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

B

Beach MC, Roter D, Korthuis PT, Epstein RM, Sharp V, Ratanawongsa N, Cohn J, Eggly S, Sankar A, Moore RD, Saha S. A multicenter study of physician mindfulness and health care quality. Ann Fam Med. 2013 Sep-Oct;11(5):421-8.
(HIV/AIDs , Physician Mindfulness, United States)
PURPOSE: Mindfulness (ie, purposeful and nonjudgmental attentiveness to one's own experience, thoughts, and feelings) is associated with physician well-being. We sought to assess whether clinician self-rated mindfulness is associated with the quality of patient care. METHODS: We conducted an observational study of 45 clinicians (34 physicians, 8 nurse practitioners, and 3 physician assistants) caring for patients infected with the human immunodeficiency virus (HIV) who completed the Mindful Attention Awareness Scale and 437 HIV-infected patients at 4 HIV specialty clinic sites across the United States. We measured patient-clinician communication quality with audio-recorded encounters coded using the Roter Interaction Analysis System (RIAS) and patient ratings of care. RESULTS: In adjusted analyses comparing clinicians with highest and lowest tertile mindfulness scores, patient visits with high-mindfulness clinicians were more likely to be characterized by a patient-centered pattern of communication (adjusted odds ratio of a patient-centered visit was 4.14; 95% CI, 1.58-10.86), in which both patients and clinicians engaged in more rapport building and discussion of psychosocial issues. Clinicians with high-mindfulness scores also displayed more positive emotional tone with patients (adjusted β = 1.17; 95% CI, 0.46-1.9). Patients were more likely to give high ratings on clinician communication (adjusted prevalence ratio [APR] = 1.48; 95% CI, 1.17-1.86) and to report high overall satisfaction (APR = 1.45; 95 CI, 1.15-1.84) with high-mindfulness clinicians. There was no association between clinician mindfulness and the amount of conversation about biomedical issues. CONCLUSIONS: Clinicians rating themselves as more mindful engage in more patient-centered communication and have more satisfied patients. Interventions should determine whether improving clinician mindfulness can also improve patient health outcomes.

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, Saha S, Korthuis PT, Eggly S, Cohn J, Sharp V, Moore RD, Wilson IB. Impact of a brief patient and provider intervention to improve the quality of communication about medication adherence among HIV patients. Patient Educ Couns. 2015 Sep;98(9):1078-83.
(HIV/AIDS, Communication Skills, Adherence, United States)
INTRODUCTION: Medication adherence is essential in HIV care, yet provider communication about adherence is often suboptimal. We designed this study to improve patient-provider communication about HIV medication adherence. METHODS: We randomized 26 providers at three HIV care sites to receive or not receive a one-hour communication skills training based on motivational interviewing principles applied to medication adherence. Prior to routine office visits, non-adherent patients of providers who received the training were coached to discuss adherence with their providers. Patients of providers who did not receive the training providers were not coached. We audio-recorded and coded patient-provider interactions using the roter interaction analysis system (RIAS). RESULTS: There was more dialogue about therapeutic regimen in visits with intervention patients and providers (167 vs 128, respectively, p=.004), with the majority of statements coming from providers. These visits also included more brainstorming solutions to nonadherence (41% vs. 22%, p=0.026). Intervention compared with control visit providers engaged in more positive talk (44 vs. 38 statements, p=0.039), emotional talk (26 vs. 18 statements, p<0.001), and probing of patient opinion (3 vs. 2 statements, p=0.009). CONCLUSION: A brief provider training combined with patient coaching sessions, improved provider communication behaviors and increased dialogue regarding medication adherence. KEYWORDS: Communication skills training; HIV/AIDS; Medication adherence

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.

Beach MC, Saha S, Korthuis PT, Sharp V, Cohn J, Wilson IB, Eggly S, Cooper LA, Roter D, Sankar A, Moore R. Patient-Provider Communication Differs for Black Compared to White HIV-Infected Patients. AIDS Behav. 2010 Jan 12. [Epub ahead of print]
(Race/Cross-Culture, HIV/AIDS. United States)
Poor patient-provider interactions may play a role in explaining racial disparities in the quality and outcomes of HIV care in the United States. We analyzed 354 patient-provider encounters coded with the Roter Interaction Analysis System across four HIV care sites in the United States to explore possible racial differences in patient-provider communication. Providers were more verbally dominant in conversations with black as compared to white patients. This was largely due to black patients' talking less than white patients. There was no association between race and other measures of communication. Black and white patients rated their providers' communication similarly. Efforts to more effectively engage patients in the medical dialogue may lead to improved patient-provider relationships, self-management, and outcomes among black people living with HIV/AIDS.

Beach MC, Saha S, Korthuis PT, Sharp V, Cohn J, Wilson I, Eggly S, Cooper LA, Roter D, Sankar A, Moore R. Differences in patient-provider communication for Hispanic compared to non-Hispanic white patients in HIV care. J Gen Intern Med. 2010 Jul;25(7):682-7. Epub 2010 Mar 18.
(Race/Cross-Culture, HIV/AIDS, United States)
BACKGROUND: Hispanic Americans with HIV/AIDS experience lower quality care and worse outcomes than non-Hispanic whites. While deficits in patient-provider communication may contribute to these disparities, no studies to date have used audio recordings to examine the communication patterns of Hispanic vs. non-Hispanic white patients with their health care providers. OBJECTIVE: To explore differences in patient-provider communication for English-speaking, HIV-infected Hispanic and non-Hispanic white patients. DESIGN: Cross-sectional analysis. SETTING: Two HIV care sites in the United States (New York and Portland) participating in the Enhancing Communication and HIV Outcomes (ECHO) study. SUBJECTS: Nineteen HIV providers and 113 of their patients. MEASUREMENTS: Patient interviews, provider questionnaires, and audio-recorded, routine, patient-provider encounters coded with the Roter Interaction Analysis System (RIAS). RESULTS: Providers were mostly non-Hispanic white (68%) and female (63%). Patients were Hispanic (51%), and non-Hispanic white (49%); 20% were female. Visits with Hispanic patients were less patient-centered (0.75 vs. 0.90, p = 0.009), with less psychosocial talk (80 vs. 118 statements, p < 0.001). This pattern was consistent among Hispanics who spoke English very well and those with less English proficiency. There was no association between patient race/ethnicity and visit length, patients' or providers' emotional tone, or the total number of patient or provider statements categorized as socioemotional, question-asking, information-giving, or patient activating. Hispanic patients gave higher ratings than whites (AOR 3.05 Hispanic vs. white highest rating of providers' interpersonal style, 95% CI 1.20-7.74). CONCLUSION: In this exploratory study, we found less psychosocial talk in patient-provider encounters with Hispanic compared to white patients. The fact that Hispanic patients rated their visits more positively than whites raises the possibility that these differences in patient-provider interactions may reflect differences in patient preferences and communication style rather than "deficits" in communication. If these findings are replicated in future studies, efforts should be undertaken to understand the reasons underlying them and their impact on the quality and equity of care.

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.

Bensing JM, Verheul W, Jansen J, Langewitz WA. Looking for trouble: the added value of sequence analysis in finding evidence for the role of physicians in patients' disclosure of cues and concerns. Med Care. 2010 Jul;48(7):583-8.
(Interaction Analysis, Primary Care, Netherlands)
BACKGROUND: Not knowing patient concerns can lead to misunderstandings, incomplete diagnoses, patient dissatisfaction, and nonadherence. Although many studies show relations between physician communication and patients' expression of cues or concerns, most of these studies are cross-sectional, thus limiting the interpretation of these relationships. Sequence analysis can show the immediate effects of physician communication behaviors. OBJECTIVE: To show the added value of sequence analysis in finding evidence for the role of physician communication in patients' disclosure of cues and concerns. RESEARCH QUESTIONS: Which physician communication predicts patients' expression of cues or concerns when using 2 different types of analysis: sequence analysis and cross-sectional analysis? METHODS: In a sample of 99 videotaped medical encounters with hypertensive patients in General Practice, we coded communication with Roter Interaction Analysis System and timed physician eye contact. For the cross-sectional analyses, we performed Poisson regression analyses to establish which physician communication is related to the total amount of patient cues and concerns. For the sequential analyses, we performed logistic regression analyses to establish which physician communication is directly followed by cues or concerns. We report incidence rate ratios and odds ratios (ORs), respectively. RESULTS: Both methods show that physicians' facilitative communication (1.21 and 2.33, respectively), eye contact (1.02 and 1.51, respectively), and psychosocial questions (2.42 and 3.50, respectively) are related to more disclosure of cues and concerns. Moreover, sequence analysis shows that patients' expression of cues or concerns is less often preceded by physician social talk (OR = 0.49), giving instructions (OR = 0.38) and providing biomedical information (OR = 0.45) or counseling (OR = 0.39). In the cross-sectional analyses, these relations are absent or-before controlling for confounding variables-even in the opposite direction. All reported results are significant at P < 0.01 or P < 0.001. CONCLUSIONS: Although cross-sectional analyses and sequence analyses show grossly the same results, sequence analysis is more precisely in demonstrating the direct influence of physician communication on subsequent cues and concerns by the patient. Physicians should avoid long monologues with medical information and should use facilitative communication, eye contact, and psychosocial questions to help patients express themselves. PRACTICE IMPLICATIONS: The implications for medical education are discussed.

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.

Björkman B, Golsäter M, Simeonson RJ, Enskär K. Will it Hurt? Verbal Interaction between Child and Radiographer during Radiographic Examination. J Pediatr Nurs. 2013 Apr 23.
(Paraprofessionals, Pediatrics, Sweden)
This study investigated the nature of verbal interactions between child, parent and radiographer and the extent to which it varied as a function of the child's age. The participants were 20 female radiographers and 32 children (3-15years) examined for acute injuries. The verbal interactions during the examination were video recorded and analyzed using the Roter Interaction Analysis System (RIAS). Results indicated that 80% of the verbal interaction was accounted for by the radiographer, 17% by the child and 3% by the parent. The distribution of utterances varied with regard to children's age.

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.

Blanch-Hartigan D, Hall JA, Roter DL, Frankel RM. Gender bias in patients' perceptions of patient-centered behaviors. Patient Educ Couns. 2010 Sep;80(3):315-20. Epub 2010 Jul 17.
(Gender, Standardized Patients, United States)
OBJECTIVE: This research examines whether patient perceptions are equivalently associated with patient-centered behavior in male and female medical students, and tests the impact of a message emphasizing the importance of patient-centeredness on analogue patients' perceptions of male and female medical students' performance. METHODS: Sixty-one medical students interacting with standardized patients (SPs) were viewed by 384 analogue patients (APs). APs were randomly assigned to receive a message emphasizing the value of patient-centeredness or of technical competence, or a neutral message, and then evaluated the medical students' competence in the interactions. Students' patient-centeredness was measured using the Four Habits Coding Scheme and Roter Interaction Analysis System. RESULTS: APs in the neutral and technical competence conditions gave higher competence ratings to more patient-centered male students, but not to more patient-centered female students. However, APs who received the patient-centeredness message gave higher competence ratings to both male and female students who were higher in patient-centeredness. CONCLUSION: Making it clear that patient-centeredness is a dimension of physician competence eliminated a gender bias in evaluating performance. PRACTICE IMPLICATIONS: Because patient perceptions are often used in evaluations, gender biases must be understood and reduced so both male and female providers receive appropriate credit for their patient-centered behaviors.

Borghi L, Johnson I, Barlascini L, Moja EA, Vegni E. Do occupational therapists' communication behaviours change with experience? Scand J Occup Ther. 2016;23(1):50-6.
(Communication Skills, Outside Primary Care, Standardized Patients, Italy)
BACKGROUND: An increasing amount of literature has studied changes in communication skills in medical and nursing undergraduate students. AIM: To evaluate whether occupational therapists' communication behaviours change with experience. MATERIAL AND METHODS: A total of 45 participants (second-year OT students, final-year OT students, professional OTs) were enrolled and met three simulated clients. The role plays were video-recorded and analysed through OT-RIAS (Occupational Therapy-Roter Interaction Analysis System). Chi-square tests were used to analyse the statistical differences between groups for the OT-RIAS categories. RESULTS: Process represented 30.74% of communication for second-year students, 33.69% for final year students, and 35.58% for professional OTs; Occupational therapy ranged from 30.41% in the second-year students to 32.54% in the undergraduates and 37.04% in the professional OTs; Medical increased from 18.66% to 34.33% of the final-year students and 47.01% of the professional therapists. Personal and Psychosocial slightly decreased through experience. Emotional decreased gradually: 39.8% in the second-year students, 29.54% in final-year students, and 30.66% in professional OTs. CONCLUSION: During training in occupational therapy the communication skills changed, assuming a more technical shape, increasing control and content-related OT communication. Nevertheless, the therapists' communication behaviours showed the endurance of attention to the client's point of view. KEYWORDS: Communication; OT-RIAS; occupational therapy; videotaped simulated visits

Boss RD, Donohue PK, Larson SM, Arnold RM, Roter DL. Family Conferences in the Neonatal ICU: Observation of Communication Dynamics and Contributions. Pediatr Crit Care Med. 2016 Mar;17(3):223-30.
(Family Conferences, Bad/Difficult News Delivery, United States)
OBJECTIVES: Clinicians in the neonatal ICU must engage in clear and compassionate communication with families. Empirical, observational studies of neonatal ICU family conferences are needed to develop counseling best practices and to train clinicians in key communication skills. We devised a pilot study to record and analyze how interdisciplinary neonatal ICU clinicians and parents navigate difficult conversations during neonatal ICU family conferences. DESIGN: We prospectively identified and audiotaped a convenience sample of neonatal ICU family conferences about "difficult news." Conversations were analyzed using the Roter interaction analysis system, a quantitative tool for assessing content and quality of patient-provider communication. SETTING: An urban academic children's medical center with a 45-bed level IV neonatal ICU. SUBJECTS: Neonatal ICU parents and clinicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed 19 family conferences that included 31 family members and 23 clinicians. The child's mother was included in all conferences, and a second parent, usually the father, was present in 13 conferences. All but one conference included multiple medical team members. On average, physicians contributed 65% of all dialogue, regardless of who else was present. Over half (56%) of this dialogue involved giving medical information; under 5% of clinician dialogue involved asking questions of the family, and families rarely (5% of dialogue) asked questions. Conversations were longer with the presence of nonphysician clinicians, but this did not increase the amount of dialogue about psychosocial information or increase parent dialogue. CONCLUSIONS: We collected a novel repository of audiorecorded neonatal ICU family meetings that offers insights into discussion content and process. These meetings were heavily focused on biomedical information even when interdisciplinary clinicians were present. Clinicians always talked more than parents, and no one asked many questions. Maximizing the participation of interdisciplinary clinicians in neonatal ICU family meetings may require explicit strategies. Methods to increase family engagement should be targeted.

Boss RD, Donohue PK, Roter DL, Larson SM, Arnold RM. "This is a decision you have to make": using simulation to study prenatal counseling. Simul Healthc. 2012 Aug;7(4):207-12.
(Decision-Making, Prenatal, Standardized Patients, United States)
INTRODUCTION: Prenatal decision making during extremely preterm labor is challenging for parents and physicians. Ethical and logistical concerns have limited empirical descriptions of physician counseling behaviors in this setting and constricted opportunities for communication training. This pilot study examines how simulation might be used to engage neonatologists in reflecting on their usual prenatal counseling behaviors. METHODS: Neonatology physicians counseled a couple (standardized patients) with the female patient having impending delivery at 23 3/7 weeks. Encounters were videotaped. Physicians completed post encounter surveys and debriefing interviews. Mixed-methods analysis explored the outcomes of clinical verisimilitude and counseling behaviors. RESULTS: All 10 neonatology physicians found that the simulation was highly realistic and that their behaviors paralleled neonatologist self-report in other studies. Physicians contributed more than 80% of encounter dialogue and mostly focused on biomedical information related to the acute perinatal period. Physicians spent nearly a quarter of each encounter in building relationships and expressing empathy. Most physicians initiated discussion about quality versus quantity of life but infrequently elicited the parents' related goals and values. When medical factors and family preferences were held constant, physicians assumed variable responsibility for making decisions about resuscitation. Most physicians declined parent requests for treatment recommendations, although all of those physicians felt more than 75% certain about what should be done. CONCLUSIONS: Simulation can reproduce the decisional context of prenatal counseling for extremely premature labor. These results have implications for communication training in any setting where physicians and patients without established relationships must discuss acute diagnoses and make high-stakes medical decisions.

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 JD, Wissow LS, Cook BL, Longway S, Caffery E, Pefaure C. Mental health communications skills training for medical assistants in pediatric primary care. J Behav Health Serv Res. 2013 Jan;40(1):20-35.
(Mental Health, Paraprofessionals, Pediatrics, United States)
Paraprofessional medical assistants (MAs) could help to promote pediatric primary care as a source of mental health services, particularly among patient populations who receive disparate mental health care. This project piloted a brief training to enhance the ability of MAs to have therapeutic encounters with Latino families who have mental health concerns in pediatric primary care. The evaluation of the pilot found that MAs were able to master most of the skills taught during the training, which improved their ability to have patient-centered encounters with families during standardized patient visits coded with the Roter Interaction Analysis System. Parents interviewed 1 and 6 months following the training were more than twice as willing as parents interviewed 1 month before the training to discuss mental health concerns with MAs, and they had better perceptions of their interactions with MAs (all p < 0.01) even after controlling for a range of patient and visit characteristics. Before training, 10.2% of parents discussed a mental health concern with the MA but not the physician; this never happened 6 months after training. This pilot provides preliminary evidence that training MAs holds potential to supplement other educational and organizational interventions aimed at improving mental health services in pediatric primary care, but further research is necessary to test this type of training in other settings and among different patient populations.

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.

Butalid L, Verhaak PF, Bensing JM. Changes in general practitioners' sensitivity to patients' distress in low back pain consultations. Patient Educ Couns. 2015 Oct;98(10):1207-13.
(Patient Distress/Emotion/Cues, Primary Care, The Netherlands)
OBJECTIVE: We aim to study GPs' sensitivity to patients' distress and communication on psychosocial factors prior to and after the introduction of the clinical guideline for low back pain. METHODS: Consultations from previous studies on doctor-patient communication in the Netherlands were available for secondary analyses. We selected consultations in which patients presented low back pain complaints (N=168; 25 from 1989, 6 from 1995, 116 from 2001, 21 from 2008) and analyzed these consultations using the Roter Interaction Analysis System (RIAS) and the Verona Coding Definitions of Emotional Sequences (VR-CoDES). RESULTS: GPs more often acknowledged psychosocial factors during consultations after implementation of the guideline for non-specific low back pain. Moreover, patients more often voiced their worries, while GPs put more emphasis on providing biomedical information and counseling during these consultations. CONCLUSIONS: GPs tend to emphasize biomedical factors rather than supporting their patients emotionally. Patients are likely to voice their worries implicitly, indicating they have a need for emotional support from their GPs. PRACTICE IMPLICATIONS:GPs now face the challenge of not only recognizing psychosocial aspects during consultations with low back pain, but also actively eliciting concerns regarding these psychosocial aspects. KEYWORDS: Cues and concerns; Doctor–patient communication; General practice; Low back pain; Psychosocial factors.

Butalid L, Bensing JM, Verhaak PF. Talking about psychosocial problems: an observational study on changes in doctor-patient communication in general practice between 1977 and 2008. Patient Educ Couns. 2014 Mar;94(3):314-21.
(Communication Skills, Primary Care, The Netherlands)
OBJECTIVE: To examine whether GPs' communication styles have changed since the introduction and implementation of clinical guidelines for psychosocial problems in Dutch general practice in the 1990s. METHODS: From a database of 5184 consultations videotaped between 1977 and 2008, 512 consultations assessed by GPs as 'completely psychosocial' were coded with RIAS (Roter Interaction Analysis System). The 121 consultations prior to and 391 consultations after implementation of guidelines were analyzed whether communication styles have changed over time. RESULTS: We found that GPs were more likely to consider consultations to be mainly (17%) or completely (12%) psychosocial after the implementation of guidelines. They gave more biomedical and psychosocial information and advice in the second period compared to the first period. We also found that empathy decreased over time (frequency of empathic statements by GPs changed from 2.9-3.2 to 1.4-1.6 between periods). CONCLUSION: Communication in psychosocial consultations has changed; GPs have become more focused on task-oriented communication (asking questions, giving information and advice) and less on showing empathy. PRACTICE IMPLICATIONS: GPs face the challenge of integrating an evidence-based approach of applying guidelines that promote active symptom exploration with understanding patients' personal contexts and giving room to their emotions.

Butalid L, Verhaak PF, Boeije HR, Bensing JM. Patients' views on changes in doctor-patient communication between 1982 and 2001: a mixed-methods study. BMC Fam Pract. 2012 Aug 8;13:80.
(Communication Skills, Primary Care, The Netherlands)
BACKGROUND: Doctor-patient communication has been influenced over time by factors such as the rise of evidence-based medicine and a growing emphasis on patient-centred care. Despite disputes in the literature on the tension between evidence-based medicine and patient-centered medicine, patients' views on what constitutes high quality of doctor-patient communication are seldom an explicit topic for research. The aim of this study is to examine whether analogue patients (lay people judging videotaped consultations) perceive shifts in the quality of doctor-patient communication over a twenty-year period. METHODS: Analogue patients (N = 108) assessed 189 videotaped general practice consultations from two periods (1982-1984 and 2000-2001). They provided ratings on three dimensions (scale 1-10) and gave written feedback. With a mixed-methods research design, we examined these assessments quantitatively (in relation to observed communication coded with RIAS) and qualitatively. RESULTS: 1) The quantitative analyses showed that biomedical communication and rapport building were positively associated with the quality assessments of videotaped consultations from the first period, but not from the second. Psychosocial communication and personal remarks were related to positive quality assessments of both periods; 2) the qualitative analyses showed that in both periods, participants provided the same balance between positive and negative comments. Listening, giving support, and showing respect were considered equally important in both periods. We identified shifts in the participants' observations on how GPs explained things to the patient, the division of roles and responsibilities, and the emphasis on problem-focused communication (first period) versus solution-focused communication (last period). CONCLUSION: Analogue patients recognize shifts in the quality of doctor-patient communication from two different periods, including a shift from problem-focused communication to solution-focused communication, and they value an egalitarian doctor-patient relationship. The two research methods were complementary; based on the quantitative analyses we found shifts in communication, which we confirmed and specified in our qualitative analyses.

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