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

L

Labhardt ND, Aboa SM, Manga E, Bensing JM, Langewitz W. Bridging the gap: How traditional healers interact with their patients. A comparative study in Cameroon. Trop Med Int Health. 2010 Jun 9. [Epub ahead of print]
(Interaction Analysis, Traditional Healing, Cameroon)
Summary Objective: To compare traditional healers (TH) and Cameroonian representatives of Western medicine (Western providers (WP)) in terms of patient characteristics and communication patterns during the consultation in rural Cameroon. Methods A facility-based comparative study was conducted. Seven TH were compared to eight WP in the same district. Patients (five per provider) provided detailed socio-demographic data. Recorded consultations were analysed with the Roter Interaction Analysis System (RIAS). Results Patients were similar in socio-demographic characteristics except for age, where TH patients were on average 9 years younger (P < 0.05). Patients of TH travelled 2.5 times as far to their provider as did patients in the WP group (79 vs. 31 km; P < 0.05) and paid 12 times more for their treatment (123 vs. 10 Euros; P < 0.05). Consultations of TH were shorter (5.6 vs. 10.3 min, P < 0.01), had fewer utterances (100 vs. 166, P < 0.05) and the patient's share in the communication was smaller (P < 0.01). TH had a higher percentage of lifestyle and psychosocial information at the expense of medical information (P < 0.05) and communicated more emotionally (P < 0.001). They asked more frequently for their patients' opinion (P < 0.01) and explicitly discussed their patients' concept of illness (P < 0.001). Patients of TH responded with a higher percentage of active communication (P < 0.05) i.e. question asking (P < 0.01). Conclusions Our data contradict the idea that the lack of money or geographical access to Western health care in rural Africa is the main reason for people to consult traditional healers. Compared to WP, TH interacted very differently with their clients, using a more patient-centred communication style, to seek common ground with patients. This different type of interaction could be a relevant factor contributing to the popularity of traditional healers in Cameroon.

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

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

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

Langewitz WA, Edlhaimb HP, Höfner C, Koschier A, Nübling M, Leitner A. [Evaluation of a two year curriculum in psychosocial and psychosomatic medicine--handling emotions and communicating in a patient centred manner].[Article in German] Psychother Psychosom Med Psychol. 2010 Nov;60(11):451-6. Epub 2010 Jun 16.
(Interaction Analysis, Emotion Handling, Austria)
Psychosomatic Medicine is aiming at a comprehensive understanding of patient's requests. This requires patient-centred communication. During the two-year course for "Psychosomatic Medicine"of the Lower-Austrian Medical Chamber at the Danube-University Krems relevant techniques are trained. This paper reports on the analysis of 120 video-consultations with simulated patients (30 participants, two per participant before and after the training) using a modified version of the Roter Interaction Analysis System (RIAS). Results show a considerable increase in participant's ability to respond to emotional utterances and to use techniques of patient-centred communication: percentage of appropriate utterances related to the sum of all utterances: from 9.78 ± 3.5 to 13.56 ± 4.7 (ANOVA with repeated measures: p < 0.001). Furthermore, participants allow patients longer stretches of uninterrupted speech: increase from 1.76 ± 1.4 to 2.47 ± 2.3 utterances (p < 0.001) helping them into a narrative style of conversation.

Langewitz W, Heydrich L, Nübling M, Szirt L, Weber H, Grossman P. Swiss Cancer League communication skills training programme for oncology nurses: an evaluation. J Adv Nurs. 2010 Oct;66(10):2266-77. doi: 10.1111/j.1365-2648.2010.05386.x. Epub 2010 Jul 16.
(Communication Skills Training, Oncology, Switzerland)
AIM: This paper is a report of an evaluation of the effectiveness of a communication skills training programme for oncology nurses. BACKGROUND: Clinical care for patients with cancer is increasingly being divided between nurses and physicians, with nurses being responsible for the continuity of patient care, and oncologists choosing and explaining the basics of anti-cancer therapy. Therefore, oncology nurses will profit from evidence-based communication skills training to allow them to perform in a professional way. METHODS: Between 2003 and 2006 pre- and post-intervention videos of interviews with simulated patients were compared using the Roter Interaction Analysis System. Patient centeredness was assessed by counting segments of appropriate mutual responding to cues and by calculating length of uninterrupted patient speech. FINDINGS: Appropriate empathic (1.6% vs. 3.2%), reassuring statements (2.3% vs. 3.4%), questions concerning psychosocial information (2.8% vs. 4.0%) increased statistically significantly; utterances containing medical information decreased on the part of nurses (17.8% vs. 13.3%) and patients (8.1% vs. 6.7%); and patients provided more psychosocial information (3.3% vs. 5.7%). The level of congruence and empathic responses to patients' emotional cues increased statistically significantly, as did the length of uninterrupted speech (3.7-4.3 utterances; all P < 0.05). CONCLUSION: The communication skills training of the Swiss Cancer League could be used as a model to achieve substantial improvements in patient-centred communication. Sequence analysis of utterances from patient-provider interaction should be used to assess the amount of patient-centred talk.

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

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

Leone D, Lamiani G, Vegni E, Larson S, Roter DL. Error disclosure and family members' reactions: does the type of error really matter? To describe how Italian clinicians disclose medical errors with clear and shared lines of responsibility. Patient Educ Couns. 2015 Apr;98(4):446-52.
(Italy, Physician Error/Malpractice, Standardized Patients)
METHODS: Thirty-eight volunteers were video-recorded in a simulated conversation while communicating a medical error to a simulated family member (SFM). They were assigned to a clear responsibility error scenario or a shared responsibility one. Simulations were coded for: mention of the term "error" and apology; communication content and affect using the Roter Interaction Analysis System. SFMs rated their willingness to have the patient continue care with the clinician. RESULTS: Clinicians referred to an error and/or apologized in 55% of the simulations. The error was disclosed more frequently in the clear responsibility scenario (p<0.02). When the "error" was explicitly mentioned, the SFM was more attentive, sad and anxious (p≤0.05) and less willing to have the patient continue care (p<0.05). Communication was more patient-centered (p<0.05) and affectively dynamic with the SFMs showing greater anxiety, sadness, attentiveness and respectfulness in the clear responsibility scenario (p<0.05). CONCLUSIONS: Disclosing errors is not a common practice in Italy. Clinicians disclose less frequently when responsibility is shared and indicative of a system failure. PRACTICE IMPLICATIONS: Training programs to improve disclosure practice considering the type of error committed should be implemented.

Lerner B, Roberts JS, Shwartz M, Roter DL, Green RC, Clark JA. Distinct communication patterns during genetic counseling for late-onset Alzheimer's risk assessment. Patient Educ Couns. 2014 Feb;94(2):170-9.
(Genetics Counseling, Communication Skills, United States)
OBJECTIVE: To identify and characterize patient-provider communication patterns during disclosure of Alzheimer's disease genetic susceptibility test results and to assess whether these patterns reflect differing models of genetic counseling. METHODS: 262 genetic counseling session audio-recordings were coded using the Roter Interactional Analysis System. Cluster analysis was used to distinguish communication patterns. Bivariate analyses were used to identify characteristics associated with the patterns. RESULTS: Three patterns were identified: Biomedical-Provider-Teaching (40%), Biomedical-Patient-Driven (34.4%), and Psychosocial-Patient-Centered (26%). Psychosocial-Patient-Centered and Biomedical-Provider-Teaching sessions included more female participants while the Biomedical-Patient-Driven sessions included more male participants (p=0.04). CONCLUSION: Communication patterns observed reflected the teaching model primarily, with genetic counseling models less frequently used. The emphasis on biomedical communication may potentially be at the expense of more patient-centered approaches. PRACTICE IMPLICATIONS: To deliver more patient-centered care, providers may need to better balance the ratio of verbal exchange with their patients, as well as their educational and psychosocial discussions. The delineation of these patterns provides insights into the genetic counseling process that can be used to improve the delivery of genetic counseling care. These results can also be used in future research designed to study the association between patient-centered genetic counseling communication and improved patient outcomes. KEYWORDS: Alzheimer's disease; Genetic counseling; Genetic testing; Patient-centeredness; Patient–provider communication

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

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

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

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

Liekens S, Vandael E, Roter D, Larson S, Smits T, Laekeman G, Foulon V. Impact of training on pharmacists' counseling of patients starting antidepressant therapy. Patient Educ Couns. 2014 Jan;94(1):110-5.
(Pharmacy, Mental Health, Belgium)
OBJECTIVE: To measure the impact of a one-day depression-related training program on pharmacists' counseling of unannounced "mystery shoppers" (MS) starting antidepressant therapy. METHODS: Clustered RCT pharmacies; intervention group pharmacists received communication skills training related to depression (n=21); control pharmacists did not (n=19). Eight months after training, the 40 community pharmacies were visited by MS with a first prescription for antidepressants. The pharmacy interactions were recorded and analyzed using the Roter Interaction Analysis System (RIAS). Mann-Whitney U tests were used to evaluate the impact of training on pharmacy interactions and MS evaluations of the pharmacists' skills and attitudes. RESULTS: Interactions of intervention group pharmacists were significantly longer and consisted of more education and counseling statements about lifestyle and psychosocial concerns. Intervention group pharmacists asked more questions about medical condition and therapeutic regimen, as well as socioemotional concerns. MS gave more socioemotional information to intervention group pharmacists and were more positive in their assessment of these pharmacists' skills and attitudes (p values<0.05). CONCLUSION: Pharmacist training in depression care can positively affect the quality of patient care. PRACTICE IMPLICATIONS: Postgraduate training in depression related services is a worthwhile approach to improve the quality of pharmaceutical care.

Liu CC, Wissow L. How post-call resident doctors perform, feel and are perceived in out-patient clinics. Med Educ. 2011 Jul;45(7):669-77.
(Resident Training, United States)
CONTEXT: Recently, in the USA, the Accreditation Council for Graduate Medical Education guidelines limited residents' consecutive duty to 24 hours. In Europe, the European Working Time Directive limits the average working week to 48 hours. OBJECTIVES: This study aimed to examine the performance of post-call residents in out-patient interviews using subjective and objective measures and to assess residents' subjective feelings. METHODS: We conducted a cross-sectional analysis of a systematic sample of 170 paediatric primary care consultations conducted during 117 clinic sessions served by 47 residents at a teaching hospital, including 34 consultations conducted during 23 sessions by 20 post-call residents. Interviews were audiotaped and quantitatively analysed using the Roter Interactional Analysis System (RIAS). Residents and patients' parents gave subjective appraisals of the visits using short questionnaires. Major covariates are resident gender and the timing of the clinic. RESULTS: Results did not show significant differences between post-call residents and their peers who had left the hospital on time in most components of the out-patient interview. Subtle yet probably important differences emerged with findings that post-call residents were significantly less likely to ask a parent to repeat what she had just said, and parents seeing post-call residents were more likely to request the resident to repeat what he or she had just said and to check if the resident understood what they had said. Post-call residents were rated by objective coders as having better attitudes than their left-on-time counterparts, yet subjectively felt less satisfied and more fatigued. Female post-call residents felt less competent, less productive and less energetic; male post-call residents felt more challenged, more demoralised and busier. CONCLUSIONS: The changes in activating and partnering talk that occur in post-call residents are consistent with findings concerning sleep deprivation and speech. Female and male residents tended to attribute their post-call performance to different factors. Setting limits on working hours might help to avoid potential negative impacts on post-call resident feelings, and the impact of working hours on resident performance warrants further exploration.

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

Lussier MT, Richard C, Glaser E, Roberge D. The impact of a primary care e-communication intervention on the participation of chronic disease patients who had not reached guideline suggested treatment goals. Patient Educ Couns. 2016 Apr;99(4):530-41.
(Online/Web-based, Patient Education, Primary Care, Canada)
OBJECTIVE: To evaluate the efficacy of two web-based educational approaches on doctor-patient communication. The study focused on chronic disease (CD) patients in a lengthy relationship with their family physician (FP) who had not reached guideline suggested treatment goals (off-target) for their CDs. METHODS: 322 hypertensive, diabetic, or dyslipidemic patients of 18 FPs were randomised into three groups: Usual Care (UC), e-Learning (e-L) and e-Learning+Workshop (e-L+W). Interventions were based on Cegala's PACE system: Prepare, Ask questions, Check understanding, Express concerns. Communication was evaluated using the Roter Interaction Analysis System (RIAS), MEDICODE and questionnaires. RESULTS: Encounter length was similar across groups. RIAS showed that e-L+W group engaged in more socio-emotional talk and PACE-like utterances. MEDICODE showed that interventions increased frequency, initiative and dialogue for selected CD medication themes. Quality of communication was perceived as satisfactory at baseline and did not change. CONCLUSION: Following interventions, CD patients were more activated even in well-established doctor-patient relationships. PRACTICE IMPLICATIONS: PACE web-based interventions are accessible and effective at increasing CD patients' participation. They increase legitimacy to express the patient experience. FPs should present this type of training to CD patients as an integral part of their routine practice and consider referring patients to complete it. KEYWORDS: Chronic disease; Interpersonal communication; Medication discussions; Patient activation; Patient participation; Primary health care; Web-based patient education; e-Learning

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