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


Hack SM, Medoff DR, Brown CH, Fang L, Dixon LB, Klingaman EA, Park SG, Kreyenbuhl JA. Predictors of Patient Communication in Psychiatric Medication Encounters Among Veterans With Serious Mental Illnesses. Psychiatr Rehabil J. 2016 May 9.
(Mental Health, Communication Skills, United States)
OBJECTIVE: Person-centered psychiatric services rely on consumers actively sharing personal information, opinions, and preferences with their providers. This research examined predictors of consumer communication during appointments for psychiatric medication prescriptions. METHODS: The Roter Interaction Analysis System was used to code recorded Veterans Affairs psychiatric appointments with 175 consumers and 21 psychiatric medication prescribers and categorize communication by purpose: biomedical, psychosocial, facilitation, or rapport-building. RESULTS: Regression analyses found that greater provider communication, symptomology, orientation to psychiatric recovery, and functioning on the Repeatable Battery for the Assessment of Neuropsychological Status Attention and Language indices, as well as consumer diagnostic label, were positive predictors of consumer communication, though the types of communication impacted varied. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Provider communication is the easiest variable to intervene on to create changes in consumer communication. Future research should also consider how cognitive and symptom factors may impact specific types of consumer communication in order to identify subgroups for targeted interventions.

Hafskjold L, Sundler AJ, Holmström IK, Sundling V, van Dulmen S, Eide H. A cross-sectional study on person-centred communication in the care of older people: the COMHOME study protocol. BMJ Open. 2015 Apr 15;5(4).
(Norway, The Netherlands, Sweden, Communication Skills/Training, Primary Care)
INTRODUCTION: This paper presents an international cross-sectional study on person-centred communication with older people receiving healthcare (COMHOME). Person-centred care relies on effective communication, but few studies have explored this with a specific focus on older people. The main aim of the COMHOME study is to generate knowledge on person-centred communication with older people (>65 years) in home healthcare services, radiographic and optometric practice. METHODS AND ANALYSIS: This study will explore the communication between care providers and older persons in home care services. Home healthcare visits will be audiorecorded (n=500) in Norway, the Netherlands and Sweden. Analyses will be performed with the Verona Coding Definitions for Emotional Sequences (VR-CoDES), the Roter Interaction Analysis System (RIAS) and qualitative methods. The content of the communication, communicative challenging situations as well as empathy, power distance, decision-making, preservation of dignity and respect will be explored. In Norway, an additional 100 encounters, 50 in optometric practice (video recorded) and 50 in radiographic practice (audiorecorded), will be analysed. Furthermore, healthcare providers' self-reported communication skills, empathy, mindfulness and emotional intelligence in relation to observed person-centred communication skills will be assessed using well-established standardised instruments. ETHICS AND DISSEMINATION: Depending on national legislation, approval of either the central ethical committees (eg, nation or university), the national data protection officials or the local ethical committees (eg, units of home healthcare) was obtained. Study findings will be disseminated widely through peer-reviewed publications and conference presentations. The research findings will add knowledge to improve services provided to this vulnerable group of patients. Additionally, the findings will underpin a training programme for healthcare students and care providers focusing on communication with older people.

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

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

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

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

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

Hall JA, Roter DL, Blanch DC, Frankel RM. Observer-rated rapport in interactions between medical students and standardized patients. Patient Educ Couns. 2009 Sep;76(3):323-7.
(Communication Skills, Standardized Patients, Resident/Medical Student Training, United States)
OBJECTIVE: To measure rapport between medical students and standardized patients using observer ratings; to relate these ratings to students' emotional awareness and to behavior within the medical interaction; and to assess the relative validity of using excerpts of different lengths for the measurement of rapport. METHODS: Third-year medical students (N=141) were videotaped during a 15-min interaction with a standardized patient, and rapport as well as other communication variables were measured using trained coders. Rapport was measured with good interrater reliability by trained coders who viewed three 1-min excerpts. Emotional awareness was measured by a test of recognizing facial expressions of emotion, self-ratings of emotional self-awareness, and peer ratings of interpersonal sensitivity. Finally, participants who viewed the videotapes while imagining themselves to be the patient (analogue patients) provided impressions of the students, including satisfaction. RESULTS: Rapport based on all three minutes was positively correlated with accuracy in decoding facial expressions of emotion, self-reported attention to one's own emotions, peer ratings of sensitivity, communication behaviors of the medical student and standardized patient, and analogue patients' positive impressions and satisfaction. Rapport based on just the first minute of the interaction was significantly related to many of these variables. CONCLUSION: Rating short excerpts of behavior is a valid and efficient methodology for capturing the concept of rapport. PRACTICE IMPLICATIONS: Clinicians, researchers, and educators should focus on rapport building, even very early in the medical visit.

Hall JA, Roter DL, Blanch DC, Frankel RM. Nonverbal sensitivity in medical students: implications for clinical interactions. J Gen Intern Med. 2009 Nov;24(11):1217-22.
(Attitudes/Relationship, Resident/Medical Student Training, Standardized Patients, United States)
BACKGROUND: Clinicians' accuracy in perceiving nonverbal cues has potentially important consequences, but has received insufficient research. OBJECTIVE: To examine the relation of medical students' nonverbal sensitivity to their gender and personal traits, as well as to their communication and impressions made during a standardized patient (SP) visit. DESIGN: Psychometric testing, questionnaire, and observation. SETTING: One US medical school. PARTICIPANTS: Two-hundred seventy-five third-year medical students. MEASUREMENTS: Nonverbal sensitivity and attitudes were measured using standard instruments. Communication during the SP visit was measured using trained coders and analogue patients who viewed the videotapes and rated the favorability of their impressions of the student. RESULTS: Nonverbal sensitivity was higher in female than male students (P < 0.001) and was positively correlated with self-reported patient-centered attitudes (P < 0.01) and ability to name one's own emotions (P < 0.05). It was also associated with less distressed (P < 0.05), more dominant (P < 0.001), and more engaged (P < 0.01) behavior by the SP, and with more liking of the medical student (P < 0.05) and higher ratings of compassion (P < 0.05) by the analogue patients. Correlations between nonverbal sensitivity and other variables were generally stronger and different for male than female students, but nonverbal sensitivity predicted analogue patients' impressions similarly for male and female students. CONCLUSION: Medical students' nonverbal sensitivity was related to clinically relevant attitudes and behavioral style in a clinical simulation.

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

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

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

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

Hardeman W, Lamming L, Kellar I, De Simoni A, Graffy J, Boase S, Sutton S, Farmer A, Kinmonth AL. Implementation of a nurse-led behaviour change intervention to support medication taking in type 2 diabetes: beyond hypothesised active ingredients (SAMS Consultation Study). Implement Sci. 2014 Jun 5;9:70.
(Adherence, Nursing, United Kingdom)
BACKGROUND: Implementation of trial interventions is rarely assessed, despite its effects on findings. We assessed the implementation of a nurse-led intervention to facilitate medication adherence in type 2 diabetes (SAMS) in a trial against standard care in general practice. The intervention increased adherence, but not through the hypothesised psychological mechanism. This study aimed to develop a reliable coding frame for tape-recorded consultations, assessing both a priori hypothesised and potential active ingredients observed during implementation, and to describe the delivery and receipt of intervention and standard care components to understand how the intervention might have worked. METHODS: 211 patients were randomised to intervention or comparison groups and 194/211 consultations were tape-recorded. Practice nurses delivered standard care to all patients and motivational and action planning (implementation intention) techniques to intervention patients only. The coding frame was developed and piloted iteratively on selected tape recordings until a priori reliability thresholds were achieved. All tape-recorded consultations were coded and a random subsample double-coded. RESULTS: Nurse communication, nurse-patient relationship and patient responses were identified as potential active ingredients over and above the a priori hypothesised techniques. The coding frame proved reliable. Intervention and standard care were clearly differentiated. Nurse protocol adherence was good (M (SD) = 3.95 (0.91)) and competence of intervention delivery moderate (M (SD) = 3.15 (1.01)). Nurses frequently reinforced positive beliefs about taking medication (e.g., 65% for advantages) but rarely prompted problem solving of negative beliefs (e.g., 21% for barriers). Patients' action plans were virtually identical to current routines. Nurses showed significantly less patient-centred communication with the intervention than comparison group. CONCLUSIONS: It is feasible to reliably assess the implementation of behaviour change interventions in clinical practice. The main study results could not be explained by poor delivery of motivational and action planning components, definition of new action plans, improved problem solving or patient-centred communication. Possible mechanisms of increased medication adherence include spending more time discussing it and mental rehearsal of successful performance of current routines, combined with action planning. Delivery of a new behaviour change intervention may lead to less patient-centred communication and possible reduction in overall trial effects.

Hausmann LR, Hannon MJ, Kresevic DM, Hanusa BH, Kwoh CK, Ibrahim SA. Impact of perceived discrimination in healthcare on patient-provider communication. Med Care. 2011 Jul;49(7):626-33.
(Race/Cross-Culture, Communication Skills, United States)
BACKGROUND: The impact of patients' perceptions of discrimination in healthcare on patient-provider interactions is unknown. OBJECTIVE: To examine association of past perceived discrimination with subsequent patient-provider communication. RESEARCH DESIGN: Observational cross-sectional study. SUBJECTS: African-American (N=100) and white (N=253) patients treated for osteoarthritis by orthopedic surgeons (N=63) in 2 Veterans Affairs facilities. MEASURES: Patients were surveyed about past experiences with racism and classism in healthcare settings before a clinic visit. Visits were audio-recorded and coded for instrumental and affective communication content (biomedical exchange, psychosocial exchange, rapport-building, and patient engagement/activation) and nonverbal affective tone. After the encounter, patients rated visit informativeness, provider warmth/respectfulness, and ease of communicating with the provider. Regression models stratified by patient race assessed the associations of racism and classism with communication outcomes. RESULTS: Perceived racism and classism were reported by more African-American patients than by white patients (racism: 70% vs. 26% and classism: 73% vs. 53%). High levels of perceived racism among African-American patients was associated with less positive nonverbal affect among patients [β=-0.41, 95% confidence interval (CI)=-0.73 to -0.09] and providers (β=-0.34, 95% CI=-0.66 to -0.01) and with low patient ratings of provider warmth/respectfulness [odds ratio (OR)=0.19, 95% CI=0.05-0.72] and ease of communication (OR=0.22, 95% CI=0.07-0.67). Any perceived racism among white patients was associated with less psychosocial communication (β=-4.18, 95% CI=-7.68 to -0.68), and with low patient ratings of visit informativeness (OR=0.40, 95% CI=0.23-0.71) and ease of communication (OR=0.43, 95% CI=0.20-0.89). Perceived classism yielded similar results. CONCLUSIONS: Perceptions of past racism and classism in healthcare settings may negatively impact the affective tone of subsequent patient-provider communication.

Hausmann LR, Hanusa BH, Kresevic DM, Zickmund S, Ling BS, Gordon HS, Kwoh CK, Mor MK, Hannon MJ, Cohen PZ, Grant R, Ibrahim SA. Orthopedic communication about osteoarthritis treatment: Does patient race matter? Arthritis Care Res (Hoboken). 2011 May;63(5):635-42
(Race/Cross-Culture, United States)
OBJECTIVE: To understand racial disparities in the use of total joint replacement, we examined whether there were racial differences in patient-provider communication about treatment of chronic knee and hip osteoarthritis in a sample of African American and white patients referred to Veterans Affairs orthopedic clinics. METHODS: Audio recorded visits between patients and orthopedic surgeons were coded using the Roter Interaction Analysis System and the Informed Decision-Making model. Racial differences in communication outcomes were assessed using linear regression models adjusted for study design, patient characteristics, and clustering by provider. RESULTS: The sample (n = 402) included 296 white and 106 African American patients. Most patients were men (95%) and ages 50-64 years (68%). Almost half (41%) reported an income < $20,000. African American patients were younger and reported lower incomes than white patients. Visits with African American patients contained less discussion of biomedical topics (ß = -9.14; 95% confidence interval [95% CI] -16.73, -1.54) and more rapport-building statements (ß = 7.84; 95% CI 1.85, 13.82) than visits with white patients. However, no racial differences were observed with regard to length of visit, overall amount of dialogue, discussion of psychosocial issues, patient activation/engagement statements, physician verbal dominance, display of positive affect by patients or providers, or discussion related to informed decision making. CONCLUSION: In this sample, communication between orthopedic surgeons and patients regarding the management of chronic knee and hip osteoarthritis did not, for the most part, vary by patient race. These findings diminish the potential role of communication in Veterans Affairs orthopedic settings as an explanation for well-documented racial disparities in the use of total joint replacement.

Havranek EP, Hanratty R, Tate C, Dickinson LM, Steiner JF, Cohen G, Blair IA. The effect of values affirmation on race-discordant patient-provider communication. Arch Intern Med. 2012 Nov 26;172(21):1662-7.
(Communication Skills/Training, Primary Care, Race/Cross-Culture, United States)
BACKGROUND: Communication between African American patients and white health care providers has been shown to be of poorer quality when compared with race-concordant patient-provider communication. Fear on the part of patients that providers stereotype them negatively might be one cause of this poorer communication. This stereotype threat may be lessened by a values-affirmation intervention. METHODS: In a blinded experiment, we randomized 99 African American patients with hypertension to perform a values-affirmation exercise or a control exercise before a visit with their primary care provider. We compared patient-provider communication for the 2 groups using audio recordings of the visit analyzed with the Roter Interaction Analysis System. We also evaluated visit satisfaction, trust, stress, and mood after the visit by means of a questionnaire. RESULTS: Patients in the intervention group requested and provided more information about their medical condition (mean [SE] number of utterances, 66.3 [6.8] in the values-affirmation group vs 48.1 [5.9] in the control group [P = .03]). Patient-provider communication in the intervention group was characterized as being more interested, friendly, responsive, interactive, and respectful (P = .02) and less depressed and distressed (P = .03). Patient questionnaires did not detect differences in visit satisfaction, trust, stress, or mood. Mean visit duration did not differ significantly between the groups (19.2 minutes in the control group vs 20.5 minutes in the intervention group [P = .29]). CONCLUSIONS: A values-affirmation exercise improves aspects of patient-provider communication in race-discordant primary care visits. The clinical impact of the intervention must be defined before widespread implementation can be recommended.

Hayward J, Thomson F, Milne H, Buckingham S, Sheikh A, Fernando B, Cresswell K, Williams R, Pinnock H. 'Too much, too late': mixed methods multi-channel video recording study of computerized decision support systems and GP prescribing. J Am Med Inform Assoc. 2013 Jun;20(e1):e76-84.
(Computer Use, Patient Safety, Primary Care, United Kingdom)
OBJECTIVE: Computerized decision support systems (CDSS) are commonly deployed to support prescribing, although over-riding of alerts by prescribers remains a concern. We aimed to understand how general practitioners (GPs) interact with prescribing CDSS in order to inform deliberation on how better to support prescribing decisions in primary care. MATERIALS AND METHODS: Quantitative and qualitative analysis of interactions between GPs, patients, and computer systems using multi-channel video recordings of 112 primary care consultations with eight GPs in three UK practices. RESULTS: 132 prescriptions were issued in the course of 73 of the consultations, of which 81 (61%) attracted at least one alert. Of the total of 117 alerts, only three resulted in the GP checking, but not altering, the prescription. CDSS provided information and safety alerts at the point of generating a prescription. This was 'too much, too late' as the majority of the 'work' of prescribing occurred prior to using the computer. By the time an alert appeared, the GP had formulated the problem(s), potentially spent several minutes considering, explaining, negotiating, and reaching agreement with the patient about the proposed treatment, and had possibly given instructions and printed an information leaflet. DISCUSSION: CDSS alerts do not coincide with the prescribing workflow throughout the whole GP consultation. Current systems interrupt to correct decisions that have already been taken, rather than assisting formulation of the management plan. CONCLUSIONS: CDSS are likely to be more acceptable and effective if the prescribing support is provided much earlier in the process of generating a prescription. KEYWORDS: Clinical Computerised Decision Support (CDSS); Electronic Health Record; Prescribing Safety; Primary Care; Safety Alerts

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

Henry SG, Eggly S. The effect of discussing pain on patient-physician communication in a low-income, black, primary care patient population. J Pain. 2013 Jul;14(7):759-66.
(Patient Distress/Emotion/Cues, Race/Cross-Culture, United States)
Patients and physicians report that discussions about pain are frequently frustrating and unproductive. However, the relationship between discussions about pain and patient-physician communication is poorly understood. We analyzed 133 video-recorded visits and patient self-report data collected at a clinic providing primary care to a low-income, black patient population. We used "thin slice" methods to rate two or three 30-second video segments from each visit on variables related to patient and physician affect (ie, displayed emotion) and patient-physician rapport. Discussions about pain were associated with a .32 increase in patient unease (P < .001) and a .21 increase in patient positive engagement (P = .004; standardized coefficients) compared to discussions about other topics during the same visit. Discussions about pain were not significantly associated with patient-physician rapport, physician unease, or physician positive engagement. Patient pain severity was significantly associated with greater physician and patient unease (P = .01), but not with other variables. Findings suggest that primary care patients, but not their physicians, display significantly greater emotional intensity during discussions about pain compared to discussions about other topics. PERSPECTIVE: This study used direct observation of video-recorded primary care visits to show that discussions about pain are associated with heightened displays of both positive and negative patient emotions. These displays of emotion could potentially influence pain-related outcomes.

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

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

Hunziker S, Schläpfer M, Langewitz W, Kaufmann G, Nüesch R, Battegay E, Zimmerli LU. Open and hidden agendas of "asymptomatic" patients who request check-up exams. BMC Fam Pract. 2011 Apr 19;12:22.
(Primary Care, Switzerland)
BACKGROUND: Current guidelines for a check-up recommend routine screening not triggered by specific symptoms for some known risk factors and diseases in the general population. Patients' perceptions and expectations regarding a check-up exam may differ from these principles. However, quantitative and qualitative data about the discrepancy between patient- and provider expectations for this type of clinic consultation is lacking. METHODS: For a year, we prospectively enrolled 66 patients who explicitly requested a "check-up" at our medical outpatient division. All patients actively denied upon prompting having any symptoms or specific health concerns at the time they made their appointment. All consultations were videotaped and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation ("open agendas") and for cues to hidden patient agendas using the Roter interaction analysis system (RIAS). RESULTS: All patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients. The remaining 59 patients spontaneously mentioned a mean of 4.2 ± 3.3 symptoms during their first consultation. In 23 patients a total of 31 hidden agendas were revealed. The primary categories for hidden agendas were health concerns, psychosocial concerns and the patient's concept of disease. CONCLUSIONS: The majority of patients requesting a general check-up tend to be motivated by specific symptoms and health concerns and are not "asymptomatic" patients who primarily come for preventive issues. Furthermore, physicians must be alert for possible hidden agendas, as one in three patients have one or more hidden reasons for requesting a check-up.

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