Resources
Bibiliography and Abstracts of RIAS Studies through 2014

Following are abstracts of RIAS studies, listed in alphabetical order by first 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

W

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.

Waller G, Hamberg K, Forssén A. GPs asking patients to self-rate their health: a qualitative study. Br J Gen Pract. 2015 Sep;65(638):e624-9.
(Attitudes/Relationship, Primary Care, Sweden)
BACKGROUND: In epidemiological research, self-rated health is an independent predictor of mortality, cardiovascular diseases, and other critical outcomes. It is recommended for clinical use, but research is lacking. AIM: To investigate what happens in consultations when the question 'How would you assess your general health compared with others your own age?' is posed. DESIGN AND SETTING: Authentic consultations with GPs at health centres in Sweden. METHOD: Thirty-three planned visits concerning diabetes, pain, or undiagnosed symptoms were voice-recorded. Dialogue regarding self-rated health was transcribed verbatim and analysed using a systematic text condensation method. Speaking time of patients and doctors was measured and the doctors' assessment of the value of the question was documented in a short questionnaire. RESULTS: Two overarching themes are used to describe patients' responses to the question. First, there was an immediate reaction, often expressing strong emotions, setting the tone of the dialogue and influencing the continued conversation. This was followed by reflection regarding their functional ability, management of illnesses and risks, and/or situation in life. The GPs maintained an attitude of active listening. They sometimes reported a slight increase in consultation time or feeling disturbed by the question, but mostly judged it as valuable, shedding additional light on the patients' situation and making it easier to discuss difficulties and resources. The patients' speaking time increased noticeably during this part of the consultation. CONCLUSION: Asking patients to comparatively self-rate their health is an effective tool in general practice. KEYWORDS: GP; comparative self-rated health; consultations; family medicine; qualitative analysis

Washington Cole KO, Roter DL. Starting the conversation: Patient initiation of weight-related behavioral counseling during pregnancy. Patient Educ Couns. 2016 May 3.
(Prenatal, United States)
OBJECTIVE: To examine the relationship between patient initiation and weight-related behavioral counseling during pregnancy. METHODS: We examined audio recordings of prenatal visits between 22 obstetricians and 120 patients for behavioral counseling using the Roter Interaction Analysis System and the 5A's behavioral counseling framework. We used multivariate regression models to examine the relationship between patient initiation and communication outcomes. RESULTS: Overall, 55% of prenatal visits included any behavioral counseling. Patients initiated counseling episodes 45.5% of these visits. Patients were less verbally dominated by their clinicians in prenatal visits with patient-initiated behavioral counseling episodes (difference in clinician verbal dominance ratio=0.73, 95% CI=0.16-1.30). Patient-initiated counseling episodes included more socioemotional communication relative to those initiated by clinicians (p=0.02). The total duration of counseling was 28s longer (95% CI 0.27-56.0s) and clinicians were more likely to use two or more 5A's strategies (OR=3.61, 95% CI=1.01-12.88) when patients initiated discussions. CONCLUSIONS: Patient initiation may lead to behavioral counseling that is longer in duration and includes more 5A's strategies, possibly mediated by socioemotional communication. PRACTICE IMPLICATIONS: Participatory prenatal care communication may lead to more effective counseling that is responsive to women's concerns.

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.

Weiner SJ, Schwartz A, Cyrus K, Binns-Calvey A, Weaver FM, Sharma G, Yudkowsky R. Unannounced standardized patient assessment of the Roter Interaction Analysis System: the challenge of measuring patient-centered communication. J Gen Intern Med. 2013 Feb;28(2):254-60.
(Standardized Patients, Primary Care, United States)
BACKGROUND: Despite wide-spread endorsement of patient-centered communication (PCC) in health care, there has been little evidence that it leads to positive change in health outcomes. The lack of correlation may be due either to an overestimation of the value of PCC or to a measurement problem. If PCC measures do not capture elements of the interaction that determine whether the resulting care plan is patient-centered, they will confound efforts to link PCC to outcomes. OBJECTIVE: To evaluate whether one widely used measure of PCC, the Roter Interaction Analysis System (RIAS), captures patient-centered care planning. DESIGN: RIAS was employed in the coding of unannounced standardized patient (USP) encounters that were scripted so that the failure to address patient contextual factors would result in an ineffective plan of care. The design enabled an assessment of whether RIAS can differentiate between communication behavior that does and does not result in a care plan that takes into account a patient's circumstances and needs. PARTICIPANTS: Eight actors role playing four scripted cases (one African American and one Caucasian for each case) in 399 visits to 111 internal medicine attending physicians. MAIN MEASURES: RIAS measures included composites for physician utterance types and (in separate models) two different previously applied RIAS patient-centeredness summary composites. The gold standard comparison measure was whether the physician's treatment plan, as abstracted from the visit note, successfully addressed the patient's problem. Mixed effects regression models were used to evaluate the relationship between RIAS measures and USP measured performance, controlling for a variety of design features. KEY RESULTS: None of the RIAS measures of PCC differentiated encounters in which care planning was patient-centered from care planning in which it was not. CONCLUSIONS: RIAS, which codes each utterance during a visit into mutually exclusive and exhaustive categories, does not differentiate between conversations leading to and not leading to care plans that accommodate patients' circumstances and needs.

Weingarten MA, Guttman N, Abramovitch H, Margalit RS, Roter D, Ziv A, Yaphe J, Borkan JM. An anatomy of conflicts in primary care encounters: a multi-method study. Fam Pract. 2010 Feb;27(1):93-100. Epub 2009 Nov 30.
(Conflict, Primary Care, Israel)
BACKGROUND: Medical consultations are replete with conflicts, particularly in the current era of explicit and implicit rationing practices in health care organizations. Although such conflicts may challenge the doctor-patient relationship, little is known about them or their consequences. AIMS: To systematically describe the nature of doctor-patient conflicts in medical encounters and the strategies physicians use when faced with conflicts. METHODS: Analysis of 291 videotaped routine encounters with 28 general practitioners, using a novel adaptation of the Roter interaction analysis system software, provided quantitative empirical data on the conflicts and on the communication process. Seven focus groups (56 GPs) provided qualitative insights and guided the analysis. RESULTS: Conflicts were identified in 40% of consultations; 21% of these were related to the rationing of health care resources. In conflictual encounters, both the opening and closing phases of the encounter were shorter than in non-conflictual encounters. In coping with resource rationing, the commonest strategy was to accept the dictates of the system without telling the patients about other options. When conflict of this type occurred, doctors showed more opposition to the patients rather than empathy. CONCLUSIONS: Doctors often face conflicts in their routine work, but resource-related conflicts are especially difficult and expose the dual loyalties of the doctor to the patient and to the system. Insights derived from this research can be used to design training interventions that improve doctors' efficacy in coping with conflicts and ultimately allow them to provide better patient care.

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.

Wiering BM, Albada A, Bensing JM, Ausems MG, van Dulmen AM. The influence of dispositional optimism on post-visit anxiety and risk perception accuracy among breast cancer genetic counselees. Psychooncology. 2013 Apr 29.
(Genetics Counseling, The Netherlands)
OBJECTIVE: Much is unknown about the influence of dispositional optimism and affective communication on genetic counselling outcomes. This study investigated the influence of counselees' optimism on the counselees' risk perception accuracy and anxiety, while taking into account the affective communication during the first consultation for breast cancer genetic counselling. METHODS: Counselees completed questionnaires measuring optimism, anxiety and the perceived risk that hereditary breast cancer runs in the family before, and anxiety and perceived risk after the first consultation. Consultations were videotaped. The duration of eye contact was measured, and verbal communication was rated using the Roter Interaction Analysis System. RESULTS: Less-optimistic counselees were more anxious post-visit (β = -.29; p = .00). Counsellors uttered fewer reassuring statements if counselees were more anxious (&beta: = - .84; p = .00) but uttered more reassurance if counselees were less optimistic (β = -.76; p = .01). Counsellors expressed less empathy if counselees perceived their risk as high (β = -1.51; p = .04). An increase in the expression of reassurance was related to less post-visit anxiety (β = -.35; p = .03). More empathy was related to a greater overestimation of risk (β = .92; p = .01). CONCLUSIONS: Identification of a lack of optimism as a risk factor for high anxiety levels enables the adaptation of affective communication to improve genetic counselling outcomes. Because reassurance was related to less anxiety, beneficial adaptation is attainable by increasing counsellors' reassurance, if possible. Because of a lack of optimally adapted communication in this study, further research is needed to clarify how to increase counsellors' ability to adapt to counselees.

Wissow LS, Brown JD, Krupnick J. Therapeutic alliance in pediatric primary care: preliminary evidence for a relationship with physician communication style and mothers' satisfaction. J Dev Behav Pediatr. 2010 Feb-Mar;31(2):83-91.
(Pediatrics, United States)
OBJECTIVES: Studies in pediatric primary care suggest that interactions between parents and providers may have therapeutic impact on children's mental health problems. Methods to measure interactions specific to mental health outcomes have been developed in psychotherapy but are only beginning to be applied in primary care. We tested an adaptation of the Vanderbilt Therapeutic Alliance Scale (VTAS) for rating parent-provider interactions in pediatric primary care. METHODS: Recoding, using the VTAS, of 50 previously collected audiotapes of visits to a pediatric residents' continuity clinic. Concurrent validity of VTAS coding was measured by comparing it to independent coding using the Roter Interaction Analysis System. Predictive validity was tested by comparing VTAS scores to parent ratings of the residents' behavior in the domains of interpersonal sensitivity, partnership, and informativeness. RESULTS: The VTAS demonstrated a factor structure very similar to the structure observed when it has been used to rate mental health visits. VTAS patient and provider subscale scores correlated with corresponding Roter Interaction Analysis System measures of parent and resident participation. Total VTAS scores correlated most strongly with Roter Interaction Analysis System scores indicating emotion and rapport-building statements from the resident. Total VTAS scores predicted parents' ratings of residents' interpersonal sensitivity but not ratings of partnership or informativeness. CONCLUSION: It appears possible to use therapeutic alliance to rate interactions in primary care. Measuring alliance may bring greater efficiency to primary care mental health studies because of its potential specificity as a marker of mental health-related outcomes.

Wissow L, Gadomski A, Roter D, Larson S, Lewis B, Brown J. Aspects of mental health communication skills training that predict parent and child outcomes in pediatric primary care. Patient Educ Couns. 2011 Feb;82(2):226-32. Epub 2010 May 5.
(Communication Skills/ Training, Pediatrics, Adolescent Medicine, Mental Health, United States)
OBJECTIVE: Training in communication can change clinician behaviors, but brief training may function by altering attitudes rather than teaching new skills. We used data from a trial of mental health training for office-based primary care to determine indicators of uptake that predicted parent and child outcomes. METHODS: Clinicians (n=50) were randomized to be controls or receive training. Uptake was determined comparing pre- and post-training visits with standardized patients (SPs) coded for skills and patient centeredness. Clinical outcomes were assessed by recruiting and following 403 children/youth ages 5-16 making visits to participants. At 6 months, change in mental health was assessed by parent and youth reports using the Strengths and Difficulties Questionnaire. RESULTS: Trained clinicians used more agenda setting, time, and anger management skills than controls and showed increased patient centeredness toward SP parents, but not adolescents. Increased patient-centeredness toward parents predicted improvement in child/youth symptoms and functioning (rated by parents), and improvement in youth-rated symptoms. Increased skills alone were not associated with improvement, but patients of clinicians above the mean for both skill and patient-centeredness change improved most.

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.
(Pediatrics, 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, 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 D, Larson SM, Wang MC, Hwang WT, Johnson R, Luo X. Mechanisms behind the failure of residents' longitudinal primary care to promote disclosure and discussion of psychosocial issues. Arch Pediatr Adolesc Med. 2002 Jul;156(7):685-92.
(Communication Skills/Training, Pediatrics, Patient Distress/Cues, United States)
CONTEXT: Longitudinality (care by a single physician over time) and continuity (receipt of most care from a single physician) are believed to enhance patient-physician relationships and facilitate disclosure of emotional distress, but some studies suggest this potential goes unrealized. OBJECTIVES: To determine whether care in a pediatric residents' continuity clinic promotes, over time, increased discussion, disclosure, and detection of parents' social and emotional distress and to understand physicians' communication behaviors underlying changes with time. DESIGN: Longitudinal, observational study of parent-physician interaction over the course of 1 year. PARTICIPANTS: One hundred ninety parents (90% African American) and their infants' primary care physicians (31 [4 Asians and 27 whites] first- and second-year pediatric residents). MAIN OUTCOME MEASURES: Frequency with which parents and physicians raised topics related to parental mood and family or social functioning; proportion of distressed parents discussing mood or functioning; and physicians' detection of parent distress. RESULTS: Physician initiation of psychosocial topics fell in the course of longitudinal relationships (odds of initiation in visits > or =6 vs odds of initiation in visits 1-5 = 0.46 [95% confidence limits, 0.31%, 0.67%]); parent initiation did not change over time nor was it increased by greater levels of continuity. Length of relationship was not associated with increased physician detection of parental distress or with increased rates of disclosure by distressed parents. Physicians' positively framed leading questions, and their avoidant responses to prior parental disclosures were significantly associated with decreased odds of problem disclosure. In contrast, visits in which parents or physicians raised psychosocial topics were characterized, on average, by 40% higher levels of physicians' "patient-centeredness" (increases of about 100 utterances per visit [95% confidence limits, 65.7%, 133.9%]). CONCLUSIONS: Longitudinal relationships between residents and patients may not be sufficient to promote the discussion, disclosure, and detection of psychosocial issues. Training in communication skills may help residents achieve the potential and goals of longitudinal care.

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.

Wittenberg-Lyles E, Oliver DP, Kruse RL, Demiris G, Gage LA, Wagner K. Family Caregiver Participation in Hospice Interdisciplinary Team Meetings: How Does It Affect the Nature and Content of Communication? Health Commun. 2012 Mar 21. [Epub ahead of print]
(Palliative/Hospice, Companions/Caregivers, United States)
Collaboration between family caregivers and health care providers is necessary to ensure patient-centered care, especially for hospice patients. During hospice care, interdisciplinary team members meet biweekly to collaborate and develop holistic care plans that address the physical, spiritual, psychological, and social needs of patients and families. The purpose of this study was to explore team communication when video-conferencing is used to facilitate the family caregiver's participation in a hospice team meeting. Video-recorded team meetings with and without family caregiver participation were analyzed for communication patterns using the Roter Interaction Analysis System. Standard meetings that did not include caregivers were shorter in duration and task-focused, with little participation from social workers and chaplains. Meetings that included caregivers revealed an emphasis on biomedical education and relationship-building between participants, little psychosocial counseling, and increased socioemotional talk from social workers and chaplains. Implications for family participation in hospice team meetings are highlighted.

Wolff JL, Clayman ML, Rabins P, Cook MA, Roter DL. An exploration of patient and family engagement in routine primary care visits. Health Expect. 2012 Oct 29.
(Companions/Caregivers, Primary Care, Geriatrics, United States) BACKGROUND: Older adults are commonly accompanied to routine medical visits. Whether and how family companion behaviours relate to visit processes is poorly understood. OBJECTIVE: To examine family companion behaviours in relation to older adults' medical visit processes. DESIGN AND PARTICIPANTS: Observational study of 78 accompanied primary care patients ages 65 and older. MAIN OUTCOME MEASURES: Medical visit communication (coded using RIAS), patient verbal activity (as a proportion of visit statements) and visit duration (in min), from audio recordings. RESULTS: Companions' facilitation of patient involvement was associated with greater patient question asking (P = 0.017) and orienting statements, less passive agreement (P = 0.004) and social talk (P = 0.013) and visits that were 3.4 min longer (P = 0.025). Facilitation of patient understanding was associated with less physician question asking (P = 0.004), visits that were 3.0 min longer (P = 0.031), and lower patient verbal activity (30.3% vs. 36.9% of visit statements; P = 0.028). Facilitation of doctor understanding was associated with greater patient biomedical information giving (P = 0.049). Autonomy detracting behaviours were not associated with visit duration but were associated with lower levels of patient verbal activity (36.3% vs. 29.1% of visit statements; P = 0.041). When companions assumed more behaviours, medical visits were incrementally longer (16.1, 19.5, 21.7 min, corresponding to 0-1, 2-4 and 5+ behaviours; P < 0.001 both contrasts), and patients were less verbally active (35.6%, 33.9%, 27.1% of visit statements; P = 0.09 and P = 0.009, respectively). DISCUSSION: Behaviours assumed by patients' companions were associated with visit communication, patient verbal activity and visit duration. CONCLUSIONS: Interventions to capitalize on family companions' presence may benefit medical visit processes.

Wolff JL, Roter DL. Older adults' mental health function and patient-centered care: does the presence of a family companion help or hinder communication? J Gen Intern Med. 2012 Jun;27(6):661-8. Epub 2011 Dec 17.
(Companions/Caregivers, Mental Health, United States)
BACKGROUND: Late-life mental health disorders are prevalent, costly, and commonly under-diagnosed and under-treated. OBJECTIVE: To investigate whether family companion presence in routine primary care visits helps or hinders patient-centered processes among older adults with poor mental health function. DESIGN AND PARTICIPANTS: Observational study of accompanied (n = 80) and unaccompanied (n = 310) primary care patients ages 65 and older. MAIN MEASURES: Audio-taped medical visit communication, coded with the Roter Interactional Analysis System, and three process measures: visit duration (in minutes), patient/companion verbal activity, and a ratio of patient-centered communication, adjusted for patient age, gender, race, and physical function. Participants were stratified by SF-36 mental health subscale (MCS) using two approaches (1) standardized population midpoint to delineate "good" (50+) and "poor" health (< 50) and (2) clinically derived cut-points (<35; 35-49; 50+). RESULTS: When patients with poor mental health were accompanied by a family companion, patient/companions provided less psychosocial information, physicians engaged in less question-asking and partnership-building, and both patient/companions and physicians contributed more task-oriented, biomedical discussion. Accompanied patients with poor mental health were less likely to experience patient-centered communication relative to unaccompanied patients (aOR = 0.21; 95% CI: 0.06, 0.68); no difference was observed for patients with good mental health (aOR = 1.02; 95% CI: 0.46, 2.27). Verbal activity was comparable for accompanied patients/companions and unaccompanied patients in both mental health strata. Medical visits were 2.3 minutes longer when patients with good mental health were accompanied (b = 2.31; p = 0.006), but was comparable for patients with poor mental health (b = -0.037; p = 0.827). Study findings were amplified in the lowest functioning mental health subgroup (MCS < 35): medical visits were shorter, and communication was least patient-centered (p = 0.019) when these patients were accompanied. CONCLUSIONS: Older adults with poor mental health function may experience more communication challenges in the form of shorter visits and less patient-centered communication when a family companion is present.

Wolff JL, Roter DL. Family presence in routine medical visits: a meta-analytical review. Soc Sci Med. 2011 Mar;72(6):823-31. Epub 2011 Feb 24.
(Companions/Caregivers, Primary Care, United States)
Older adults are commonly accompanied to routine physician visits, primarily by adult children and spouses. This is the first review of studies investigating the dynamics and consequences of patient accompaniment. Two types of evidence were examined: (1) observational studies of audio and/or videotaped medical visits, and (2) surveys of patients, families, or health care providers that ascertained experiences, expectations, and preferences for family companion presence and behaviors in routine medical visits. Meta-analytic techniques were used to summarize the evidence describing attributes of unaccompanied and accompanied patients and their companions, medical visit processes, and patient outcomes. The weighted mean rate of patient accompaniment to routine adult medical visits was 37.6% in 13 contributing studies. Accompanied patients were significantly older and more likely to be female, less educated, and in worse physical and mental health than unaccompanied patients. Companions were on average 63 years of age, predominantly female (79.4%), and spouses (54.7%) or adult children (32.2%) of patients. Accompanied patient visits were significantly longer, but verbal contribution to medical dialog was comparable when accompanied patients and their family companion were compared with unaccompanied patients. When a companion was present, health care providers engaged in more biomedical information giving. Given the diversity of outcomes, pooled estimates could not be calculated: of 5 contributing studies 0 were unfavorable, 3 inconclusive, and 2 favorable for accompanied relative to unaccompanied patients. Study findings suggest potential practical benefits from more systematic recognition and integration of companions in health care delivery processes. We propose a conceptual framework to relate family companion presence and behaviors during physician visits to the quality of interpersonal health care processes, patient self management and health care.

Wolff JL, Roter DL, Barron J, Boyd CM, Leff B, Finucane TE, Gallo JJ, Rabins PV, Roth DL, Gitlin LN. A tool to strengthen the older patient-companion partnership in primary care: results from a pilot study. J Am Geriatr Soc. 2014 Feb;62(2):312-9.
(Geriatrics, Companions/Caregivers, United States)
OBJECTIVES: To determine the acceptability of a pre-consultation checklist for older adults who attend medical visits with an unpaid companion and to evaluate its effects on visit communication. DESIGN: Randomized controlled pilot study. SETTING: Academic geriatrics ambulatory clinic. PARTICIPANTS: Thirty-two individuals aged 65 and older and their unpaid companions. INTERVENTION: A self-administered checklist was compared with usual care. The checklist was designed to elicit and align patient and companion perspectives regarding health concerns to discuss with the doctor and stimulate discussion about the companion's role in the visit. MEASUREMENT: PRIMARY OUTCOME: ratio of patient-centered communication, coded from visit audiotapes. SECONDARY OUTCOMES: checklist acceptability; visit duration; patient-companion verbal activity; patient- and physician-reported perspectives of the visit. RESULTS: All intervention patients and companions (n = 17) completed the checklist, and all participants (n = 32 dyads) completed the study. Patients and companions stated that the checklist was easy to complete (88%) and useful (91%), and they uniformly (100%) recommended it to other patients. Communication was significantly more patient-centered in intervention group visits (ratio of 1.22 vs 0.71; P = .03). Visit duration (35.0 and 30.6 minutes; P = .34) and percentage of total verbal activity contributed by patients and companions (58.2% and 56.3% of visit statements; P = .50) were comparable in the intervention and control groups, respectively. Physicians were more likely to indicate that intervention companions "helped them provide good care to the patient" (94% vs 60%; P = .02). Intervention patients were more likely to indicate that they "better understood their doctor's advice and explanations" because their companion was present (82% vs 47%; P = .03). CONCLUSION: A checklist to elicit and align perspectives of older adults and their companions resulted in enhanced patient-centered medical visit communication. KEYWORDS: family caregiver; patient-provider communication; physician office; primary health care.

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.

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