Bibiliography and Abstracts of RIAS Studies through 2012
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
Ratanawongsa N, Korthuis PT, Saha S, Roter D, Moore RD, Sharp VL, Beach MC. Clinician Stress and Patient-Clinician Communication in HIV Care. J Gen Intern Med. 2012 Jul 21. [Epub ahead of print]
(HIV, Communication Skills, Physician Satisfaction, United States)
BACKGROUND: Clinician stress is common, but few studies have examined its relationship with communication behaviors. OBJECTIVE: To investigate associations between clinician stress and patient-clinician communication in primary HIV care. DESIGN: Observational study. PARTICIPANTS: Thirty-three primary HIV clinicians and 350 HIV-infected adult, English-speaking patients at three U.S. HIV specialty clinic sites. MAIN MEASURES: Clinicians completed the Perceived Stress Scale, and we categorized scores in tertiles. Audio-recordings of patient-clinician encounters were coded using the Roter Interaction Analysis System. Patients rated the quality of their clinician's communication and overall quality of medical care. We used regression with generalized estimating equations to examine associations between clinician stress and communication outcomes, controlling for clinician gender, clinic site, and visit length. KEY RESULTS: Among the 33 clinicians, 70 % were physicians, 64 % were women, 67 % were non-Hispanic white, and the mean stress score was 3.9 (SD 2.4, range 0-8). Among the 350 patients, 34 % were women, 55 % were African American, 23 % were non-Hispanic white, 16 % were Hispanic, and 30 % had been with their clinicians >5 years. Verbal dominance was higher for moderate-stress clinicians (ratio = 1.93, p < 0.01) and high-stress clinicians (ratio = 1.76, p = 0.01), compared with low-stress clinicians (ratio 1.45). More medical information was offered by moderate-stress clinicians (145.5 statements, p <0.01) and high-stress clinicians (125.9 statements, p = 0.02), compared with low-stress clinicians (97.8 statements). High-stress clinicians offered less psychosocial information (17.1 vs. 19.3, p = 0.02), and patients of high-stress clinicians rated their quality of care as excellent less frequently than patients of low-stress clinicians (49.5 % vs. 66.9 %, p < 0.01). However, moderate-stress clinicians offered more partnering statements (27.7 vs. 18.2, p = 0.04) and positive affect (3.88 vs. 3.78 score, p = 0.02) than low-stress clinicians, and their patients' ratings did not differ. CONCLUSIONS: Although higher stress was associated with verbal dominance and lower patient ratings, moderate stress was associated with some positive communication behaviors. Prospective mixed methods studies should examine the complex relationships across the continuum of clinician well-being and health communication. CONCLUSIONS: Although higher stress was associated with verbal dominance and lower patient ratings, moderate stress was associated with some positive communication behaviors. Prospective mixed methods studies should examine the complex relationships across the continuum of clinician well-being and health communication.
Ratanawongsa N, Roter D, Beach MC, Laird SL, Larson SM, Carson KA, Cooper LA. Physician burnout and patient-physician communication during primary care encounters. J Gen Intern Med. 2008 Oct;23(10):1581-8.
(Primary Care, United States)
BACKGROUND: Although previous studies suggest an association between provider burnout and suboptimal self-reported communication, no studies relate physician burnout to observed patient-physician communication behaviors. OBJECTIVE: To investigate the relationship between physician burnout and observed patient-physician communication outcomes in patient-physician encounters. DESIGN: Longitudinal study of enrollment data from a trial of interventions to improve patient adherence to hypertension treatment. SETTING: Fifteen urban community-based clinics in Baltimore, MD. PARTICIPANTS: Forty physicians and 235 of their adult hypertensive patients, with oversampling of ethnic minorities and poor persons. Fifty-three percent of physicians were women, and the average practice experience was 11.2 years. Among the 235 patients, 66% were women, 60% were African-American, and 90% were insured. MEASUREMENTS: Audiotape analysis of communication during outpatient encounters (one per patient) using the Roter Interaction Analysis System and patients' ratings of satisfaction with and trust and confidence in the physician. RESULTS: The median time between the physician burnout assessment and the patient encounter was 15.1 months (range 5.6-30). Multivariate analyses revealed no significant differences in physician communication based on physician burnout. However, compared with patients of low-burnout physicians, patients of high-burnout physicians gave twice as many negative rapport-building statements (incident risk ratio 2.06, 95% CI 1.58-2.86, p < 0.001). Physician burnout was not significantly associated with physician or patient affect, patient-centeredness, verbal dominance, or length of the encounter. Physician burnout was also not significantly associated with patients' ratings of their satisfaction, confidence, or trust. CONCLUSIONS: Physician burnout was not associated with physician communication behaviors nor with most measures of patient-centered communication. However, patients engaged in more rapport-building behaviors. These findings suggest a complex relationship between physician burnout and patient-physician communication, which should be investigated and linked to patient outcomes in future research.
Richard C, Lussier MT. MEDICODE: an instrument to describe and evaluate exchanges on medications that occur during medical encounters. Patient Educ Couns. 2006 Dec;64(1-3):197-206.
(Primary Care, United States)
OBJECTIVE: To examine the psychometric properties of MEDICODE, a coding instrument developed to assess medication discussions during medical consultations. METHODS: Inter-coder reliability, test-retest stability, and concurrent validity with the Roter Interaction Analysis System (RIAS) and predictive validity with the Medical Interview Satisfaction Scale (MISS) were calculated. RESULTS: Inter-coder reliability and test-retest stability for medication class and status were both very good. Inter-coder agreement and test-retest stability for theme identification were mostly over 90%. Kappa values for theme identification varied from acceptable to excellent for 21 of the 29 and for 26 of the 37 Kappa coefficients that could be calculated. The mean percent agreement between MEDICODE and RIAS for medication class was of 96.8% and the mean Kappa value was 0.83. Although the mean percent agreement for the presence of a theme in MEDICODE and RIAS was 81%, the average Kappa coefficients were lower at 0.40. However, each of the four broad theme categories had its share of themes with robust Kappa values. We found significant positive correlations (p < 0.05) between discussions of medication main effects and instructions with patient satisfaction. CONCLUSION: With a reasonable amount of training, the coders were able to produce reliable and valid measures of discussions of medications during medical consultations. PRACTICAL IMPLICATIONS: MEDICODE will facilitate the study of the impact of the nature and intensity of discussions about medications during consultations on patient medication knowledge, medication recall and compliance.
Rost K, Roter D. Predictors of recall of medication regimens and recommendations for lifestyle change in elderly patients. Gerontologist. 1987 Aug;27(4):510-5.
(Primary Care, United States)
Post-visit recall of medication regimens and lifestyle recommendations was explored among 83 elderly patients making visits to a clinic which specialized in care of the elderly. Recall was problematic, with the average elderly patient failing to recall 46% of the medications recorded in the chart. Of the 42 patients receiving lifestyle recommendations, 52% failed to recall them post-visit. Patterns of communication during the visit were more strongly related to recall than patients' ages, affective state or cognitive functioning.
Rost K, Roter D, Bertakis K, Quill T. Physician-patient familiarity and patient recall of medication changes. The Collaborative Study Group of the SGIM Task Force on the Doctor and Patient. Fam Med. 1990 Nov-Dec;22(6):453-7.
(Primary Care, Patient Recall and Satisfaction, United States)
Although patients regularly see the same physicain for medical care, little is known about the effects of physician-patient familiarity on important visit outcomes. In a study of visits made to 79 physicians in 11 primary care settings, investigators sought to determine: 1) whether patient recall of prescription medication changes improved as physician-patient familiarity increased, and 2) whether characteristics which predicted recall for newer patients also predicted recall for intermediate and established patients. Sixty-six percent of patients recalled all medication changes recommended during the visit. While recall did not improve as physician-patient familiarity increased, predictors of recall did differ. Generally, the more drug information the physician gave during the concluding segment of the visit, the fewer drug changes the patient remembered. However, this relationship reversed as physician-patient familiarity increased. Elderly patients demonstrated diminished recall regardless of the number of previous visits. The findings suggest that the lengthy provision of drug information actually succeeds in heightening medication recall only when the physician and patient have a well-established relationship. In earlier stages, asking patients to restate recommendations may be a more effective strategy to enhance patient recall.
Rost K, Roter D, Quill T, Bertakis K. Capacity to remember prescription drug changes: deficits associated with diabetes. Collaborative Study Group of the Task Force on the Medical Interview. Diabetes Res Clin Pract. 1990 Oct;10(2):183-7.
(Primary Care, Patient Recall and Satisfaction, United States)
This study compared the capacity of 44 diabetes patients and 131 non-diabetic patients to remember prescription medication recommendations made during return visits to primary care clinics. Diabetes patients were 1.6-times less likely to remember all medication recommendations immediately after the visit than non-diabetic patients, a discrepancy which remained significant after controlling for sociodemographic, health status and treatment differences between the two groups. The results suggest that the cognitive deficits that diabetes patients demonstrate in laboratory testing may be severe enough to diminish their ability to learn treatment recommendations made in primary care settings. Further research is needed to determine whether recall is problematic for diabetes patients in general, or primarily for those in poor metabolic control. Clinicians who treat diabetes patients need to incorporate readily implemented strategies to promote patient recall for substantial numbers of diabetes patients to benefit from pharmacological treatment.
Roter DL. Oral literacy demand of health care communication: challenges and solutions. Nurs Outlook. 2011 Mar-Apr;59(2):79-84.
(Interaction Analysis, Literacy, United States)
Literacy deficits are widespread; one-quarter of the U.S. population has below basic literacy skills and the health consequences of literacy deficits are well-known and significant. While the need to simplify written health education print material is widely recognized, there has been little attempt to describe or reduce the literacy demand of health care dialogue. Patients with limited literacy complain they are not given information about their problems in ways they can understand, leaving them uninformed, frustrated, and distrustful. The purpose of this article is to review a conceptual approach to describing oral literacy demand in health care dialogue, to review several key studies that support the predictive validity of the conceptual framework in regard to patient satisfaction and recall of information, and to propose several practical ways to diminish literacy demand and facilitate more effective health care exchanges with patients.
Roter DL. Patient participation in the patient-provider interaction: the effects of patient question asking on the quality of interaction, satisfaction, and compliance. Health Educ Monogr. 1977 Winter;5(4):281-315
(Primary Care, Patient Recall or Satisfaction, United States)
The purpose of this study was to investigate the effectiveness, dynamics, and consequences of a health education intervention designed to increase patient question asking during the patient's medical visit. Data were collected at a Baltimore family and community health center which provides outpatient services to a low income, predominantly black and female population. The majority of the study participants were, in addition, elderly and chronically ill. A total of 294 patients and 3 providers took part in the study. The study design included random assignment of patients to experimental and placebo groups with two non-equivalent (non-randomized) control groups. Findings included: (1) The experimental group patients asked more direct questions and fewer indirect questions than did placebo group patients. (2) The experimental group patient-provider interaction was characterized by negative affect, anxiety, and anger, while the placebo group patient-provider interaction was characterized as mutually sympathetic. (3) The experimental group patients were less satisfied with care received in the clinic on the day of their visit than were placebo patients. (4) The experimental group patients demonstrated higher appointment-keeping ratios (an average number of appointments kept divided by an average number of appointments made) during a four-month prospective monitoring period.
Roter DL. Patient question asking in physician-patient interaction. Health Psychol. 1984;3(5):395-409.
(Primary Care, United States)
Patient question asking may be regarded as not only a method of information seeking but as a mechanism of patient participation in the medical dialogue. As such, the study of question asking behavior provides insight into the physician-patient communication process. Presented is an analysis of data gathered as part of an experimental intervention designed to increase patient question asking during routine medical visits. Audiotape recordings of two physicians in 123 medical visits were content analyzed to identify the number, content, and form of patient questions, as well as a variety of other interaction variables. These measures were then related to patient satisfaction with care. Findings indicate that the experimental intervention had significant effect on increasing the number of direct questions asked and that these were asked outside of their usual interaction pattern. Further, the relationship between question asking and satisfaction differed in the two groups. The study contributes to our understanding of physician-patient communication dynamics and the information seeking process.
Roter DL. Elderly patient-physician communication: A descriptive study of content and affect during the medical encounter. Advances in Health Education. 1991;3:179-190.
(Primary Care, United States)
This paper investigates the communication dynamics between elderly patients and their physicians during the medical encounter with a special focus on physicians' perception and response to patients' emotional state during the visit. The study was conducted in the outpatient facilities of a large teaching hospital and included observations of 83 patient encounters with 3 physicians. Each encounter was audiotaped and followed with patient and physician exit questionnaires. Physicians were quite sensitive to the emotional state of their patients, as measured by objective coders and standardized tests. Moreover, communication between patients and physicians was considerably different in medical visits for patients rated by their physician as psychologically distressed than for patients rated as nondistressed. Physicians were more likely to use open-ended questions regarding feelings and emotions, and provide reassurance and comfort to patients they rated as anxious, demented, depressed, emotionally dependent, or irritated. These patients were also less likely to receive medical information about their medical condition.
Roter DL, Cole KA, Kern DE, Barker LR, Grayson M. An evaluation of residency training in interviewing skills and the psychosocial domain of medical practice. J Gen Intern Med. 1990 Jul-Aug;5(4):347-54.
(Primary Care, Communication Skills Training, United States)
Competent use of interviewing skills is important for the care of all patients but is especially critical, and frequently deficient, in meeting the needs of patients experiencing emotional distress. This study presents an evaluation of a curriculum in communication and psychosocial skills taught to first-year medical residents. A randomized experimental design compared trained and untrained residents' (n = 48) performances with a simulated patient presenting with atypical chest pain and psychosocial distress. Evaluation was based on analysis of videotapes, simulated patient report of residents' behaviors, and chart notation. Trained compared with untrained residents asked more open-ended questions and fewer leading questions, summarized main points more frequently, did more psychosocial counseling, and were rated as having better communication skills by the simulated patient. The use of more focused and psychosocially directed questions, and fewer leading and grab-bag questions, was associated with more accurate diagnoses and management recorded in the medical chart. However, no significant difference was found in the charting practices of trained versus untrained residents.
Roter D, Ellington L, Erby LH, Larson S, Dudley W. The Genetic Counseling Video Project (GCVP): models of practice. Am J Med Genet C Semin Med Genet. 2006 Nov 15;142(4):209-20.
(Genetic Counseling, United States)
Genetic counseling is conceptualized as having both "teaching" and "counseling" functions; however, little is known about how these functions are articulated in routine practice. This study addresses the question by documenting, on videotape, the practices of a national sample of prenatal and cancer genetic counselors (GCs) providing routine pre-test counseling to simulated clients (SCs). One hundred and seventy-seven GCs recruited at two annual conferences of the National Society of Genetic Counselors (NSGC) were randomly assigned to counsel one of six female SCs of varying ethnicity, with or without a spouse, in their specialty. One hundred and fifty-two videotapes were coded with the Roter Interaction Analysis System (RIAS) and both GCs and SCs completed evaluative questionnaires. Two teaching and two counseling patterns of practice emerged from cluster analysis. The teaching patterns included: (1) clinical teaching (31%) characterized by low psychosocial, emotional and facilitative talk, high levels of clinical exchange, and high verbal dominance; and (2) psycho-educational teaching (27%) characterized by high levels of both clinical and psychosocial exchange, low levels of emotional and facilitative talk, and higher verbal dominance. The counseling patterns included: (1) supportive counseling (33%) characterized by low psychosocial and clinical exchange, high levels of emotional and facilitative talk, and low verbal dominance; and (2) psychosocial counseling (9%) with high emotional and facilitative talk, low clinical and high psychosocial exchange, and the lowest verbal dominance. SCs ratings of satisfaction with communication, the counselor's affective demeanor, and the counselor's use of non-verbal skills were highest for the counseling model sessions. Both the teaching and counseling models seem to be represented in routine practice and predict variation in client satisfaction, affective demeanor, and nonverbal effectiveness.
Roter DL, Erby L, Larson S, Ellington L. Oral literacy demand of prenatal genetic counseling dialogue: Predictors of learning. Patient Educ Couns. 2009 Jun;75(3):392-7. Epub 2009 Feb 27.
(Health Literacy, Genetic Counseling, United States)
OBJECTIVE: To assess the relationship between the oral literacy demand of genetic counseling sessions and the ability of low literate subjects to learn genetics-related information. METHODS: Ninety-six simulated genetic counseling sessions were videotaped and shown to 312 subjects recruited to imagine themselves as the session's client. Study measures included oral literacy demand, operationalized as: (1) use of key genetics terms; (2) informational context; (3) general language complexity; and (4) structural characteristics of dialogue interactivity. The study outcome was learning of genetics-related information. RESULTS: Subjects with restricted literacy (below 8th grade level) learned more when viewing sessions with greater dialogue interactivity and more personally contextualized information. Subjects with adequate literacy skills, however, tended to learn less in low literacy demand sessions. CONCLUSION: The oral literacy demand of medical dialogue represents a learning obstacle to low literate subjects. However, this may not be the case for those with greater literacy skills who can understand the complex language and process the dense informational load of high demand sessions. PRACTICE IMPLICATIONS: In order to meet the educational needs of all patients, clinicians must attend to both the informativeness and the oral literacy demand of their communication.
Roter DL, Erby LH, Larson S, Ellington L. Assessing oral literacy demand in genetic counseling dialogue: preliminary test of a conceptual framework. Soc Sci Med. 2007 Oct;65(7):1442-57. Epub 2007 Jul 5.
(Health Literacy, Genetic Counseling, United States)
Health literacy deficits affect half the American patient population and are linked to poor health, ineffective disease management and high rates of hospitalization. Restricted literacy has also been linked with less satisfying medical visits and communication difficulties, particularly in terms of the interpersonal and informational aspects of care. Despite growing attention to these issues by researchers and policy makers, few studies have attempted to conceptualize and assess those aspects of dialogue that challenge persons with low literacy skills, i.e., the oral literacy demand within medical encounters. The current study uses videotapes and transcripts of 152 prenatal and cancer pretest genetic counseling sessions recorded with simulated clients to develop a conceptual framework to explore oral literacy demand and its consequences for medical interaction and related outcomes. Ninety-six prenatal and 81 cancer genetic counselors-broadly representative of the US National Society of Genetic Counselors-participated in the study. Key elements of the conceptual framework used to define oral literacy demand include: (1) use of unfamiliar technical terms; (2) general language complexity, reflected in the application of Microsoft Word grammar summary statistics to session transcripts; and, (3) structural characteristics of dialogue, including pacing, density, and interactivity. Genetic counselor outcomes include self-ratings of session satisfaction, informativeness, and development of rapport. The simulated clients rated their satisfaction with session communication, the counselor's effective use of nonverbal skills, and the counselor's affective demeanor during the session. Sessions with greater overall technical term use were longer and used more complex language reflected in readability indices and multi-syllabic vocabulary (measures averaging p < .05). Sessions with a high proportionate use of technical terms were characterized by shorter visits, high readability demand, slow speech speed, fewer and more dense counselor speaking turns and low interactivity (p < .05).The higher the use of technical terms, and the more dense and less interactive the dialogue, the less satisfied the simulated clients were and the lower their ratings were of counselors' nonverbal effectiveness and affective demeanor (all relationships p < .05). Counselors' self-ratings of informativeness were also inversely related to use of technical terms (p < .05). Just as print material can be made more reader-friendly and effective following established guidelines, the medical dialogue may also be made more patient-centered and meaningful by having providers monitor their vocabulary and language, as well as the structural characteristics of interaction, thereby lowering the literacy demand of routine medical dialogue. These consequences are important for all patients but may be even more so for patients with restricted literacy.
Roter DL, Ewart CK. Emotional inhibition in essential hypertension: obstacle to communication during medical visits? Health Psychol. 1992;11(3):163-9.
(Primary Care, Patient Emotional Distress, United States)
A substantial literature on the "hypertensive personality" links essential hypertension (EH) with the suppression of negative emotions, implying that suppression may elevate blood pressure. Yet affective inhibition might also impair communication with health care providers and exacerbate EH by limiting therapeutic collaboration. We studied 542 patient-physician interviews from a national sample to see if patients with EH (n = 203) were less likely to exhibit negative emotions than normotensive patients (n = 339) as rated by their physicians and independent observers. EH patients did not differ from others on self-rated emotional or physical health. However, physicians were less accurate in characterizing the emotional states of EH patients than those of normotensive patients, and they rated EH patients as exhibiting fewer signs of distress during the visit. Independent observers also judged the EH patients as less distressed than normotensives, thereby validating the physicians' appraisals. Content analysis disclosed that physicians paid less attention to psychosocial concerns and concentrated on biomedical matters to a greater degree with hypertensive patients than with their normotensive patients. EH patients, particularly those experiencing emotional distress, appear to have patterns of self-presentation that could present an obstacle to effective communication with their physicians, and this difficulty may be amplified by physicians' disinclination to probe for emotional difficulty.
Roter DL, Geller G, Bernhardt BA, Larson SM, Doksum T. Effects of obstetrician gender on communication and patient satisfaction. Obstet Gynecol. 1999 May;93(5 Pt 1):635-41.
(Outside Primary Care, United States)
OBJECTIVE: To describe patient-obstetrician communication during the first prenatal visit and its relationship to physician gender and patient satisfaction. METHODS: The first prenatal visit of 87 women with 21 obstetricians (11 male and ten female) was audiotaped and analyzed using the Roter Interaction Analysis System. Patient satisfaction was measured by postvisit questionnaire. RESULTS: Communication during first prenatal visits was largely biomedical, with little psychosocial or social discussion. Male physicians conducted longer visits than females (26 minutes versus 21.9 minutes, P < .05) and engaged in more facilitative communication (ie, making sure they were understood and providing direction and orientation) and explicit statements of concern and partnership (z > 1.96, P < .05). Female physicians devoted more communication to agreements, disagreements, and laughter than males (z > 1.96, P < .05). Satisfaction with physicians' emotional responsiveness and informational partnership was related to female physician gender and a variety of task-focused and affective communication variables. CONCLUSION: Communication and satisfaction between women and obstetricians during initial prenatal visits is related to physician gender and patient satisfaction. Male physicians conducted longer visits but women were more satisfied with female physicians.
Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: a meta-analytic review. JAMA. 2002 Aug 14;288(6):756-64.
(Gender, Primary Care)
CONTEXT: Physician gender has been viewed as a possible source of variation in the interpersonal aspects of medical practice, with speculation that female physicians facilitate more open and equal exchange and a different therapeutic milieu from that of male physicians. However, studies in this area are generally based on small samples, with conflicting results. OBJECTIVE: To systematically review and quantify the effect of physician gender on communication during medical visits. DATA SOURCES: Online database searches of English-language abstracts for the years 1967 to 2001 (MEDLINE, AIDSLINE, PsycINFO, and Bioethics); a hand search was conducted of reprint files and the reference sections of review articles and other publications. STUDY SELECTION: Studies using a communication data source, such as audiotape, videotape, or direct observation, and large national or regional studies in which physician report was used to establish length of visit, were identified through bibliographic and computerized searches. Twenty-three observational studies and 3 large physician-report studies reported in 29 publications met inclusion criteria and were rated. DATA EXTRACTION: The Cohen d was computed based on 2 reviewers' (J.A.H. and Y.A.) independent extraction of quantitative information from the publications. Study heterogeneity was tested using Q statistics and pooled effect sizes were computed using the appropriate effects model. The characteristics of the study populations were also extracted. DATA SYNTHESIS: Female physicians engage in significantly more active partnership behaviors, positive talk, psychosocial counseling, psychosocial question asking, and emotionally focused talk. There were no gender differences evident in the amount, quality, or manner of biomedical information giving or social conversation. Medical visits with female physicians are, on average, 2 minutes (10%) longer than those with male physicians. Obstetrics and gynecology may present a different pattern than that of primary care, with male physicians demonstrating higher levels of emotionally focused talk than their female colleagues. CONCLUSIONS: Female primary care physicians engage in more communication that can be considered patient centered and have longer visits than their male colleagues. Limited studies exist outside of primary care, and gender-related practice patterns in some subspecialties may differ from those evident in primary care.
Roter DL, Hall JA. Physician's interviewing styles and medical information obtained from patients. J Gen Intern Med. 1987 Sep-Oct;2(5):325-9.
(Primary Care, Communication Skills Training, United States)
This paper investigates the association between physicians' interviewing styles and medical information obtained during simulated patient encounters. The sources of data are audiotapes and transcripts of two standardized patient cases presented by trained patient simulators to 43 primary care practitioners. Transcripts were scored for physician proficiency using expert-generated criteria and were content-analyzed to assess the process of communication and information content. Relevant patient disclosure was also scored from the transcripts based on expert-generated criteria. Findings were: 1) On the whole, physicians elicited only slightly more than 50% of the medical information considered important according to expert consensus, with a range from 9% to 85%. 2) Both open and closed questions were substantially related to patient disclosure of medical information to the physician, but open questions were substantially more so (Pearson correlations of 0.37 and 0.72, respectively). 3) Patient education, particularly information regarding prognosis, cause, and prevention, was substantially related to patient disclosure of medical information to the physician (Pearson correlations of 0.44, 0.36, and 0.34, respectively). 5) Finally, clinical expertise was only weakly associated with patient disclosure of medical information to the physician (Pearson correlation of 0.16).
Roter DL, Hall JA, Blanch-Hartigan D, Larson S, Frankel RM. Slicing it thin: new methods for brief sampling analysis using RIAS-coded medical dialogue. Patient Educ Couns. 2011 Mar;82(3):410-9.
(Interaction Analysis, United States)
OBJECTIVE: To explore the relationship between one-minute slices and full-session interaction and the predictive validity of the slices to ratings of affect and rapport. METHODS: Third-year medical students (n=253) were videotaped during an OSCE. All interaction was coded using the Roter Interaction Analysis System (RIAS) and samples were drawn at minutes 1, 5, and 9 and extracted from the coded database. The slices were related in multivariate analysis to full-session interaction, corrected for slice content, and correlated with affect ratings of participants and independently rated judgments of rapport. RESULTS: One-minute slices explained 33% of full-session variance in student interaction and 30% of variance in standardized patient interaction. Slices were significantly correlated with affective ratings of participants and independent judgments of rapport in a similar pattern as full-session interaction analysis. CONCLUSIONS: One-minute slices of interaction can provide a meaningful degree of insight into OSCE session communication with both concurrent and predictive validity to ratings of session affect and rapport. PRACTICE IMPLICATIONS: Evidence of concurrent and predictive validity further supports use of this approach as a research tool that provides an efficient means of analyzing processes of care, examining variation in communication throughout a visit and predicting visit outcomes.
Roter DL, Hall JA, Katz NR. (1987). Relations between physicians' behaviors and patients' satisfaction, recall, and impressions: An analogue study. Med Care. 1987 May;25(5):437-51.
(Primary Care, Patient Recall and Satisfaction, United States)
This paper investigates associations between physicians' task-oriented and socioemotional behaviors, on the one hand, and analogue patients' satisfaction, recall of information, and global impressions. The study is based on role-playing subjects' responses to interactions between physicians and simulated patients. Audiotapes of two standardized patient cases presented by trained patient simulators to 43 primary care physicians were rated by role-playing patients (N = 258), and electronically filtered excerpts from the encounters were rated for vocal affect by 37 independent judges. Content analysis was made of the visits' transcripts to assess interaction process and to identify all medical information communicated. Finally, speech error rate was calculated from a combination of audiotape and transcript. Findings revealed that role-playing patients clearly distinguished task from socioemotional behaviors of the physicians, and a consistent pattern of association emerged between physicians' task behaviors and role-playing patients' satisfaction, recall, and impressions. Within the task domain, patient-centered skills (i.e., giving information and counseling) were consistently related to patient effects in a positive direction, but physician-centered behaviors (i.e., giving directions and asking questions) demonstrated the opposite relationship. A negative pattern of association was also evident between physicians' socioemotional behaviors and patient effects.
Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians' interviewing skills and reducing patients' emotional distress: A randomized clinical trial. Arch Intern Med 1995 Sep 25;155(17):1877-84.
(Primary Care, Communication Skills Training, Patient Emotional Distress, United States)
BACKGROUND: Despite high prevalence, emotional distress among primary care patients often goes unrecognized during routine medical encounters. OBJECTIVE: To explore the effect of communication-skills training on the process and outcome of care associated with patients' emotional distress. METHODS: A randomized, controlled field trial was conducted with 69 primary care physicians and 648 of their patients. Physicians were randomized to a no-training control group or one of two communication-skills training courses designed to help physicians address patients' emotional distress. The two training courses addressed communication through problem-defining skills or emotion-handling skills. All office visits of study physicians were audiotaped until five emotionally distressed and five nondistressed patients were enrolled based on patient response to the General Health Questionnaire. Physicians were also audiotaped interviewing a simulated patient to evaluate clinical proficiency. Telephone monitoring of distressed patients for utilization of medical services and General Health Questionnaire scores was conducted 2 weeks, 3 months, and 6 months after their audiotaped office visits. RESULTS: Audiotape analysis of actual and simulated patients showed that trained physicians used significantly more problem-defining and emotion-handling skills than did untrained physicians, without increasing the length of the visit. Trained physicians also reported more psychosocial problems, engaged in more strategies for managing emotional problems with actual patients, and scored higher in clinical proficiency with simulated patients. Patients of trained physicians reported reduction in emotional distress for as long as 6 months. CONCLUSIONS: Important changes in physicians' communication skills were evident after an 8-hour program. The training improved the process and outcome of care without lengthening the visits.
Roter DL, Knowles N, Somerfield M, Baldwin J. Routine communication in sexually transmitted disease clinics: an observational study. Am J Public Health 1990 May;80(5):605-6.
(Outside Primary Care, United States)
Sixty STD patients were followed during the course of their clinic visit which averaged 2.75 professional contacts. Based on audiotape analysis, virtually all patients received a diagnosis; however, 25 percent of the patients did not receive any information about treatment or prevention, and only 57 percent of patients were given complete information. Patient recall of the information they were given averaged about 43 percent. Patients not seen by a physician during their clinic visit achieved higher recall rates than patients seen by a physician.
Roter D, Larson S. The Roter interaction analysis system (RIAS): utility and flexibility for analysis of medical interactions. Patient Educ Couns 2002 Apr;46(4):243-51.
(Primary Care, United States)
The Roter interaction analysis system (RIAS), a method for coding medical dialogue, is widely used in the US and Europe and has been applied to medical exchanges in Asia, Africa, and Latin America. Contributing to its rapid dissemination and adoption is the system's ability to provide reasonable depth, sensitivity, and breadth while maintaining practicality, functional specificity, flexibility, reliability, and predictive validity to a variety of patient and provider outcomes. The purpose of this essay is two-fold. First, to broadly overview the RIAS and to present key capabilities and coding conventions, and secondly to address the extent to which the RIAS is consistent with, or complementary to, linguistic-based techniques of communication analysis.
Roter DL, Larson S. The relationship between residents’ and attending physicians’ communication during primary care visits: an illustrative use of the Roter Interaction Analysis System (RIAS). Health Commun 2001;13(1);33-48.
(Primary Care, United States)
This is a descriptive study of residents' and attending physicians' communication profiles during primary care encounters. A small study sample of 10 audiotapes of medical visits between patients and their medical residents was used to illustrate the application of the RIAS. In 8 of these visits, an attending physician was present and consulted with the resident about the case for varying periods of time. RIAS analysis was structured to explore the relationship between these residents and their attending physicians' communication. Differences in the communication profile distributions between residents and attendings were evident in all four of the visit functions—education and counseling, data-gathering, rapport-building, and providing procedural cues to the patient.
Roter DL, Larson SM, Beach MC, Cooper LA. Interactive and evaluative correlates of dialogue sequence: A simulation study applying the RIAS to turn taking structures. Patient Educ Couns. 2008 Apr;71(1):26-33.
(Interaction Analysis, United States)
OBJECTIVE: This study explores novel characterizations of turn taking structure and its interaction and evaluative correlates. METHODS: The Roter Interaction Analysis System (RIAS) was applied to videotapes of 51 physicians with a simulated patient (SP) to create a variety of novel turn taking measures including turn frequency, rate of interactivity, density, duration, and statement pacing. RESULTS: Visits averaged 52 speaker turns with an interactivity rate of 3.9 turns per visit minute. For physicians, turn duration averaged 13.7s with a turn density of 4.2 statements paced at one statement every 3s. For the SP, turn duration was 3s with a turn density of 1.4 statements paced at one statement every 2s. More turns, briefer turn duration and faster physician pacing were significantly related to positive ratings of affective demeanor, interpersonal satisfaction and collaborative decision-making. These measures, and interactivity, were also associated with a RIAS-based patient-centeredness score and more overall patient talk. CONCLUSION: Turn taking structures can be characterized in novel ways lending depth and richness to our understanding of dialogue, relationships to the patient-centeredness of a visit, and evaluative judgments of physician performance. PRACTICE IMPLICATIONS: The study findings suggest specificity to the interviewing admonishment "talk less and listen more" by enhancing the interactivity of the dialogue and guarding against doctors tendency toward long monologues.
Roter DL, Larson S, Fischer CS, Arnold RM, Tulsky, JA. Experts practice what they preach: A descriptive study of best and normative practices in end of life discussions. Arch Intern Med. 2000 Dec 11-25;160(22):3477-85.
(Primary Care, United States)
BACKGROUND: Advance directives (ADs) are widely regarded as the best available mechanism to ensure that patients' wishes about medical treatment at the end of life are respected. However, observational studies suggest that these discussions often fail to meet their stated goals. OBJECTIVES: To explore best practices by describing what physicians who are considered expert in the area of end of-life bioethics or medical communication do when discussing ADs with their patients and to explore the ways in which best practices of the expert group might differ in content or style from normative practice derived from primary care physicians' discussions of ADs with their patients collected as part of an earlier study. DESIGN: Nonexperimental, descriptive study of audiotaped discussions. SETTING: Outpatient primary care practices in the United States. PARTICIPANTS: Eighteen internists who have published articles in the areas of bioethics or communication and 48 of their patients. Fifty-six academic internists and 56 of their established patients in 5 practice sites in 2 locations-Durham, NC, and Pittsburgh, Pa. Eligible patients were at least 65 years old or suffered from serious medical illness and had not previously discussed ADs with their physician. Expert clinicians had discretion regarding patient selection, while the internists chose patients according to a predetermined protocol. MEASUREMENTS: Coders applied the Roter Interaction Analysis System (RIAS) to audiotapes of the medical visits to describe communication dynamics. In addition, the audiotapes were scored on 21 items reflecting physician performance in specific skills related to AD discussions. RESULTS: Experts spent close to twice as much time (14.7 vs 8.1 minutes, P < .001) and were less verbally dominant (P < .05) than other physicians during AD discussions. When length of visit was controlled statistically, the expert physicians gave less information about treatment procedures and biomedical issues (P < .05) and asked fewer related questions (P < . 05) but tended toward more psychosocial and lifestyle discussion and questions. Experts engaged in more partnership building (P < .05) with their patients. Patients of the expert physicians engaged in more psychosocial and lifestyle discussion (P < .001), and more positive talk (P < .05) than patients of community physicians. Expert physicians scored higher on the 21 items reflecting AD-specific skills (P < .001). CONCLUSIONS: Best practices as reflected in the performance of expert physicians reflect differences in measures of communication style and in specific AD-related proficiencies. Physician training in ADs must be broad enough to include both of these domains.
Roter DL, Larson S, Sands DZ, Ford DE, Houston T. Can e-mail messages between patients and physicians be patient-centered? Health Commun. 2008 Jan-Feb;23(1):80-6.
(e-mail Communication, United States)
This study explores the extent to which e-mail messages between patients and physicians mimic the communication dynamics of traditional medical dialogue and its fulfillment of communication functions. Eight volunteers drawn from a larger study of e-mail users agreed to supply copies of their last 5 e-mail messages with their physicians and the physician replies. Seventy-four e-mail messages (40 patient and 34 physician) were provided and coded using the Roter Interactive Analysis System. The study found that physicians' e-mails are shorter and more direct than those of patients, averaging half the number of statements (7 vs. 14; p < .02) and words (62 vs. 121; p < .02). Whereas 72% of physician and 59% of patient statements were devoted to information exchange, the remaining communication is characterized as expressing and responding to emotions and acting to build a therapeutic partnership. Comparisons between e-mail and with face-to-face communication show many similarities in the address of these tasks. The authors concluded that e-mail accomplishes informational tasks but is also a vehicle for emotional support and partnership. The patterns of e-mail exchange appear similar to those of in-person visits and can be used by physicians in a patient-centered manner. E-mail has the potential to support the doctor-patient relationship by providing a medium through which patients can express worries and concerns and physicians can be patient-centered in response.
Roter DL, Larson S, Shinitzky H, Chernoff R, Serwint JR, Adamo G, Wissow L. Use of an innovative video feedback technique to enhance communication skills training. Med Educ. 2004 Feb;38(2):145-57.
(Communication Skills Training, Video Feedback, Pediatrics, United States)
CONTEXT: Despite growing interest in medical communication by certification bodies, significant methodological and logistic challenges are evident in experiential methods of instruction. OBJECTIVE: There were three study objectives: 1) to explore the acceptability of an innovative video feedback programme to residents and faculty; 2) to evaluate a brief teaching intervention comprising the video feedback innovation when linked to a one-hour didactic and role-play teaching session on pediatric residents' communication with a simulated patient; and 3) to explore the impact of resident gender on communication change. DESIGN: Pre/post comparison of residents' performance in videotaped interviews with simulated patients before and after the teaching intervention. Individually tailored feedback on targeted communication skills was facilitated by embedding the Roter Interaction Analysis System (RIAS) within a software platform that presents a fully coded interview with instant search and review features. SETTING/PARTICIPANTS: 28 first year residents in a large, urban, pediatric residency programme. RESULTS: Communication changes following the teaching intervention were demonstrated through significant improvements in residents' performance with simulated patients pre and post teaching and feedback. Using paired t-tests, differences include: reduced verbal dominance; increased use of open-ended questions; increased use of empathy; and increased partnership building and problem solving for therapeutic regimen adherence. Female residents demonstrated greater communication change than males. CONCLUSIONS: The RIAS embedded CD-ROM provides a flexible structure for individually tailoring feedback of targeted communication skills that is effective in facilitating communication change as part of a very brief teaching intervention.
Roter D, Lipkin M Jr, Korsgaard A. Sex differences in patients' and physicians' communication during primary care medical visits. Med Care 1991 Nov;29(11):1083-93.
(Primary Care, Gender, Patient Satisfaction, United States)
This study reports on the analysis of audiotapes of 537 adult, chronic disease patients and their 127 physicians (101 men and 26 women) in a variety of primary care practice settings to explore differences attributable to the effects of the patient's and the physician's sex on the process of communication during medical visits. Compared to male physicians, women conducted longer medical visits (22.9 vs 20.3 minutes; F(1,515) = 7.9, P less than .005), with substantially more talk F(1,518) = 19.5, P less than .000. Differences were especially evident during the history segment of the visit when female physicians talked 40% more than male physicians (F(1,518) = 20.1, P less than .000) and when patients of female physicians talked 58% more than male physicians' patients (F(1,448) = 24.4, P less than .000). Compared to male physicians, female physicians engaged in more positive talk, partnership-building, question-asking, and information-giving. Similarly, when with female compared to male physicians, patients engaged in more positive talk, more partnership-building, question-asking, and information-givingrelated to both biomedical and psychosocial topics.
Roter DL, Rosenbaum J, deNegri B, Renaud D, DiPrete-Brown L, Hernandez O. The effects of a continuing medical education programme in interpersonal communication skills on doctor practice and patient satisfaction in Trinidad and Tobago. Med Educ 1998 Mar;32(2):181-9.
(Primary Care, Communication Skills Training, Trinidad and Tobago)
This study investigates the effects of a brief training programme on the communication skills of doctors in ambulatory care settings in Trinidad and Tobago. Evaluation of doctor performance is based on analysis of audiotapes of doctors with their patients during routine clinic visits and on patient satisfaction ratings. A pre-test/post-test quasi-experimental study design was used to evaluate the effects of exposure to the training programme. Doctors were assigned to groups based on voluntary participation in the programme. Audiotapes of the 15 participating doctors (nine trained and six control) with 75 patients at baseline and 71 patients at the post-training assessment were used in this analysis. The audiotapes were content-coded using the Roter Interaction Analysis System (RIAS). Doctors trained in communication skills used significantly more target skills post-training than their untrained colleagues. Trained doctors used more facilitations in their visits and more open-ended questions than other doctors. There was also a trend towards more emotional talk, and more close-ended questions. Patients of trained doctors talked more overall, gave more information to their doctors and tended to use more positive talk compared to other patients. Trained doctors were judged as sounding more interested and friendly, while patients of trained doctors were judged as sounding more dominant, responsive and friendly than patients of untrained doctors. Consistent with these communication differences, patient satisfaction tended to be higher in visits of trained doctors.
Roter DL, Roter HL, Feinstein M. Podiatrist-patient interaction during routine podiatry visits. J JAm Podiatry Assoc 1984 Nov;74(11):553-8.
(Outside Primary Care, United States)
The authors present an empirical description of the content of routine podiatry practice and its relationship to a number of patient effects. Tape recordings of a sampling of 20 patients from private podiatry practices were analyzed to determine typical interaction profiles. Elements of interaction were related to patients' questionnaire responses in such areas as recall of therapeutic recommendations, recall of discussion topcis, and patient satisfaction. Overall findings indicate that satisfaction among podiatry patients was high, with the most significant predictors of satisfaction being: 1) discussion of self-care and preventive activities, 2) short medical history segments, 3) interaction marked by laughter and joking, and 4) physician request for patient opinion on treatment or cause of the problem.
Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA 1997 Jan 22-29;277(4):350-6.
(Primary Care, Patient Recall or Satisfaction, Physician Satisfaction, United States)
OBJECTIVES: To use audiotape analysis to describe communication patterns in primary care, to relate these to ideal relationship types as described in the literature, and to explore the patterns' relationships with physician and patient characteristics and satisfaction. DESIGN: Description of routine communication in primary care based on audiotape analysis and patient and physician exit questionnaires. SETTING: A total of 11 ambulatory clinics and private practices. PARTICIPANTS: The participants were 127 physicians and 537 patients coping with ongoing problems related to disease. MAIN OUTCOMES MEASURES: Roter Interactional Analysis System (RIAS) and patient and physician exit satisfaction questionnaires. RESULTS: Cluster analysis revealed 5 distinct communication patterns: (1) "narrowly biomedical," characterized by closed-ended medical questions and biomedical talk occurring in 32% of visits; (2) "expanded biomedical," like the restricted pattern but with moderate levels of psychosocial discussion occurring in 33% of the visits; (3) "biopsychosocial," reflecting a balance of psychosocial and biomedical topics (20% of the visits); (4) "psychosocial," characterized by psychosocial exchange (8% of visits); and (5) "consumerist," characterized primarily by patient questions and physician information giving (8% of visits). Biomedically focused visits were used more often with more sick, older, and lower income patients by younger, male physicians. Physician satisfaction was lowest in the narrowly biomedical pattern and highest in the consumerist pattern, while patient satisfaction was highest in the psychosocial pattern. CONCLUSIONS: Primary care communication patterns range from narrowly biomedical to consumerist patterns and parallel the ideal forms of patient-physician relationships described in the literature.
Roter DL, Wexler R, Naragon P, Forrest B, Dees J, Almodovar A, Wood J. The impact of patient and physician computer mediated communication skill training on reported communication and patient satisfaction. Patient Educ Couns. 2012 Sep;88(3):406-13. Epub 2012 Jul 11.
(Online/Web-Based, Communication Skills/Training, Patient Satisfaction, United States)
OBJECTIVE: The objective was to evaluate parallel patient and physician computer-mediated communication skill training on participants' report of skill use and patient satisfaction. METHODS: Separate patient and clinician web-tools comprised of over 500, 10-s video clips demonstrating patient-centered skills in various ways. Four clinician members of the American Academy of Family Physicians National Research Network participated by enrolling 194 patients into a randomized patient trial and 29 physicians into a non-randomized clinician trial of respective interventions. All participants completed baseline and follow-up self-report measures of visit communication and satisfaction. RESULTS: Intervention patients reported using more skills than controls in five of six skill areas, including identification of problems/concerns, information exchange, treatment adherence, shared decision-making and interpersonal rapport (all p < .05); post intervention, physicians reported using more skills in the same 5 areas (all p < .01). Intervention group patients reported higher levels of satisfaction than controls in five of six domains (all p < .05).CONCLUSION: Communication skill training delivered in a computer mediated format had a positive and parallel impact on both patient and clinician reported use of patient-centered communication and in patient satisfaction. PRACTICE IMPLICATIONS: Computer-mediated interventions are cost and time effective thereby increasing patient and clinician willingness to undertake training.