient outcomes.

Shaw WS, Pransky G, Winters T, Tveito TH, Larson SM, Roter DL. Does the presence of psychosocial "yellow flags" alter patient-provider communication for work-related, acute low back pain? J Occup Environ Med. 2009 Sep;51(9):1032-40.
(Work-Related Health, Psychosocial Factors, United States)
OBJECTIVE: To determine whether patterns of patient-provider communication might vary depending on psychosocial risk factors for back disability. METHODS: Working adults (N = 97; 64% men; median age = 38 years) with work-related low back pain completed a risk factor questionnaire and then agreed to have provider visits audiotaped. Verbal exchanges were divided into utterances and coded for content, then compared among low-, medium-, and high-risk patients. RESULTS: Among high-risk patients only, providers asked more biomedical questions, patients provided more biomedical information, and providers used more language to engage patients and facilitate communication. There were no group differences in psychosocial exchanges. CONCLUSIONS: Clinicians may recognize the need for more detailed assessment of patients with multiple psychosocial factors, but increases in communication are focused on medical explanations and therapeutic regimen, not on lifestyle and psychosocial factors.

Sheldon LK, Ellington L, Barrett R, Dudley WN, Clayton MF, Rinaldi K. Nurse responsiveness to cancer patient expressions of emotion. Patient Educ Couns. 2008 Dec 23.[Epub ahead of print]
(Nursing, oncology, United States)
OBJECTIVE: This theoretically based study examined nurse responses to cancer patient expressions of emotion using a videotaped, simulated cancer patient. METHODS: This study used an experimental crossover design with a videotaped patient expressing anger, sadness, and neutral emotion to elicit nurse responses. Seventy-four nurses from eight sites participated. Responses were coded using Roter interaction analysis system. Correlations explored relationships between variables that impact communication (age, gender, work experience, trait anxiety, work stress, self-efficacy). Regression models explored the effect of variables on nurse affective responsiveness. RESULTS: Patient expressions of sadness elicited more affective responses than anger. Expressions of anger or neutral emotion elicited more instrumental behaviors than sadness. Variables such as age, work stress and work experience were significantly correlated. No variables predicted affective responsiveness to patient expressions of anger or sadness. CONCLUSION: Nurse communication showed significant variation in response to patient emotional expressions. Understanding the relationships between demographic, personality, and work variables, and identification of new variables that influence nurse-patient communication, has implications for interventional studies. PRACTICE IMPLICATIONS: Over 90% of the participants indicated that the videotape simulation would be a useful method for teaching and practicing communication skills with patients expressing emotions.

Siminoff LA, Ravdin P, Colabianchi N, Sturm CM. Doctor-patient communication patterns in breast cancer adjuvant therapy discussions. Health Expect 2000 Mar;3(1):26-36.
(Oncology, United States)
OBJECTIVE: To identify variables within the patient-oncologist communication pattern that impact overall patient comprehension and satisfaction within the breast cancer adjuvant therapy (AT) setting. SETTING AND PARTICIPANTS: Fifty patients were recruited from a number of academic and community-based oncology practices. Fifteen oncologists participated. MAIN VARIABLES: Three communication variables were identified: percentage of total utterances spoken by the patient, percentage of total physician utterances that were coded as affective (i.e. emotional), and total number of questions asked by the patient during the consultation. Knowledge and satisfaction were assessed by a variety of outcome measures, including knowledge items and satisfaction as measured by VASs, the satisfaction with decision scale and the decisional conflict scale. RESULTS: The level of patient knowledge about breast cancer and satisfaction with the clinical encounter showed a tendency to correlate with the variables measuring aspects of patient-physician communication style. Patients who spoke more or asked more questions tended to be more knowledgeable whilst patients whose physicians used more affective language tended to know less but to be more satisfied with their clinical encounter. CONCLUSIONS: In order to optimize patients' degree of comprehension and satisfaction with their breast cancer adjuvant therapy, physicians need to increase their affective participation in clinical encounters whilst encouraging patients to ask questions and to actively participate in the decision-making process.

Sondell K, Sonderfeldt B, Palmqvist S. A method for communication analysis in prosthodontics. Acta Odontol Scand 1998 Feb;56(1):48-56
(Outside Primary Care, Sweden)
Particularly in prosthodontics, in which the issues of esthetic preferences and possibilities are abundant, improved knowledge about dentist patient communication during clinical encounters is important. Because previous studies on communication used different methods and patient materials, the results are difficult to evaluate. There is, therefore, a need for methodologic development. One method that makes it possible to quantitatively describe different interaction behaviors during clinical encounters is the Roter Method of Interaction Process Analysis (RIAS). Since the method was developed in the USA for use in the medical context, a translation of the method into Swedish and a modification of the categories for use in prosthodontics were necessary. The revised manual was used to code 10 audio recordings of dentist patient encounters at a specialist clinic for prosthodontics. No major alterations of the RIAS manual were made during the translation and modification. The study shows that it is possible to distinguish patterns of communication in audio-recorded dentist patient encounters. The method also made the identification of different interaction profiles possible. These profiles distinguished well among the audio-recorded encounters. The coding procedures were tested for intra-rater reliability and found to be 97% for utterance classification and lambda = 0.76 for categorization definition. It was concluded that the revised RIAS method is applicable in communication studies in prosthodontics.

Sondell K, Soderfeldt B, Palmqvist S. Dentist-patient communication and patient satisfaction in prosthetic dentistry. Int J Prosthodont 2002 Jan-Feb;15(1):28-37
(Outside Primary Care, Sweden)
PURPOSE: Dentist-patient verbal communication dimensions on patient satisfaction were investigated in a prosthodontic context, controlling for the age and gender of patients and dentists and the amount of delivered prosthodontic treatment. Two concepts of satisfaction were defined, one for the single visit (satisfaction with care), and one for the overall result (satisfaction with treatment outcome). MATERIALS AND METHODS: Audio recordings of 61 patients meeting 15 dentists were made in three specialist clinics of prosthetic dentistry. The prosthodontic treatment periods with fixed tooth- or implant-supported prostheses, on average 20 months, were monitored by questionnaires. One visit near the end of each treatment period was audio recorded. The recorded verbal communication was analyzed with the Roter Interaction Analysis System-Dental. RESULTS: Bivariate analysis showed that patients of female dentists were more satisfied in the long-term perspective than patients of male dentists. In logistic multivariate regression models, the verbal communication dimensions "information-dentist horizon" and "information-patient horizon," together with the mouth involvement of the prosthodontics, influenced patient satisfaction with treatment outcome. CONCLUSION: Patients undergoing extensive prosthodontic rehabilitation should be given the opportunity to ask and talk about their dental health, and dentists should minimize their question-asking and orientating behavior during the encounters to help improve patient satisfaction with treatment outcome.

Sondell K, Soderfeldt B, Palmqvist S. Underlying dimensions of verbal communication between dentists and patients in prosthetic dentistry. Patient Educ Couns. 2003 Jun;50(2):157-65.
(Outside Primary Care, Sweden)
The study explores whether the task-focused and socio-emotional dimensions of clinical communication is recognizable in the verbal communication context of prosthetic dentistry, as well as if there are other dimensions of communication in that context. Sixty-one audio recordings were made at three specialist clinics of prosthetic dentistry in Sweden. Sixty-one patients and 15 dentists participated. Sixty-one prosthetic rehabilitation periods were followed. Tooth- or implant-supported fixed prostheses were placed during this time. One visit near the end of each rehabilitation period was audiorecorded. The verbal communication was analyzed with the Roter Interaction Analysis System (RIAS)-dental. The categories were subjected to exploratory factor analysis. Patient and dentist verbal behavior could not be defined exclusively as socio-emotional or task-focused but had to be defined in other dimensions; Emotional exchange, information exchange-patient horizon, relation building exchange, information exchange-dentist horizon, and administrative and counseling exchange. Since the 'emotional exchange' factor was found to capture the largest share of the variance in the communicated patterns, the present study suggests that prosthetic care in dentistry is basically a human relationship with strong emotional communicative content.

Sondell K, Sonderfeldt B, Palmqvist S, Adell A. Communication during prosthodontic treatment—dentist, patient, and dental nurse. Int J Prosthodont 2000 Nov-Dec;13(6):506-12.
(Outside Primary Care, Sweden)
PURPOSE: This study described and explored verbal communication during prosthodontic treatment. MATERIALS AND METHODS: Sixty-one patients and 15 dentists participated. Sixty-one prosthetic treatment periods, during which fixed tooth- or implant-supported prostheses were placed, were followed. One visit during each treatment period was audio recorded. The recorded verbal communication was analyzed with the Roter Interaction Analysis System-dental. The inter-rater reliability was 95% to 97% for utterance classification and kappa = 0.71 to 0.78 for categorization definition. RESULTS: There were 43,663 utterances available for analysis. Of those, 59% was dentist communication, 28% was patient communication, and 10% was dental nurse communication. Other persons, e.g., dental technicians, contributed with 3%. The dentist-patient communication contained more task-focused than socioemotional behaviors. Female patients used socioemotional talk to a greater extent than did the male patients. Dentists and patients of different genders communicated more overall, especially male dentists with female patients. The age difference between dentist and patient had no effect on the amount or type of communication. The dental nurse talked slightly more with male patients. CONCLUSION: When different genders met there was more communication, and the talk was more socioemotional when the patient was female.

Suchman AL, Roter D, Green M, Lipkin M Jr. Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy on Physician and Patient. Med Care 1993 Dec;31(12):1083-92.
(Primary Care, Physician Satisfaction, United States)
To study encounter-specific physician satisfaction we collected exit questionnaires from patients and physicians following 550 primary care office visits. The physicians' questionnaire included 20 items pertaining to satisfaction with the visit, one of which was an assessment of global satisfaction. Using a boot-strap technique, we factor analyzed the satisfaction questions in 10 repeated samples. Four distinct dimensions of physician satisfaction emerged: satisfaction with the patient-physician relationship, with the data collection process, with the appropriateness of the use of time, and with the absence of excessive demands on the part of the patient. Each scale was found to be reliable; global satisfaction was most closely related to the relationship factor. Satisfaction with use of time and the adequacy of data collection tended to be stable for individual physicians across a range of patients whereas global satisfaction and satisfaction with the relationship and the demanding nature of the patient and were more variable, hence most unique to each encounter. This study of physician satisfaction represents an effort to incorporate knowledge about physicians' subjective experiences into a systematic understanding of the dynamics of the medical interview.

Sugarman J, Roter D, Cain C, Wallace R, Schmechel D, Welsh-Bohmer KA. Proxies and consent discussions for dementia research. J Am Geriatr Soc. 2007 Apr;55(4):556-61.
(Informed Consent, Geriatrics, United States)
OBJECTIVES: To better understand the nature of informed consent encounters for research involving patients with dementia that requires proxy consent. DESIGN: Audiotaping of informed-consent encounters for a study of genetic markers for sporadic Alzheimer's disease. SETTING: Outpatients at an Alzheimer's disease research center. PARTICIPANTS: Patients with dementia and their companions. MEASUREMENTS: Audiotapes were analyzed to characterize communication style and coverage of the standard elements of informed consent and, using the Roter Interaction Analysis System, to capture the dynamics of three-way interaction between the patient, their companion, and the physician investigator. RESULTS: Of 26 informed consent encounters, all involved a patient, a companion, and a physician. Patients had a mean Mini-Mental State Examination (MMSE) score of 21.8. For patients, 49% of their interactions involved agreement and approval (positive statements), 16% psychosocial information, 7% biomedical information, 7% asking questions, and 7% expressing emotion. Companion interactions involved 37% positive statements and 19% biomedical information. Physician interactions involved emotional expressiveness (30%) and positive statements (19%). Discussion length was positively related to MMSE score (Spearman rho=0.45; P < .02). Coverage of required elements of informed consent was fairly comprehensive and had no relationship to patients' MMSE scores. CONCLUSION: These data should inform policies regarding the ethically appropriate ways of conducting research with cognitively impaired adults. For example, patients in this study were more silent than their companions and the physician, but when patients spoke, they primarily agreed with what was said. Although this might first seem to signal assent, such an interpretation should be made with caution for persons with dementia. In addition, previous work on informed consent has focused on its cognitive aspects, but these data reveal that the emotional and social dimensions warrant attention.

Tates K, Meeuwesen L, Bensing J, Elbers E. Joking or decision-making? Affective and instrumental behaviour in doctor-patient-child communication. Psychology and Health 2004, 17(3): 281-295.
(Primary Care, Netherlands)
Advocating active child participation in medical encounters is in line with demands for shared decision-making and informed consent. The sparse literature on doctor-child communication, however, conceptualizes children as passive participants and depicts the stereotype of a ‘joking’ relationship, which is limited mainly to affective behaviour. This descriptive study explores the nature of communication in the doctor-parent-child triad at the general practitioner’s surgery. Video-taped observations of 106 medical interviews were analyzed in terms of affective and instrumental behaviour. An adjusted version of the Roter Interaction Analysis System (RIAS) was used to analyze the doctor-parent-child triad. The videos, taken over a period of over almost twenty years, made it possible to look for the presence of effects over time. The results show that the stereotype of doctor-child interaction as a joking relationship doe not hold true. In fact, besides affective behaviour, there was more exchange of instrumental behavior. The age if the child was positively related to child participation. Time appears to have had a rather limited effect on the child’s participation. Whereas GPs accommodated their behaviour to the child’s age by displaying more instrumental behaviour towards older children the nature of parental behavior appeared to be almost constant. The results are discussed in terms of the relevance for shared decision-making in medical consultations regarding children, and recommendations are given for medical practice and health education.

Theadom A, de Lusignan S, Wilson E, Chan T. Using three-channel video to evaluate the impact of the use of the computer on the patient-centredness of the general practice consultation. Inform Prim Care. 2003;11(3):149-56.
(Primary Care, Computer Use, United Kingdom)
The aim of this study was to assess the feasibility of using three-channel video to explore the impact of the computer on general practitioner (GP) consultations. A previous study had highlighted the limitations of using single-channel video: firstly, there was a lack of information about exactly how the computer was being used, and secondly difficulty in interpreting the body language of the consulting clinician. More information was needed to understand the impact of the computer on the consultation, and in this pilot three-channel video was used to overcome these constraints. Four doctors consulted, with the patient's role played by an actor with a preset script and preloaded personal and family history record programmed into the computer. The output was analysed using the Roter Interaction Analysis System (RIAS) and observational methods were used to explore the effect of computers on aspects of verbal and non-verbal behaviour and the completeness of the computer data record. Three-channel video proved to be a feasible and valuable technique for the analysis of primary care GP consultations, with advantages over single-channel video. Interesting differences in non-verbal and verbal behaviour became apparent with different types of computer use during the consultation. Implications for the three-channel video technique for training, monitoring GP competence and providing feedback are discussed.

Timmermans LM, van der Maazen RW, van Spaendonck KP, Leer JW, Kraaimaat FW. Enhancing patient participation by training radiation oncologists. Patient Educ Couns. 2006 Oct;63(1-2):55-63.
(Radiotherapy, The Netherlands)
OBJECTIVE: Several studies have shown that patients' active participation to their medical interaction is beneficial for their information processing and their quality of life. Unfortunately, cancer patients often act rather passively in contact with their oncologists. We investigated whether cancer patients' participation in radiation therapy consultations could be enhanced by specific communicative behaviours of the radiation oncologists (ROs). METHODS: Eight ROs and 160 patients participated; 80 patients in the pre training group and 80 patients in the post training group. The ROs were trained to use specific communicative behaviours that are supposed to encourage patient participation. In the training special attention was paid to communicative requirements in the first minutes of the consultation. The communicative behaviours of the ROs and the cancer patients were measured by the Roter Interaction Analysis System, and compared before and after the RO training. RESULTS: From the start throughout the entire consultation, patients in the post training group participated more in interactions than patients in the pre training group: they discussed more psychosocial issues, expressed more concerns and contributed more to decision-making. CONCLUSION: Cancer patients' participation in the initial radiation oncology consultations can be increased by training of ROs. PRACTICE IMPLICATIONS: The results suggest that doctors working with cancer patients should receive communication training and feedback on a regular base.

Timmermans LM, van der Maazen RW, Leer JW, Kraaimaat FW. Palliative or curative treatment intent affects communication in radiation therapy consultations. Psychooncology. 2006 Aug;15(8):713-25.
(Radiotherapy, Palliative Care, The Netherlands)
Objective: To assess whether communication in radiotherapy consultations is affected by palliative or curative treatment intent. Subjects and methods: The study involved 160 patients and 8 radiation oncologists. Eighty patients visited the radiation oncologist (RO) for palliative treatment and 80 for curative treatment. The consultation prior to radiation treatment was analyzed with the Roter Interaction Analysis System (RIAS). Within three days, patients completed a quality of life questionnaire (EORTC-QLQ-C30).Results: In palliative radiotherapy (PRT) consultations, ROs asked more (closed-ended) biomedical and psychosocial questions and provided more information on prognosis than in consultations for curative radiotherapy (CRT). Patients in both groups provided a great deal of psychosocial information but asked few questions. The ROs expressed more concerns in the PRT consultations, while patients did not. PRT patients received fewer supportive remarks than CRT patients. In both groups, explicit decision-making received little attention. Proxies who accompanied the patients took a more active role in PRT than in CRT consultations.Conclusion: Communication in radiotherapy is affected by treatment intent with respect to the main contents of the consultation.

Timmermans LM, van der Maazen RW, Verhaak CM, van Roosmalen MS, van Daal WA, Kraaimaat FW. Patient participation in discussing palliative radiotherapy. Patient Educ. Couns. 2005 Apr; 57(1):53-61.
(Palliative Care, Netherlands)
Cancer patients' participation in doctor-patient interactions has been shown to be an important factor in the emotional processing of their condition, particularly when only palliative treatments can be offered. In this study, we assessed incurable cancer patients' participation in initial consultations with their radiation oncologists (ROs). RO stimulation of patient participation and discussions about treatment decisions were also measured. The entire consultation was videotaped and analyzed using the Roter Interaction Analysis System (RIAS). Patients' participation proved to be low on medical information, but high on discussing their experiences and life circumstances. The ROs stimulated patient participation mainly by providing medical information and giving patients opportunities to tell their stories. Decisions about radiation treatment had previously taken place and were rarely discussed in the consultations studied. The results suggest that patient participation in palliative treatment consultations might be improved for facilitating patients' emotional processing of the incurable nature of their cancer.

Timmermans LM, van Zuuren FJ, van der Maazen RW, Leer JW, Kraaimaat FW. Monitoring and blunting in palliative and curative radiotherapy consultations. Psychooncology. 2007 Dec;16(12):1111-20.
(Palliative Care, Netherlands)
Objective: The present research paper investigates how cancer patients' monitoring and blunting coping styles are reflected in their communications during their initial radiotherapy consultations and in their evaluations of the consultation. Additionally, it is explored how a patient's disease status (curative versus palliative) influences the effects of his or her cognitive styles.Methods: The study included 116 oncology patients receiving treatment from eight radiation oncologists. For 56 patients treatment intent was palliative and for the remaining 60 curative. The patients' communicative behaviors were assessed using the Roter Interaction Analysis System (RIAS). Within three days the patients completed a monitoring and blunting inventory and after another six weeks they evaluated the treatment decision and treatment information by postal questionnaire.Results: Monitoring was positively and blunting negatively related to the patient's expression of questions, emotions and decision-making issues. After six weeks 'high monitors' as opposed to 'low monitors' reported having more doubts about the treatment decision and being less satisfied with the information received while 'high blunters' expressed fewer doubts and more satisfaction than 'low blunters' did. Significant associations were all attributable to the palliative treatment group.Conclusion: Cancer patients' communicative behaviors vis-à-vis their oncologist hinge on their cognitive styles and an unfavorable disease status enhances the effects. Copyright (c) 2007 John Wiley & Sons

van den Brink-Muinen A, Bensing JM, Kerssens JJ. Gender and communication style in general practice. Differences between women's health care and regular health care. Med Care. 1998 Jan;36(1):100-6.
(Primary Care, Netherlands)
OBJECTIVES: Differences were investigated between general practitioners providing women's health care (4 women) and general practitioners providing regular health care (8 women and 8 men). Expectations were formulated on the basis of the principles of women's health care and literature about gender differences. METHODS: Data were used from 405 videotaped consultations of female patients (over 15 years). Roter's Interaction Analysis System (RIAS) was used to measure the verbal affective and instrumental behavior of the doctors and their patients. These data were supplemented by various nonverbal measures. The data were analyzed by means of multilevel analysis. RESULTS: Doctors in the women's health care practice (called Aletta) look at their patients and talk with them more than other doctors. The general practitioners have approximately the same affective behavior, but the Aletta doctors show more verbal attentiveness and warmth. They also give more medical information and advice. Most of the characteristics of Aletta doctors fit female doctors providing regular health care too. Male doctors show a less communicative behavior in most respects. The differences between general practitioners are reflected in their patients' communication style. CONCLUSIONS: The integration into regular care of some aspects of doctor-patient communication that were found in women's health care might be desirable in the light of the further improvement of the quality of care for women and men.

van den Brink-Muinen A, Caris-Verhallen W. Doctors' responses to patients' concerns: testing the use of sequential analysis. Epidemiol Psichiatr Soc. 2003 Apr-Jun;12(2):92-7.
(Primary Care, Interaction Analysis, Netherlands)
AIMS: The aim of this small scale study was to explore interaction sequences during the medical consultation. Specific attention was paid to how doctors responded to patient's concerns and worries. Empathic behaviours (e.g. concern, partnership, legitimizing) and facilitating behaviours (e.g. paraphrasing, agreement) were considered as an adequate response to a patient's concern. METHODS: Nine consultations of nine different GPs were randomly selected from a sample of 1600 videotaped doctor-patient consultations, that were all rated with the Roter Interaction Analysis System. Each consultation contained at least 9 utterances of patient's concern. It was investigated how doctors respond within five lags of utterances after a patient's concern. RESULTS: The results showed that doctors more often responded to a patient's concern in a facilitative way than in an empathic way. When an empathic response was given, it appeared mostly during the first utterance after the patient expressed a concern. CONCLUSIONS: The findings indicate that sequential analysis is appropriate to investigate a health care provider's specific style of responding. Based on the problems emerged during the sequential analysis, further exploration of the method is recommended.

van den Brink-Muinen A, van Dulmen S, Messerli-Rohrbach V, Bensing J. Do gender-dyads have different communication patterns? A comparative study in Western-European general practices. Patient Educ Couns. 2002 Dec;48(3):253-64.
(Primary Care, Gender, Netherlands)
From the viewpoint of quality of care, doctor-patient communication has become more and more important. Gender is an important factor in communication. Besides, cultural norms and values are likely to influence doctor-patient communication as well. This study examined (1). whether or not communication patterns of gender-dyads in general practice consultations differ across and between Western-European countries, and (2). if so, whether these differences continue to exist when controlling for patient, GP and consultation characteristics. Doctor-patient communication was assessed in six Western-European countries by coding video taped consultations of 190 GPs and 2812 patients. Cluster analysis revealed three communication patterns: a biomedical, a biopsychosocial and a psychosocial pattern. Across countries, communication patterns of the female/female dyad differed from that of the other gender-dyads. Differences in communication patterns between countries could especially be explained by differences in consultations of male doctors, irrespective of the patients' gender. It is important to take into consideration differences between gender-dyads and between countries when studying gender effects on communication across countries or when comparing studies performed in different countries.

van den Brink-Muinen A, Verhaak PF, Bensing JM, Bahrs O, Deveugele M, Gask L, Leiva F, Mead N, Messerli V, Oppizzi L, Peltenburg M, Perez A. Doctor-patient communication in different European health care systems: relevance and performance from the patients' perspective. Patient Educ Couns. 2000 Jan;39(1):115-27.
(Patient Recall or Satisfaction, Netherlands)
Our aim is to investigate differences between European health care systems in the importance attached by patients to different aspects of doctor-patient communication and the GPs' performance of these aspects, both being from the patients' perspective. 3658 patients of 190 GPs in six European countries (Netherlands, Spain, United Kingdom, Belgium, Germany, Switzerland) completed pre- and post-visit questionnaires about relevance and performance of doctor-patient communication. Data were analyzed by variance analysis and by multilevel analysis. In the non-gatekeeping countries, patients considered both biomedical and psychosocial communication aspects to be more important than the patients in the gatekeeping countries. Similarly, in the patients' perception, the non-gatekeeping GPs dealt with these aspects more often. Patient characteristics (gender, age, education, psychosocial problems, bad health, depressive feelings, GPs' assessment of psychosocial background) showed many relationships. Of the GP characteristics, only the GPs' psychosocial diagnosis was associated with patient-reported psychosocial relevance and performance. Talking about biomedical issues was more important for the patients than talking about psychosocial issues, unless the patients presented psychosocial problems to the GP. Discrepancies between relevance and performance were apparent, especially with respect to biomedical aspects. The implications for health policy and for general practitioners are discussed.

van den Brink-Muinen A, Verhaak PF, Bensing JM, Bahrs O, Deveugele M, Gask L, Mead N, Leiva-Fernandez F, Perez A, Messerli V, Oppizzi L, Peltenburg M. Communication in general practice: differences between European countries. Fam Pract. 2003 Aug;20(4):478-85.
(Primary Care, Netherlands)
BACKGROUND: Based on differences in national health care system characteristics such as the gatekeeping role of GPs (at the macrolevel) and on diverging GP and patient characteristics (at the microlevel), communication may differ between countries. Knowledge of the influence of these characteristics on doctor-patient communication will be important for setting European health care policies. OBJECTIVES: Our objectives were (i) to compare doctor-patient communication in general practice between European countries; and (ii) to investigate the influence of the gatekeeping system and GP and patient characteristics on doctor-patient communication in general practice. METHODS: Fifteen patients per GP (in total 2825 patients) of 190 GPs in six European countries were included. Participating countries were The Netherlands, Spain, the UK (gatekeeping countries), Belgium, Germany and Switzerland (non-gatekeeping countries). Data were collected by means of patient and GP questionnaires and observation of videotaped consultations, and analysed by one-way and multilevel, multivariate analysis. RESULTS: Differences in communication between countries were found in: affective and instrumental behaviour; biomedical and psychosocial talk; GPs' patient-directed gaze; and consultation length. The study showed that GPs' gatekeeping role (with registered patients) was less important for doctor-patient communication than was expected. Patient characteristics such as gender, age, having psychosocial problems, and familiarity between the doctor and the patient were the most important in explaining differences in communication. CONCLUSION: The gatekeeping role of GPs is hardly important in explaining doctor-patient communication. The relationship is more complex than expected. Patient and GP characteristics are more important. Cultural factors should be included in future studies.

van der Pasch M, Verhaak PF. Communication in general practice: recognition and treatment of mental illness. Patient Educ Couns 1998 Feb;33(2):97-112.
(Primary Care, Patient Emotional Distress, Netherlands)
From previous studies there is a lot of evidence that in primary care settings, many patients tend to express their mental problems in terms of physical symptoms. Therefore, the general practitioner (GP) needs to recognize mental problems at an early stage. Early recognition allows for adequate treatment that might speed up recovery. The present article reports on a study exploring the GP's ability to recognize mental illness, the communication style that is supposed to support this ability, the subsequent treatment of mental problems, and the patient's recovery. Two databases were used. First, an observation study, involving 351 videotaped consultations held by 15 GPs, yielded information on communication style and recognition abilities. Patients in this study were selected randomly. The second database obtained treatment data and measures of patient recovery from a 1-year follow-up study dealing with the treatment and course of mental illness. Patients in this study were selected because their GPs considered their problems "mainly psychosocial by nature". Half of them were categorized within psychological and social diagnostic categories of the International Classification for Primary Care (ICPC), the other half were categorized within physical disease categories, with an assessment by the GP that the complaints were mainly psychosocial. Results showed no significant relationships between the recognition of mental illness and nine communication features supposed to induce these abilities. There was a tendency however, for a positive association between recommended communicative behaviour of the GP and his or her tendency to give frequently psychosocial evaluations of the patient's complaints. Also, there was a negative tendency between this recommended behaviour and the degree of agreement between the GP's evaluation and the score on a psychiatric screening questionnaire. This agreement is called "accuracy". Frequent psychosocial evaluations were related to exploring behaviour and mental health referral in case of psychosocial complaints. Further, relationships between the GPs' recognition ability and various measures of patients' recovery did not prove univocal. Both positive, negative and absent relationships were found.

van Dulmen AM. Children's contribution to pediatric outpatient encounters. Pediatrics 1998 Sept;102:563-568.
(Pediatrics, Netherlands)
OBJECTIVE: Generally, increasing attention is being paid to the quality of doctor-patient communication. However, children's contributions have been, until now, primarily ignored in communication research, although there are indications that considering their views increases satisfaction and compliance. In the present study, we examined how children contributed to communication during outpatient pediatric encounters and what factors were associated with children's contributions. PATIENTS: Twenty-one consulting pediatricians videotaped a total of 302 consecutive outpatient encounters. DESIGN: Multilevel analysis was used to take into account the similarity among encounters with the same pediatrician. RESULTS: Children's contributions to the outpatient encounters were limited to 4%. Pediatricians directed one out of every four statements to the child. Although pediatricians asked children a lot of medical questions (26%), only a small part of the medical information (13%) was directed at the children. Apart from social talk and laughter, the amount of pediatrician-child communication increased with children's age. Communication with children suffering from disorders of the nervous system seemed to differ from that with children suffering from other diseases. Allowing children more room in the medical visit did not seem to increase the duration of the visit. CONCLUSIONS: Although recent legislation requires children to be adequately informed, in pediatric outpatient encounters information still tends to be directed primarily at the parents. Children do get the oppotunity to talk about social and psychosocial issues. Pediatricians may need to acquire similar communication skills to discuss medical-technical issues with the children.

van Dulmen AM. Communication during gynecological outpatient consultations. J.Psychosom Obstet Gynecol 1999;20:119-126.
(Primary Care, Netherlands)
The intimate nature of women's health problems presented during gynecological encounters places great demands on gynecologists' communicative behavior. The present study examined what patients expect from their gynecologist, how gynecologists and patients actually communicate during out-patient encounters, and what factors shape the structure and process of the encounter. Twenty-one gynecologists (13 consultants and eight residents) videotaped 303 consecutive out-patient encounters. Multilevel analysis was used to take into account the similarity among encounters with the same gynecologist. The results showed that gynecological patients expected foremost to receive clear and understandable information. One-third of the patients expected support and understanding. Psychosocial issues were hardly ever the topic of conversation. The length of the out-patient visits increased in the presence of patients' partner, with the type of problem presented, and with the frequency with which the patient disagreed with the gynecologist. The visit was also longer when gynecologists provided more medical information and asked more psychosocial questions. Although gynecological encounters focus almost exclusively on medical issues, talking about non-somatic aspects does not seem to prolong the visit as much as the presence of the patient's partner or whether or not the gynecologist and patient had met before. In view of patients' affecive needs, it would be worthwhile to examine whether gynecologists can be taught to handle patients' psychosocial needs as well.

van Dulmen AM. Physician reimbursement and the medical encounter: an observational study in Dutch pediatrics. Clinical Pediatrics 2000;39:591-601.
(Pediatrics, Netherlands)
Pediatrician reimbrusement is shifting from fee-for-service to a fixed salary. In the Netherlands, as physicians working on a fee-for-service basis have a financial interest in talking less and in carrying out more diagnostic tests and investigations, it may be questioned whether this will influence the structure and content of medical visits. With use of 302 videotaped outpatient encounters with either salaried or fee-for-service pediatricians, differences were examined in visit length, number of requests for diagnostic tests and investigations (laboratory test, endoscopy, and radiography), pediatrician-parent communication behaviors, and patient satisfaction. This investigation was carried out by means of bivariate and multilevel analysis. The results showed that the visits with salaried pediatricians lasted almost 4 minutes longer. This surplus time was not spent on social talk or on a more elaborate history taking but was used to provide more information and advice. In addition, salaried pediatricians engaged in more empathic behavior toward the patient, thereby faciliating a therapeutic relationship. No differences were found in the number of diagnostic tests and investigations or in patient satisfaction. It may be concluded that history taking and social talk took place in a fixed part of the visit. Salaried pediatricians spent more time on exchanging information with their patients and paid more attention to patient concerns and emotions. As the reimbursement shift is not likely to diminish the number of diagnostic tests and investigations and will increase the length of the medical visits, overall financial benefits may be limited.

van Dulmen AM, Bensing JM. Gender differences in gynecologist communication. Women Health. 2000;30(3):49-61.
(Gender, Netherlands)
The intimate nature of gynecological health problems requires the physician's specific attention. On the basis of previous findings in primary care, female gynecologists are expected to communicate more affectively than men. This study addressed gender differences in gynecologist communication behavior by comparing videotapes of real-life outpatient encounters with female (N = 107) and male (N = 196) gynecologists by means of bivariate and multilevel analysis. Only a few gender differences were found: female gynecologists performed longer physical examinations, showed more global attentiveness, and asked fewer medical questions. Either the duration of the medical education or the type of statistical analysis may account for this lack of gender differences.

van Dulmen AM, Holl RA. Effects of continuing pediatric education in interpersonal communication skills. Eur J Pediatr 2000;159:489-495.
(Pediatrics, Netherlands)
Paediatric care places great demands on interpersonal communication skills, especially as regards the handling of psychosocial issues. Recent shifts in paediatric morbidity and increases in patient empowerment furthermore emphasize the need for continuing paediatric education in communication skills. It is, however, debatable, whether after residency paediatric education can influence paediatrician performance. This study evaluated the effects of a 5-day experimental communication training by means of a pretest/post-test control group design. A total of 21 consulting paediatricians (10 experimental, 11 control group paediatricians) videotaped two series of consecutive outpatient encounters. Compared with the untrained control group, trained paediatricians asked more psychosocial questions and looked at the patients and their parents more often. In addition, they gave patients and parents more room to talk. No difference was found in the length of the outpatient visits. CONCLUSION: Paediatric educaton after residency influences paediatricians' verbal and nonverbal communication skills positively, especially as regards handling psychosocal issues. On the basis of these findings, it appears worthwhile to encourage continuing paediatric education in interpersonal communication skills.

van Dulmen AM, Verhaak PF, Bilo HJ. Shifts in doctor-patient communication during a series of outpatient consultations in non-insulin-dependent diabetes mellitus. Patient Educ Couns 1997 Mar;30(3):227-37.
(Primary Care, Netherlands)
As the treatment of non-insulin-dependent diabetes mellitus (NIDDM) largely depends on self-management, patient compliance and satisfaction, diabetes-specific beliefs and fears need special consideration during medical consultations by means of effective communication. Communication patterns are likely to change through time. For that reason, the first three consultations between 18 newly referred patients with poorly controlled NIDDM and their medical specialist were videotaped. Subsequently, changes in doctor's and patients' verbal and nonverbal communication behaviours during these 54 consultations were anlyzed. Furthermore, an investigation was carried out to distinguish those communication behaviours most strongly related to patient satisfaction. Findings suggest that the first consultation is most important for building an effective doctor-patient relationship, the second for discussing treatment matters, and the third for addressing psychosocial issues. Further research incorporating clinical outcome measures is recommended to determine which were the behaviours with the greatest influence on patient health outcome.

van Dulmen AM, aan Weert JC. Effects of gynaecological education on interpersonal communication skills. Br J Obstet Gynaecol 2001;108:485-491.
(Primary Care, Netherlands)
OBJECTIVE: To investigate the effects of an experimental communication course on how gynaecologists handle psychosocial issues in gynaecological consultation. DESIGN: Pre-post testing. Multilevel analysis was used to take into account the similarity among encounters with the same gynaecologist. SAMPLE: Eighteen gynaecologists (13 consultatns and 5 junior doctors) from five different hospitals participated. All gynaecologists videotaped consecutive outpatient encounters before and after attending an intensive training course. MAIN OUTCOME MEASURES: The communicative performance of the gynaecologists at pre-and post measurment. RESULTS: The gynaecologists recorded a total of 526 outpatient encounters, 272 before and 254 after the training. As a result of the training, gynaecologists' sensitivity to psychosocial aspects of their patients increased. At post measurement, the gynaecologists gave more signs of agreement, became less directive, asked fewer medical questions and more psychosocial questions. No difference was found in the duration of the outpatient visits. With the trained gynaecologists, patients asked more questions and provided more psychosocial information. CONCLUSIONS: Junior doctors and clinically experienced gynaecologists can be taught to handle psychosocial issues without lengthening the visit.

van Dulmen S. Pediatrician-parent-child communication: problem-related or not? Patient Educ Couns. 2004 Jan;52(1):61-8.
(Pediatrics, Netherlands)
Pediatricians are generally confronted with a variety of health problems. Each of these problems may benefit from another pattern of healthcare communication. It is unknown whether the communication process during pediatric visits actually differs by the nature of the child's problem. This study first examined whether three formerly identified communication patterns could be distinguished within real-life pediatric outpatient encounters (N=846). Then, communication patterns during encounters with children with respiratory (n=269) or behavioral problems (n=77) were compared. Videotaped visits were observed using the Roter Interaction Analysis System. Two-level multivariate logistic regression analysis examined what factors contributed to the communication patterns. A biopsychosocial communication pattern was observed in 45%, a psychosocial in 15% and a biomedical pattern in 40% of the visits. Child's age and pediatrician's experience were related to the communication pattern. Different patterns did indeed prevail in respiratory and behavioral problems. As less experienced pediatricians attend to psychosocial issues less, they may have to be specifically encouraged to do so.

van Dulmen S, Nubling M, Langewitz W. Doctor's responses to patients' concerns; an exploration of communication sequences in gynaecology. Epidemiol Psichiatr Soc. 2003 Apr-Jun;12(2):98-102.
(Primary Care, Interaction Analysis, Netherlands)
AIMS: Like other medical doctors, gynaecologists have difficulty attending to psychosocial issues and concerns. Communication training has proven to be effective in teaching them to spend more time on discussing these factors. However, whether or not they do this in response to patients' utterances remains unclear. The question is how gynaecologists respond to patients' concerns, whether or not they do this adequately and what the effects of a communication training are on the use of these communication sequences. METHODS: Nineteen gynaecologists participated in a study which examined the effects of a three-day residential communication training. Before and after the training the gynaecologists videotaped series of consecutive outpatient visits. The communication during these visits was rated using the Roter Interaction Analysis System. Gynaecologists' responses to patients' concerns were examined at lag one, i.e. immediately following the patient's concern. RESULTS: The most prevalent responses made by the gynaecologists were showing agreement and understanding and giving medical information. Affective responses were observed less. At postmeasurement, the gynaecologists responded neither more adequately nor inadequately to patients' concerns. CONCLUSIONS: The gynaecologists did not respond in a very affective way to patients' concerns. However, the patients did not express many concerns. Future studies should focus on more prevalent communication behaviours and incorporate more lags.

van Dulmen S, Tromp F, Grosfeld F, Ten Cate O, Bensing J. The impact of assessing simulated bad news consultations on medical students' stress response and communication performance. Psychoneuroendocrinology. 2007 Sep-Nov;32(8-10):943-50.
(Primary Care, Netherlands)
Seventy second-year medical students volunteered to participate in a study with the aim of evaluating the impact of the assessment of simulated bad news consultations on their physiological and psychological stress and communication performance. Measurements were taken of salivary cortisol, systolic and diastolic blood pressure, heart rate, state anxiety and global stress using a Visual Analogue Scale. The subjects were asked to take three salivary cortisol samples on the assessment day as well as on a quiet control day, and to take all other measures 5min before and 10min after conducting the bad news consultation. Consultations were videotaped and analyzed using the information-giving subscale of the Amsterdam Attitude and Communication Scale (AACS), the Roter Interaction Analysis System (RIAS), and the additional non-verbal measures, smiling, nodding and patient-directed gaze. MANOVA repeated measurements were used to test the difference between the cortisol measurements taken on the assessment and the control day. Linear regression analysis was used to determine the association between physiological and psychological stress measures and the students' communication performance. The analyses were restricted to the sample of 57 students who had complete data records. In anticipation of the communication assessment, cortisol levels remained elevated, indicating a heightened anticipatory stress response. After the assessment, the students' systolic blood pressure, heart rate, globally assessed stress level and state anxiety diminished. Pre-consultation stress did not appear to be related to the quality of the students' communication performance. Non-verbal communication could be predicted by pre-consultation physiological stress levels in the sense that patient-directed gaze occurred more often the higher the students' systolic blood pressure and heart rate. Post-consultation heart rate remained higher the more often the students had looked at the patient and the more information they had provided. However, the heart rate appeared to diminish the more often the students had reassured the patient. These findings suggest that in evaluating students' communication performance there is a need to take their stress levels into account.

van Weert J, van Dulmen S, Bar P, Venus E. Interdisciplinary preoperative patient education in cardiac surgery. Patient Educ Couns. 2003 Feb;49(2):105-14.
(Cardiac Surgery, Patient Education, Netherlands)
Patient education in cardiac surgery is complicated by the fact that cardiac surgery patients meet a lot of different health care providers. Little is known about education processes in terms of interdisciplinary tuning. In this study, complete series of consecutive preoperative consultations of 51 cardiac surgery patients with different health care providers (physicians, nurses and health educators) were videotaped. The information exchange between patients and providers was analyzed directly from the video recordings by using an adaptation of the Roter Interaction Analysis System (RIAS) and a checklist of relevant informational topics. Results pointed to overlaps and gaps as well as to a lack of a patient-centered approach. The physicians were mostly overlapped by the nurses, who spent almost 30% of the time on talking about medical issues. Gaps were found in giving psycho-educational information and emotional support, needed to establish effective patient education. The findings provided a sound basis for developing guidelines and changes in the organization of the education process.

van Weert JC, van Dulmen AM, Spreeuwenberg PM, Ribbe MW, Bensing JM. Effects of snoezelen, integrated in 24h dementia care, on nurse-patient communication during morning care. Patient Educ Couns. 2005 Sep;58(3):312-26.
(Nursing, Netherlands)
OBJECTIVE: To investigate the effectiveness of snoezelen, integrated in 24-hour care, on the communication of Certified Nursing Assistants (CNAs) and demented nursing home residents during morning care. METHODS: A quasi-experimental pre- and post-test design was conducted, comparing sic psychogeriatric wards, that implemented snoezelen, to six control wards, that continued in giving usual care. Measurements were performed at baseline and 18 months after a training 'snoezelen for caregivers'. Independent assessors analyzed 250 video-recordings directly from the computer, using an adapted version of the Roter Interaction Analysis System (RIAS) and non-verbal measurements. RESULTS: Trained CNAs showed a significant increase of resident-directed gaze, affective touch and smiling. The total number of verbal utterances also increased (more social conversation, agreement, talking about sensory stimuli, information and autonomy). Regarding residents, a significant treatment effect was found for smiling, CNA-directed gaze, negative verbal behaviors (less disapproval and anger) and verbal expressed autonomy. CONCLUSION: The implementation of snoezelen improved the actual communication during morning care. PRACTICE IMPLICATIONS: Teaching CNAs to provide snoezelen has added value for the quality of care. Morning care by trained CNAs appeared to take more time. This suggests that (some) time investment might be required to achieve positive effects on CNA- resident communication.

van Wieringen JC, Harmsen JA, Bruijnzeels MA. Intercultural communication in general practice. Eur J Public Health 2002 Mar;12(1):63-8.
(Primary Care, Intercultural Communication, Netherlands)
BACKGROUND: Little is known about the causes of problems in communication between health care professionals and ethnic-minority patients. Not only language difficulties, but also cultural differences may result in these problems. This study explores the influence of communication and patient beliefs about health (care) and disease on understanding and compliance of native-born and ethnic-minority patients. METHODS: In this descriptive study seven general practices located in a multi-ethnic neighbourhood in Rotterdam participated. Eighty-seven parents who visited their GP with a child for a new health problem took part: more than 50% of them belonged to ethnic-minorities. The consultation between GP and patient was recorded on video and a few days after the consultation patients were interviewed at home. GPs filled out a short questionnaire immediately after the consultation. Patient beliefs and previous experiences with health care were measured by different questionnaires in the home interview. Communication was analysed using the Roter Interaction Analysis System based on the videos. Mutual understanding between GP and patient and therapy compliance was assessed by comparing GP's questionnaires with the home interview with the parents. RESULTS: In 33% of the consultations with ethnic-minority patients (versus 13% with native-born patients) mutual understanding was poor. Different aspects of communication had no influence on mutual understanding. Problems in the relationship with the GP, as experienced by patients, showed a significant relation with mutual understanding. Consultations without mutual understanding more often ended in non-compliance with the prescribed therapy. CONCLUSION: Ethnic-minority parents more often report problems in their relationship with the GP and they have different beliefs about health and health care from native-born parents. Good relationships between GP and patients are necessary for mutual understanding. Mutual understanding has a strong correlation with compliance. Mutual understanding and consequently compliance is more often poor in consultations with ethnic-minority parents than with native-born parents.

Vegni E, Moja EA. Effects of a course on ophthalmologist communication skills: a pilot study. Educ. Health (Abingdon). 2004 Jul;17(2):163-71.
(Ophthalmology, Italy)
INTRODUCTION: Although the issue of communication skills is now considered crucial for ophthalmology, no previous research has discussed training in this field. This study aimed to discuss the effects of a 16 hour communication skills course for ophthalmologists. In particular the study assessed the interest of participants with respect to the topic and the efficacy on participants' communication skills, at least in a laboratory setting. MATERIALS AND METHODS: Eleven ophthalmologists participated in the course. Learner satisfaction was evaluated using a questionnaire with a six-point Likert scale. Course efficacy was assessed by a comparison between communicative behaviour of ophthalmologists in videoed role playing before and immediately after attending the course. Videoed consultations were coded using the Patient Centred Score Sheet (PCSS) and the Roter Interaction Analysis System (RIAS). The Wilcoxon signed rank test was used for statistical analysis. FINDINGS: The course obtained high satisfaction in participants (mean score 5.1). In the post test role playing, patient centredness increased significantly (p < 0.01). Furthermore, ophthalmologists improved their competence in using open ended questions (p < 0.02), process categories (e.g. orientation statement) (p < 0.05) and social communication categories (e.g. personal statement) (p < 0.01). DISCUSSION: According to our findings, ophthalmologists did show satisfaction for the course. Results also indicate that the course positively influenced ophthalmologist communication competence, at least in a laboratory setting. After the course, participants became more attentive to patients' psychosocial needs, both in terms of general quality of consultation (patient centredness) and in terms of using specific interpersonal skills. Present results are considered preliminary, and further research is needed with a larger sample and including an evaluation of the effects on ophthalmologists' communication skills in clinical practice.

Verhaak CM, Kraaimaat FW, Staps AC, van Daal WA. Informed consent in palliative radiotherapy: participation of patients and proxies in treatment decisions. Patient Educ Couns 2000 Aug 1;41(1):63-71.
(Oncology, Netherlands)
Informed consent is regularly discussed, but little attention has been paid to the daily practice of the patient participation in treatment decisions regarding palliative care. Therefore, an exploratory study was conducted into shared decision making between radiation oncologists and patients and proxies in interviews where decisions regarding palliative radiotherapy have to be made. Interviews of 6 radiation oncologists with 26 outpatients were recorded on audiotape. Each verbal utterance was coded with the aid of the Roter Interaction Analysis System (RIAS). Results indicated that in over 75% of the interviews, patients and proxies were not asked for their opinion regarding treatment decisions. Other treatment options or the option of abstaining from treatment were discussed in 46% of the interviews. In conclusion, in this sample informed consent was not a natural part of the daily practice of palliative radiotherapy. The question remains to what extent informed consent in palliative radiotherapy is realistic.

Verhaak C, Staps A, Kraaimaat F, Van Daal W. Communication between patient and radiotherapist prior to palliative treatment. European Journal of Cancer 1997, 33(8): S59.
(Oncology, Netherlands)
In order to examine the content of the communication between patient and radiotherapist prior to palliative treatment and the participation of patients and proxies in decision-making. Twenty-five first interviews between patient and radiotherapist were audio- and videotaped. A few days later, the patients were invited by a psychologist to reflect on their experiences with this interview. Doctor patient interviews were analyzed by the Roter Interaction Analysis System (RIAS). The interviews with the psychology were analyzed qualitatively using methods of Grounded Theory. Results indicate that during the radiotherapist patient interview, about 60% of the utterances refer to biomedical topics such as diagnosis, side-effects and treatment protocol. Prognosis and alternative treatment options are only considered roughly. About 12% of the time was paid to psychosocial aspects and emotional support. The participation of patients and proxies in the decision-making is limited or lacking. However, patients do not show significant dissatisfaction with this procedure. Because of the stressful circumstances most patients and proxies feel unable to formulate relevant questions and make treatment decisions. The results rarely show any patient participation in decision-making with regard to palliative radiotherapy. Taking into account the psychological circumstances, actual patient participation would be hardly feasible in clinical practice.

Wakefield BJ, Bylund CL, Holman JE, Ray A, Scherubel M, Kienzle MG, Rosenthal GE. Nurse and patient communication profiles in a home-based telehealth intervention for heart failure management. Patient Educ Couns. 2008 May;71(2):285-92.
(Nursing, Telehealth, United States)
OBJECTIVE: This study compared differences in nurse and patient communication profiles between two telehealth modes: telephone and videophone, and evaluated longitudinal changes in communication, nurse perceptions, and patient satisfaction. METHODS: Subjects were enrolled in a randomized controlled clinical trial evaluating a 90-day home-based intervention for heart failure. Telephone (n=14) and videophone (n=14) interactions were audio taped and analyzed using the Roter Interaction Analysis System. RESULTS: Nurses were more likely to use open-ended questions, back-channel responses, friendly jokes, and checks for understanding on the telephone compared to videophone. Compliments given and partnership were more common on the videophone. Patients were more likely to give lifestyle information and approval comments on the telephone, and used more closed-ended questions on the videophone. Nurses perceptions of the interactions were not different between the telephone and videophone, nor did their perceptions change significantly over the course of the intervention. There were no significant differences in patient satisfaction between the telephone and videophone. CONCLUSIONS: The results of this study did not support use of a videophone over the telephone. PRACTICE IMPLICATIONS: It is critical to match technologies to patient needs and use the least complex technology possible. When considering use a videophone, health care providers should critically examine the trade-offs between additional complexities with the added value of the visual interaction.

Weber H, Stöckli M, Nübling M, Langewitz WA. Communication during ward rounds in internal medicine. An analysis of patient-nurse-physician interactions using RIAS. Patient Educ Couns. 2007 Aug;67(3):343-8.
(Primary Care, Inpatient, Switzerland)
OBJECTIVE: Describe the content and of mode of patient-physician-nurse interactions during ward-rounds in Internal Medicine. METHODS: In 267/448 patients, 13 nurses, and 8 physicians from two wards in General Internal Medicine 448 interactions on ward rounds were tape recorded by observers. After exclusion of interactions with more than three participants (N=150), a random sample of 90 interactions was drawn. Data were analysed with a modified RIAS version that allowed for the registration of a third contributor and for the assessment of the direction of a communicative action (e.g.: nurse-->patient, etc.). Furthermore, time spent per individual patient was registered with a stop-watch. RESULTS: A total of 12,078 utterances (144 per ward round) were recorded. Due to problems with the comprehensibility of some interactions the final data set contains 71 ward round interactions with 10,713 utterances (151 per ward round interaction). The average time allotted to an individual patient during ward-rounds was 7.5 min (range: 3-16 min). The exchange of medical information is the main topic in physicians (39%) and nurses (25%), second common topic in patients (28%), in whom communicative actions like agreement or checking are more common (30% patients/25% physicians/22% nurses). Physicians and patients use a substantial number of communicative actions (1397/5531 physicians; 1119/3733 patients). Patients receive about 20 bits of medical or therapeutic information per contact during ward-rounds. CONCLUSIONS: If ward rounds serve as the central marketplace of information nurses' knowledge is under-represented. Further research should try to determine whether the quality of patient care is related to a well balanced exchange of information, to which nurses, physicians, and patients contribute their specific knowledge. PRACTICE IMPLICATIONS: Given the fact that in-patients in Interna Medicine usually present complex problems, the exchange of factual information, expectations, and concepts is of paramount importance. We hope that this paper is going to direct the attention of the scientific community to the characteristics of ward-rounds because they will remain the central marketplace of communication in hospital.

White J, Levinson W, Roter D. "Oh, by the way ...": the closing moments of the medical visit. J Gen Intern Med 1994 Jan;9(1):24-8.
(Primary Care, United States)
OBJECTIVE: To define and describe the communication between physicians and patients in the closing phase of the medical visit. To identify types of communication throughout the visit that are associated with the introduction of a new problem during the closing moments of the visit or with longer closures. DESIGN: Audiotaping of office visits. Tapes were analyzed using a modified Roter Interactional Analysis System (RIAS). The coders' definition of closure was compared with the opinion of communication experts. SETTING: Outpatient offices of practicing physicians. PARTICIPANTS: Eighty-eight patients visiting 20 primary care physicians participated. Physicians were selected by a letter from the Oregon Board of Medical Examiners. The mean number of years from graduation was 16 (range 3-47). One physician per site participated. MEASUREMENTS: Frequencies of physician and patient communication behaviors and global affect scores were calculated and correlations were drawn using t-test and chi-square analyses. RESULTS: The physicians initiated the closing in 86% of the visits. The physicians clarified the plan of care in 75% of the visits and asked whether the patients had more questions in 25% of the cases. The patients introduced new problems not previously discussed in 21% of the closures. New problems in closure were associated with less information exchanged previously by physicians and patients about therapy (t = -3.28, p = 0.002; t = -2.26, p = 0.03), fewer orientation statements by physicians (t = 1.86, p = 0.001), and higher patient affect scores (t = 0.252, p = 0.016). Long closures (> 2 minutes) correlated with physicians' asking open-ended questions (0.2438; p = 0.019), laughing (0.3002; p = 0.005), showing responsiveness to patients (0.3996; p < 0.001), being self-disclosing (0.3948; p < 0.001), and engaging in psychosocial discussion with patients (0.2410; p = 0.020). CONCLUSION: This study is the first description of how physicians and patients communicate during the closing of office visits. Notably, the patients raised new problems at the end of the visit in 21% of the cases. The findings suggest ways physicians might improve communication in the closing phase of the medical interview. Orienting patients in the flow of the visit, assessing patient beliefs, checking for understanding, and addressing emotions and psychosocial issues early on may decrease the number of new problems in the final moments of the visit.

Wissow LS, Gadomski A, Roter D, Larson S, Brown J, Zachary C, Bartlett E, Horn I, Luo X, Wang MC. Improving child and parent mental health in primary care: a cluster-randomized trial of communication skills training. Pediatrics. 2008 Feb;121(2):266-75.
(Primary Care, Mental Health, Parent and Child, United States)
OBJECTIVE: We examined child and parent outcomes of training providers to engage families efficiently and to reduce common symptoms of a range of mental health problems and disorders. METHODS: Training involved three 1-hour discussions structured around video examples of family/provider communication skills, each followed by practice with standardized patients and self-evaluation. Skills targeted eliciting parent and child concerns, partnering with families, and increasing expectations that treatment would be helpful. We tested the training with providers at 13 sites in rural New York, urban Maryland, and Washington, DC. Children (5-16 years of age) making routine visits were enrolled if they screened "possible" or "probable" for mental disorders with the Strengths and Difficulties Questionnaire or if their provider said they were likely to have an emotional or behavioral problem. Children and their parents were then monitored for 6 months, to assess changes in parent-rated symptoms and impairment and parent symptoms. RESULTS: Fifty-eight providers (31 trained and 27 control) and 418 children (248 patients of trained providers and 170 patients of control providers) participated. Among the children, 72% were in the possible or probable categories. Approximately one half (54%) were white, 30% black, 12% Latino, and 4% other ethnicities. Eighty-eight percent (367 children) completed follow-up monitoring. At 6 months, minority children cared for by trained providers had greater reduction in impairment (-0.91 points) than did those cared for by control providers but no greater reduction in symptoms. Seeing a trained provider did not have an impact on symptoms or impairment among white children. Parents of children cared for by trained providers experienced greater reduction in symptoms (-1.7 points) than did those cared for by control providers. CONCLUSION: Brief provider communication training had a positive impact on parent mental health symptoms and reduced minority children's impairment across a range of problems.

Wissow LS, Larson SM, Roter D, Wang MC, Hwang WT, Luo X, Johnson R, Gielen A, Wilson MH, McDonald E. SAFE Home Project. Longitudinal care improves disclosure of psychosocial information. Arch Pediatr Adolesc Med. 2003 May;157(5):419-24.
(Pediatrics, United States)
BACKGROUND: While longitudinal primary care is thought to promote patient rapport and trust, it is not known if longitudinality helps overcome barriers to communication that may occur when the patient and physician are of different ethnicities and/or sexes. OBJECTIVE: To examine if longitudinal pediatric care ameliorates disparities in parent disclosure of psychosocial information associated with ethnic and gender discordance between parent and physician. DESIGN: Longitudinal, observational study of parent-physician interaction at early visits and over the course of 1 year. PARTICIPANTS: Parents (90% African American and 10% white mothers or female guardians) and their infant's assigned primary care physician (white first- and second-year pediatric residents). MAIN OUTCOME MEASURE: Parents' psychosocial information giving measured by the Roter Interaction Analysis System. RESULTS: Sex- and race-related barriers to disclosure of psychosocial information were evident early in the parent-physician relationship. At early visits, African American mothers made 26% fewer psychosocial statements than white mothers; this discrepancy was not affected by physician sex. At early visits, white mothers made twice as many psychosocial statements when seeing white female compared with white male physicians. CONCLUSIONS: Patient-centeredness is an important factor promoting psychosocial information giving for African American and white mothers, regardless of physician sex. Longitudinal relationships facilitate mothers' disclosure to physicians of a different ethnicity or sex, but only if physicians remain patient-centered.

Wissow LS, Roter D, Bauman LJ, Crain E, Kercsmar C, Weiss K, Mitchel, H, Mohr B. Patient-provider communication during the emergency department care of children with asthma. The National Cooperative Inner-City Asthma Study. Med Care 1998 Oct;36(10):1439-50.
(Pediatrics, Patient Satisfaction or Recall, United States)
OBJECTIVES: Poor children's reliance on emergency facilities is one factor implicated in the rise of morbidity attributed to asthma. Although studies have examined doctor-patient communication during routine pediatric visits, little data are available about communication during emergency care. This study sought to describe communication during emergency treatment of childhood asthma to learn if a "patient-centered" provider style was associated with increased parent satisfaction and increased parent and child participation. METHODS: This cross-sectional, observational study examined 104 children aged 4 to 9 years and their guardian(s) attending emergency departments in seven cities. Quantitative analysis of provider-family dialogue was performed. Questionnaires measured satisfaction with care, provider informativeness, and partnership. RESULTS: Providers' talk to children was largely supportive and directive; parents received most counseling and information. Children spoke little to providers (mean: 20 statements per visit versus 156 by parents). Providers made few statements about psychosocial aspects of asthma care (mean: three per visit). Providers' patient-centered style with parents was associated with more talk from parents and higher ratings for informativeness and partnership. Patient-centered style with children was associated with five times the amount of talk from children and with higher parent ratings for "good care," but not for informativeness or partnership. CONCLUSIONS: Communication during emergency asthma care was overwhelmingly biomedical. Children took little part in discussions. A patient-centered style correlated with increased parent and child participation, but required directing conversation toward both parents and children.

Wissow LS, Roter DL, Wilson ME. Pediatrician interview style and mothers' disclosure of psychosocial issues. Pediatrics 1994 Feb;93(2):289-95.
(Pediatrics, Patient Emotional Distress, United States)
OBJECTIVE. Primary care pediatricians play an important role in the detection, diagnosis, treatment, and referral of children with mental health problems. Some parents, however, are reluctant to discuss behavioral and emotional symptoms with their child's pediatrician. Studies of patient-physician communication suggest that specific aspects of pediatrician interview style (asking questions about psychosocial issues, making supportive statements, and listening attentively) increase disclosure of sensitive information. We hypothesized that disclosures of parent and child psychosocial problems would be more likely to occur during visits when pediatricians used these techniques. DESIGN. Cross-sectional analysis of a systematic sample of pediatric primary care visits. POPULATION. Two hundred thirty-four children ages 6 months to 14 years and their mothers or female guardians attending an inner-city hospital-based pediatric primary care clinic; 52 physicians in their second or third year of pediatric residency training. METHODS. Visits audiotaped and dialogue coded using the Roter Interactional Analysis System. Independent variables included counts of pediatrician utterances in the following categories: (a) questions about psychosocial issues, (b) statements of support and reassurance, and (c) statements indicating sympathetic and attentive listening. Dependent variables were the disclosure of information about: (a) parental medical or emotional impairment, (b) family disruption, (c) use of physical punishment, and (d) aggressive or overactive child behavior. RESULTS. Use of psychosocially oriented interviewing techniques was associated with a greater likelihood of disclosure for all four of the topic areas studied. Odds ratios for disclosure, adjusted for parental concerns and child age, ranged from 1.09 to 1.22 depending on the interview technique and outcome involved. Positive associations were observed both for topics raised primarily in response to pediatrician questions (family and parent problems) and for topics raised primarily by mothers (behavior and punishment). CONCLUSIONS. Three simple communication skills were associated with disclosure of specific concerns relevant to child mental health. Training pediatricians to use these skills would help to better detect and diagnose children's mental health problems.

Wolraich ML, Albanese M, Stone G, Nesbitt D, Thomson E, Shymansky J, Bartley J, Hanson J. Medical Communication Behavior System. An interactional analysis system for medical interactions. Med Care 1986 Oct;24(10):891-903.
(Outside Primary Care, United States)
The study assessed the psychometric properties of the Medical Communication Behavior System. This observation system records time spent by the physicians and patients on specific behaviors in the categories of informational, relational, and negative situation behaviors by using hand-held electronic devices. The study included observations of 101 genetic counseling sessions and also assessed the outcome measures of patient knowledge and satisfaction. In addition, 41 of the sessions were rated using the Roter Interactional Analysis System, and 20 additional control subjects completed the post-counseling information without being observed to examine the effects of recording the session. Results showed good interobserver reliability, and evidence of concurrent, construct, and predictive validity. No differences were found between the observed and unobserved groups of any of the outcome measures.

Woods ER, Klein JD, Wingood GM, Rose ES, Wypij D, Harris SK, Diclemente RJ. Development of a new Adolescent Patient-Provider Interaction Scale (APPIS) for youth at risk for STDs/HIV. J Adolesc Health. 2006 Jun;38(6):753.e1-7.
(Adolescent Medicine, United States)
PURPOSE: Although an adult model of patient-provider mutual exchange of information has been proposed, there is no guiding model for adolescents or measurement methodology. Our purpose was to develop a new scale of patient-provider interaction for adolescents accessing reproductive health care and at risk for sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV), and assess the reliability and validity of the scale. METHODS: The Adolescent Patient-Provider Interaction Scale (APPIS) was developed from the Roter and Hall theory of doctor-patient relationships, previously validated adolescent satisfaction and communication scales, and focus group and individual elicitation interviews. To assess construct validity, the new nine-item APPIS was compared with the satisfaction scale used by the Young Adult Health Care Survey (YAHCS), and Kahn's Provider Communication Scale. Pearson correlation coefficients were used to examine convergence across scales, and factor analysis of the APPIS was performed. RESULTS: The study recruited 192 African American girls aged 17.9 +/- 1.7 years (range 15-21 years) from three sites: a county STD clinic (n = 51), urban adolescent clinic (n = 99), and a family planning clinic (n = 42). Most participants (85%) rated their overall health care highly (> or = 7 on a 10-point scale); 49% felt that both the provider and patient were "in charge" of the visit, and 88% "strongly agreed" or "agreed" that there was an equal "exchange of information" during the visit. The APPIS showed good internal consistency (Cronbach alpha = .75), and moderate convergence with the six-item YAHCS scale (r = .57, p < .001) and seven-item Kahn scale (r = .48, p < .001). Three factors emerged from exploratory factor analyses, supporting our conceptualization of patient-provider interaction as being multi-dimensional. CONCLUSIONS: A new theory-based scale of adolescent patient-provider interaction compares favorably with previous scales of health care satisfaction and communication. The new APPIS may be useful for evaluating approaches to improve health care outcomes for adolescents at-risk for STDs and HIV.

Zantinge EM, Verhaak PF, de Bakker DH, Kerssens JJ, van der Meer K, Bensing JM. The workload of general practitioners does not affect their awareness of patients' psychological problems. Patient Educ Couns. 2007 Jul;67(1-2):93-9. Epub 2007 Mar 26.
(Primary Care, Patients’ Psychological Distress, Netherlands)
OBJECTIVE: To investigate if general practitioners (GPs) with a higher workload are less inclined to encourage their patients to disclose psychological problems, and are less aware of their patients' psychological problems. METHODS: Data from 2095 videotaped consultations from a representative selection of 142 Dutch GPs were used. Multilevel regression analyses were performed with the GPs' awareness of the patient's psychological problems and their communication as outcome measures, the GPs' workload as a predictor, and GP and patient characteristics as confounders. RESULTS: GPs' workload is not related to their awareness of psychological problems and hardly related to their communication, except for the finding that a GP with a subjective experience of a lack of time is less patient-centred. Showing eye contact or empathy and asking questions about psychological or social topics are associated with more awareness of patients' psychological problems. CONCLUSION: Patients' feelings of distress are more important for GPs' communication and their awareness of patients' psychological problems than a long patient list or busy moment of the day. GPs who encourage the patient to disclose their psychological problems are more aware of psychological problems. PRACTICE IMPLICATIONS: We recommend that attention is given to all the communication skills required to discuss psychological problems, both in the consulting room and in GPs' training. Additionally, attention for gender differences and stress management is recommended in GPs' training.

Zecca G, Gradi EC, Nilsson K, Bellotti M, Dal Verme S, Vegni E, Moja EA. "All the rest is normal". A pilot study on the communication between physician and patient in prenatal diagnosis. J Psychosom Obstet Gynaecol. 2006 Sep;27(3):127-30.
(Prenatal Diagnosis, Italy)
The aim of the study was to verify in the context of prenatal diagnosis if the communicative style in consultations is modified in relation to the seriousness of the diagnosis. Videoed consultations after executing amniocentesis and ultra-sound scanning of II level were included in the study with the consent of participants. Only visits with Italian speaking couples without psychiatric problems were analyzed for the study. Selected visits were grouped into "low" (L, minor anomalies) and "high" (H, serious anomalies) visits. A modified version of the RIAS tailored for the specific context was used in the analysis. 27 visits, respectively 13 H and 14 L, were studied. Analysis of the communicative structure of the consultations did not show significant differences between the two groups. The communication during the consultation seems to be mostly influenced by a highly disease-centered model that is not dependent on the content of the consultation itself. Only emotional exchanges showed a marginally significant decrease in the H visits (t = 1.995, p = 0.057), suggesting the probable difficulty of the disease-centered model to manage emotional items during a highly dramatic consultation. Due to the exploratory nature of the study, further research is needed to test the preliminary results.

Monographs and Doctoral Theses
Abdel-Tawab, NG. Provider-cllient communication in family planning clinics in Egypt: Styles, predictors and associations with client outcomes. Dr.PH Thesis, Johns Hopkins University School of Public Health. Baltimore Maryland, 1995.

Aqil, A. Performance and its correlates: A study of family welfare workers in Pakistan. DrPH Thesis, Johns Hopkins University School of Public Health. Baltimore Maryland, 1997.

Bensing J. Doctor-patient communication and the quality of care. An observation study into affective and instrumental behavior in general practice. NIVEL, Utrecht, Holland. 1991. ISBN 90-6905-144-3.

Brink-Muinen A. Gender, health and health care in general practice. NIVEL, Utrecht, Holland. 1996. ISBN 90-6905-302-0.

Brink-Muinen, A, Verhaak PFM, Bensing JM. The Eurocommunication Study. An international comparative study in six European countries on doctor-patient communication in general practice. NIVEL, Utrecht, Holland. 1999. ISBN 90-6905-444-2.

Caris-Verhallen WMCM. Nurse-patient communication in elderly care. An observation study into verbal and nonverbal communication in nursing practice. NIVEL, Utrecht, Holland. 1999. ISBN 90-6905-366-7.

Hulsman RL. Communication skills of medical specialists in oncology. Development and evaluation of a computer-assisted instruction program. NIVEL, Utrecht, Holland. 1998. ISBN 90-6905-366-7.

Newes Adeyi G. Getting the client involved: comprehensive evaluation of a pilot training to improve WIC growth monitoring counseling sesseions in New York State. PhD Thesis, Johns Hopkins University School of Public Health. Baltimore Maryland, 1996.

Ong LML. Communication between doctors and cancer patients: taping the initial consultation. Thesis, University of Amsterdam, Faculty of Medicine. 2000. ISBN 90-9013436-0.

Renaud DB. Doctor-patient communication in chronic disease clinics in Trinidad. PhD Thesis, Johns Hopkins University School of Public Health. Baltimore Maryland, 1998.

Tates K. Doctor-parent-child communication. A multi-perspective analysis. Utrecht. Nivel, 2001.

Zeaske JA. Computer use during the pediatric visit: Patterns and predictors. PhD Thesis, Johns Hopkins University School of Public Health. Baltimore Maryland, 2000.

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