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Bibiliography and Abstracts of RIAS Studies 2011

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

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

McKinstry B, Hammersley V, Burton C, Pinnock H, Elton R, Dowell J, Sawdon N, Heaney D, Elwyn G, Sheikh A. The quality, safety and content of telephone and face-to-face consultations: a comparative study. Qual Saf Health Care. 2010 Aug;19(4):298-303. Epub 2010 Apr 29.
(Telephone, Patient Safety, Scotland)
INTRODUCTION: Telephone consulting is increasingly used to improve access to care and optimise resources for day-time work. However, there remains a debate about how such consultations differ from face-to-face consultations in terms of content quality and/or safety. To investigate this, a comparison of family doctors' telephone and face-to-face consultations was conducted. METHODS: 106 audio-recordings (from 19 doctors in nine practices) of telephone and face-to-face consultations, stratified at doctor level, were compared using the Roter Interaction Analysis Scale (RIAS) (content measure), the OPTION (observing patient involvement in decision making scale) and a modified scale based on the Royal College of General Practitioners (RCGP) consultation assessment instrument (measuring quality and safety). Patient satisfaction and enablement were measured using validated instruments. The Roter Interaction Analysis Scale scores were compared by multiple linear regression adjusting for covariates; other continuous measures by chi(2) and Student t tests and binary measures as odds ratios. RESULTS: Telephone consultations were shorter (4.6 vs 9.7 min, p < 0.001), presented fewer problems (1.2 vs 1.8, p < 0.001) and included less data gathering, counselling/advice and rapport building (all p < 0.001) than face-to-face consultations. These differences remained significant when consultation length and number of problems were taken into account. Telephone consultations were judged less likely to include sufficient information to exclude important serious illnesses. Patient involvement and satisfaction outcomes were similar in both consultation types. CONCLUSION: Although telephone consultations are convenient and judged satisfactory by patients and doctors, they may compromise patient safety more than face-to-face consultations and further research is required to elucidate this. Telephone consultations may be more suited to follow-up and management of long-term conditions than for in-hours acute management.

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

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

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

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

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

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

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

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