RIAS Works - Resources by Subject

Communication Skills/Training

Bensing JM, Sluijs EM. Evaluation of an interview training course for general practitioners. Soc Sci Med. 1985; 20(7):737-44.
(Communications Skills Training, Primary Care, Netherlands)
This article describes the evaluation of an experimental training in doctor-patient communication for general practitioners. The training was based on Rogerian theory and accommodated to the specific situation of the general practitioner. The main concept of this theory is the notion of 'unconditional positive regard'. It was expected that doctors would change their communication behaviour and that as a result patients would talk more about their psychosocial problems. The training was restricted to the diagnostic process, no therapeutic interventions were taught. The effects of this training have been measured by comparing video-tapes of live doctor-patient consultations, before and 3 months after the training. The most important result of this evaluation study turned out to be the change of the doctor's behaviour in the expected direction, but surprisingly the outcome of the consultation did not change at all: the doctors were empathically listening, but the patients did not talk more about their problems. Creating room for patients is not sufficient to induce them to discuss their personal problems with their doctors. Perhaps they do not feel like discussing their personal problems with them at all.

Blanch DC, Hall JA, Roter DL, Frankel RM. Is it good to express uncertainty to a patient? Correlates and consequences for medical students in a standardized patient visit. Patient Educ Couns. 2009 Sep;76(3):300-6. Epub 2009 Jul 14.
(Medical Education, Gender, United States)
OBJECTIVE: To examine the consequences of expressions of uncertainty (EOUs) in medical student interactions, with a particular focus on the gender of the expressor. METHODS: EOUs were identified in 147 videotaped interactions between third-year medical students and standardized patients enacting four medical scenarios. The encounters were also analyzed using the Roter Interaction Analysis System (RIAS). A subset of these interactions was shown to 244 analogue patients who rated satisfaction, liking, and perceived competence and confidence. RESULTS: Female medical students used more EOUs but not when adjusted for total number of statements. The EOU rate varied across scenarios. A higher EOU rate was perceived as more affectively negative by both RIAS trained coders and analogue patients. EOU rate was inversely related to analogue patient satisfaction and liking and this relationship was stronger for males than females. Female student use of EOUs was more strongly associated with ratings of anxiety than was male EOU use. CONCLUSION: There was an overall negative perception of medical students who expressed uncertainty; however, the strength of the associations varied due to medical student gender. PRACTICE IMPLICATIONS: The implications for medical education are discussed.

Brown LD, de Negri B, Hernandez O, Dominguez L, Sanchack JH, Roter D. An evaluation of the impact of training Honduran health care providers in interpersonal communication. Int J Qual Health Care 2000 Dec;12(6):495-501.
(Communications Skills Training, Satisfaction, Honduras)
OBJECTIVE: To evaluate the impact of interpersonal communication (IPC) training on practice and patient satisfaction and to determine the acceptability of this training to providers in a developing country. DESIGN: The study used a pre-post design with treatment and control groups. Data collection methods included interaction analysis of audio-taped clinical encounters, patient exit interviews, and a self-administered questionnaire for health providers. STUDY PARTICIPANTS: Interaction analysis was based on an experimental group of 24 doctors and a control group of eight with multiple observations for each provider). Exit interviews were carried out with 220 pre-test patients and 218 post-test patients. All 87 health providers who received training responded to the self-administered questionnaire. INTERVENTION: A brief in-service training programme on interpersonal communications was presented in three half-day sessions; these focused on overall socio-emotional communication, problem solving skills and counselling. MAIN OUTCOME MEASURES AND RESULTS: The IPC intervention was associated with more communication by trained providers (mean scores of 136.6 versus 94.4; P = 0.001), more positive talk (15.93 versus 7.99; P = 0.001), less negative talk (0.11 versus 0.59; P = 0.018), more emotional talk (15.7 versus 5.5; P = 0.021), and more medical counselling (17.3 versus 11.3; P = 0.026). Patients responded by communicating more (mean scores of 113.8 versus 79.6; P = 0.011) and disclosing more medical information (54.7 versus 41.7; P = 0.002). Patient satisfaction ratings were higher for providers who had received the training and providers reported training to be relevant and useful. CONCLUSIONS: Further validation of IPC skills and simplification of assessment methods are needed if IPC is to be an area for routine monitoring and quality improvement.

Cavaco A, Roter D. Pharmaceutical consultations in community pharmacies: utility of the Roter Interaction Analysis System to study pharmacist-patient communication. Int J Pharm Pract. 2010 Jun;18(3):141-8.
(Communication Skills, Pharmacy, Portugal)
Communication is a key issue in the delivery of healthcare services. In the pharmacy context, pharmacist-patient communication may vary from brief counselling episodes to extensive pharmaceutical care consultations. Many community pharmacies have developed practices to facilitate the effective delivery of pharmacy care, in particular to chronic patients, although the nature and extent of the services differ widely from country to country. Diabetes-focused pharmaceutical care is an example highlighting both the opportunities and challenges associated with an expansion of pharmacy services from product dispensing to pharmaceutical consultations. An area of particular challenge of such an expansion of pharmaceutical services is the development of expertise in the delivery of patient-centred pharmaceutical consultations. Although well known to medicine and nursing, patient-centredness has not been routinely incorporated into the training of pharmacists, evaluation of pharmacy practice or conduct of pharmacy-related research. There are few studies of the communication process based on analysis of an objective record such as an audio or video recording and the common perspective is largely a one-way information flow from pharmacist to patient. This has hampered the field's ability to link pharmacy communication to outcomes, including patient adherence and satisfaction with services. An extensive body of communication research on physician-patient interaction, employing the Roter Interaction Analysis System (RIAS), exists and the system presents a potentially useful tool in the pharmacy context. The purpose of this essay is to explore the utility of the RIAS for analysis of pharmacist-patient interaction and its implication for improving patient care and optimizing pharmacy-specific outcomes.

Cavaco AM, Romano J. Exploring pharmacists' communication with customers through screening services. Patient Educ Couns. 2010 Sep;80(3):377-83. Epub 2010 Jul 27.
(Communication Skills, Pharmacy, Portugal)
OBJECTIVE: To describe pharmacist-customer communication, during blood pressure and capillary cholesterol services, in a community pharmacy setting. METHODS: Participants were purposively selected and data collected by audio-recording. The encounters' verbal content was transcribed verbatim, utterances identified, time stamped, and classified according to a coding scheme of 15 categories. Four dialogue structures were analyzed: speaker turn, interactivity, turn density and turn duration. RESULTS: Eighty-three episodes were registered (51 blood pressure, 32 cholesterol). The average blood pressure episode lasted 5:35 min, with 81.2 utterances (55.3% customers), and an interactivity rate of 7 turns/min. The average cholesterol episode took 7:05 min, with 135.3 utterances (52.7% pharmacists), and an interactivity rate of 13.3 turns/min. In both cases, pharmacists asked more questions (mainly closed ones), while customers gave more information. An increased number of speaker turns and closed questions were associated to higher systolic pressure. No correlations were identified with cholesterol values. CONCLUSION: It would seem that pharmacists tend to control the exchange and its content through closed questioning. Although talk dominance is balanced, hypertensive episodes induce a higher information search. PRACTICE IMPLICATIONS: Educational interventions, focusing on pharmacists' communication competencies, should be available to favor interaction skills resulting in a customer's augment of proactive information seeking behavior.

Cooper LA, Roter DL, Carson KA, Bone LR, Larson SM, Miller ER 3rd, Barr MS, Levine DM. A randomized trial to improve patient-centered care and hypertension control in underserved primary care patients. J Gen Intern Med. 2011 Nov;26(11):1297-304. Epub 2011 Jul 6.
(Primary Care, Communication Skills Training, United States)
BACKGROUND: African Americans and persons with low socioeconomic status (SES) are disproportionately affected by hypertension and receive less patient-centered care than less vulnerable patient populations. Moreover, continuing medical education (CME) and patient-activation interventions have infrequently been directed to improve the processes of care for these populations. OBJECTIVE: To compare the effectiveness of patient-centered interventions targeting patients and physicians with the effectiveness of minimal interventions for underserved groups. DESIGN: Randomized controlled trial conducted from January 2002 through August 2005, with patient follow-up at 3 and 12 months, in 14 urban, community-based practices in Baltimore, Maryland. PARTICIPANTS: Forty-one primary care physicians and 279 hypertension patients. INTERVENTIONS: Physician communication skills training and patient coaching by community health workers. MAIN MEASURES: Physician communication behaviors; patient ratings of physicians' participatory decision-making (PDM), patient involvement in care (PIC), reported adherence to medications; systolic and diastolic blood pressure (BP) and BP control. KEY RESULTS: Visits of trained versus control group physicians demonstrated more positive communication change scores from baseline (-0.52 vs. -0.82, p = 0.04). At 12 months, the patient+physician intensive group compared to the minimal intervention group showed significantly greater improvements in patient report of physicians' PDM (β = +6.20 vs. -5.24, p = 0.03) and PIC dimensions related to doctor facilitation (β = +0.22 vs. -0.17, p = 0.03) and information exchange (β = +0.32 vs. -0.22, p = 0.005). Improvements in patient adherence and BP control did not differ across groups for the overall patient sample. However, among patients with uncontrolled hypertension at baseline, non-significant reductions in systolic BP were observed among patients in all intervention groups-the patient+physician intensive (-13.2 mmHg), physician intensive/patient minimal (-10.6 mmHg), and the patient intensive/physician minimal (-16.8 mmHg), compared to the patient+physician minimal group (-2.0 mmHg). CONCLUSION: Interventions that enhance physicians' communication skills and activate patients to participate in their care positively affect patient-centered communication, patient perceptions of engagement in care, and may improve systolic BP among urban African-American and low SES patients with uncontrolled hypertension.

de Ridder DT, Theunissen NC, van Dulmen SM. Does training general practitioners to elicit patients' illness representations and action plans influence their communication as a whole? Patient Educ Couns. 2007 Jun;66(3):327-36.
(Communication Skills Training, Netherlands)
OBJECTIVE: To examine whether the discussion of illness representations and action plans during medical encounters affects the way patients and general practitioners (GPs) communicate. METHODS: In a quasi-experimental design, 10 GPs first performed care-as-usual conversations with patients. After a 6 h training they performed consultations either emphasizing patients' illness representations or action plans. Data were collected from 70 videotaped consultations with hypertensive patients, which were analyzed using the Roter Interaction Analysis System. RESULTS: Compared with care-as-usual consultations, communication in the action plan condition resulted in an increased discussion of lifestyle issues whereas communication in the illness representation condition resulted in more discussion of patient concerns. In both experimental conditions the proportion of affective GP utterances was higher while patients contributed more to the conversation. When GPs changed their communication style, patients did accordingly. CONCLUSION: The explicit address of illness representations or action plans during consultations results in more attention to patient concerns and lifestyle issues and an overall improvement in patient-GP communication in terms of affective atmosphere and patient involvement. PRACTICE IMPLICATIONS: These findings show that after a brief training GPs are able to change their communication style in a way that allows for a more thorough consideration of patient self-management.

Farquharson L, Noble LM, Barker C, Behrens RH. Health beliefs and communication in the travel clinic consultation as predictors of adherence to malaria chemoprophylaxis. Br J Health Psychol. 2004 May;9(Pt 2):201-17.
(Communication Skills, Adherence, United Kingdom)
OBJECTIVES: The objectives were, first, to determine whether adherence to malaria prophylaxis could be predicted by (i) health beliefs specified by the Health Belief Model and the Theory of Planned Behaviour, and (ii) communication during the consultation in a travel clinic; and secondly, to examine the impact of the consultation in changing travellers' health beliefs. DESIGN: A prospective study using regression analysis. METHODS: The participants were 130 consecutive travellers attending a travel medicine clinic. Health beliefs were measured pre- and post-consultation. The consultations were coded from audiotape using the Roter Interaction Analysis System and a content analysis method recording discussion about malaria and prophylaxis. Adherence was assessed by a follow-up telephone interview. RESULTS: Perceived susceptibility to malaria, perceived benefits of medication and intentions to adhere increased significantly as a result of the consultation, and the perceived permanent nature of side effects reduced significantly. At follow-up (N = 107), 62% reported full adherence, 25% partial adherence and 12% poor/no adherence. A multinomial logistic regression analysis revealed that perceived benefits of medication, length of stay, health professional discussion about adherence and travellers' questions and statements independently predicted reported adherence. CONCLUSIONS: Health beliefs and communication significantly predicted adherence in this setting. The findings also suggested qualitative differences between travellers who adhered fully, partially or poorly. Although the clinic consultation had a positive impact, emphasizing benefits of medication and resolving potential barriers to adherence could improve adherence in the population.

Fassaert T, van Dulmen S, Schellevis F, Bensing J. Active listening in medical consultations: Development of the Active listening observation scale (ALOS-global). Patient Education and Counseling. 2007Nov;68(3):258-64.
(Communications Skills, Netherlands)
OBJECTIVE: Active listening is a prerequisite for a successful healthcare encounter, bearing potential therapeutic value especially in clinical situations that require no specific medical intervention. Although generally acknowledged as such, active listening has not been studied in depth. This paper describes the development of the Active Listening Observation Scale (ALOS-global), an observation instrument measuring active listening and its validation in a sample of general practice consultations for minor ailments. METHODS: Five hundred and twenty-four videotaped general practice consultations involving minor ailments were observed with the ALOS-global. Hypotheses were tested to determine validity, incorporating patients' perception of GPs' affective performance, GPs' verbal attention, patients' self-reported anxiety level and gender differences. RESULTS: The final 7-item ALOS-global had acceptable inter- and intra-observer agreement. Factor analysis revealed one homogeneous dimension. The scalescore was positively related to verbal attention measured by RIAS, to patients' perception of GPs' performance and to their pre-visit anxiety level. Female GPs received higher active listening scores. CONCLUSION: The results of this study are promising concerning the psychometric properties of the ALOS-global. More research is needed to confirm these preliminary findings. PRACTICE IMPLICATIONS: After establishing how active listening differentiates between health professionals, the ALOS-global may become a valuable tool in feedback and training aimed at increasing listening skills.

Finset A, Graugaard PK, Holgersen K. Salivary cortisol response after a medical interview: the impact of physician communication behaviour, depressed affect and alexithymia. Patient Educ Couns. 2006 Feb;60(2):115-24. Epub 2005 Dec 28.
(Communication Skills, Norway)
OBJECTIVE: To explore if - and possibly how - a medical interview may affect adrenocortical activity in musculo-skeletal pain patients with and without alexithymia. METHODS: Female patients (N = 54) recruited from a patient organization for fibromyalgia completed the Toronto Alexithymia Scale (TAS-20) and subgroups with, respectively, low and high scores were selected for participation. Seven physicians conducted consultations attempting to vary their communication in accordance with given guidelines. All consultations were videotaped and analysed by The Roter Interaction Analysis System (RIAS) to evaluate the actual content of the consultations. RESULTS: An increase in depressed affect from pre- to post-interview was associated with relatively high cortisol levels 24 h after the consultation, but only in patients with alexithymia. Psychosocial questions from the physician were associated with increased depressed affect immediately following the interview, but not with cortisol responses at any time. CONCLUSION: In patients with deficient affect regulation, increase in depressed affect after a medical interview may be associated with delayed effects in adrenocortical activity, possibly mediated by rumination. PRACTICE IMPLICATIONS: Providers should be sensitive to potential deficits of affect regulation in their patients.

Graugaard PK, Eide H, Finset A. Interaction analysis of physician-patient communication: the influence of trait anxiety on communication and outcome. Patient Educ Couns. 2003 Feb;49(2):149-56.
(Communication Skills, Norway)
Little attention has been paid to how patients' personality traits interfere with the communication and the outcome of physician-patient interaction. We performed an experimental study with students with high and low trait anxiety as patients. One physician conducted a single consultation with 41 students applying two beforehand-specified consultation styles. Patients completed questionnaires concerning emotional state and satisfaction. The actual content of the consultations was analyzed by Roter interaction analysis system (RIAS). The physician gave more biomedical information to low-anxiety students than high-anxiety students. Students who provided a lot of biomedical information themselves were less tense after the consultation. However, students with high anxiety were more dependent on the physician actively asking biomedical questions for them to be able to deliver that same information. In contrast to low-anxiety students, those with high anxiety were less satisfied after consultations involving many psychosocial questions posed by the physician and a good deal of emotional talk on their own part. Compared to low-anxiety students, students with high anxiety were less satisfied and tenser after consultations with much positive emotional talk on the part of the physician. We conclude that physicians and educators should be aware that psychological and emotional communication may be experienced as intrusive and inappropriate by patients with high trait anxiety when they present minor somatic problems.

Graugaard PK, Holgersen K, Eide H, Finset A. Changes in physician-patient communication from initial to return visits: a prospective study in a haematology outpatient clinic. Patient Educ Couns. 2005 Apr;57(1):22-9.
(Communication Skills, Norway)
Limited research has investigated how physician-patient interaction changes over time. We have therefore examined physician-patient communication during the two initial, as well as the seventh (on average) patient visit to a haematology outpatient clinic. Consultations were audio taped and analyzed using the Roter interaction analysis system (RIAS). Patients completed the Impact of Events Scale (IES) before and a satisfaction questionnaire after each consultation. Consultations were generally physician dominated and task-focused. While the amount of task-focused communication was significantly reduced between the initial and the return visits, the amount of socio-emotional communication remained quite stable. In return visits (but not in the two initial visits), patients with more severe diagnoses were given longer consultations and they provided more task-focused information to a less verbally dominant physician. Patients were more satisfied in the second and return visits (but not in the first), if consultations contained greater levels of socio-emotional communication.

Graugaard PK, Holgersen K, Finset A. Communicating with alexithymic and non-alexithymic patients: an experimental study of the effect of psychosocial communication and empathy on patient satisfaction. Psychother Psychosom. 2004 Mar-Apr;73(2):92-100.
(Communication Skills, Norway)
BACKGROUND: Previous studies have shown that alexithymia is associated with a wide range of somatic and psychiatric conditions. The aim of this study was to investigate experimentally how psychosocial communication and empathic response from the physician affects satisfaction in alexithymic and non-alexithymic patients. METHOD: Seven physicians and 65 female patients from a fibromyalgia patient association participated in the study. The Toronto Alexithymia Scale (TAS-20) was used to categorise patients as alexithymic or non-alexithymic. Patients also completed questionnaires regarding trait anxiety and satisfaction with their consultation. Physicians were instructed to differentiate their communication in terms of both psychosocial matters and empathic response. The content of the consultation was analysed using the Roter Interactional Analysis System. RESULTS: Regression analyses revealed that alexithymic patients were significantly more satisfied when they received a greater empathic response from the physician. Non-alexithymic patients, however, were more satisfied when the consultation was of longer duration. Psychosocial communication did not have any statistically significant effect on satisfaction in either of the two subgroups. CONCLUSIONS: Verbalised empathic response from the physician may be crucial for the alexithymic patient's post-consultation satisfaction and may thereby become the basis for a solid treatment alliance. The validity of this hypothesis should be tested in different clinical settings and with different patient populations. Future research on alexithymic patients' response to psychosocial communication may benefit from determining to what extent this communication is concerned with general distress or more complex emotional phenomena.

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

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

Joos SK, Hickman DH, Gordon GH, Baker LH. Effects of a physician communication intervention on patient care outcomes. J Gen Intern Med 1995;11:147-155.
(Communication Skills Training, United States)
OBJECTIVE. To determine whether an intervention designed to improve patient-physician communication increases the frequency with which physicians elicit patients' concerns, changes other communication behaviors, and improves health care outcomes. DESIGN. Pretest-posttest design with random assignment of physicians to intervention or control groups. SETTING. General medicine clinics of a university-affiliated Veterans Affairs Hospital. PATIENTS/PARTICIPANTS. Forty-two physicians and 348 continuity care patients taking prescription medications for chronic medical conditions. INTERVENTIONS. Intervention group physicians received 4.5 hours of training on eliciting and responding to patients' concerns and requests, and their patients filled out the Patient Requests for Services Questionnaire prior to a subsequent clinic visit. Control group physicians received 4.5 hours of training in medical decision-making. MEASUREMENTS AND MAIN RESULTS. The frequency with which physicians elicited all of a patient's concerns increased in the intervention group as compared with the control group (p = .032). Patients perceptions of the amount of information received from the physician did increase significantly (p < .05), but the actual magnitude of change was small. A measure of patient satisfaction with the physicians was high at baseline and also showed no significant change after the intervention. Likewise, the intervention was not associated with changes in patient compliance with medications or appointments, nor were there any effects on outpatient utilization. CONCLUSIONS. A low-intensity intervention changed physician behavior but had no effect on patient outcomes such as satisfaction, compliance, or utilization. Interventions may need to focus on physicians and patients to have the greatest effect.

Kalet A, Earp JA, Kowlowitz V. How well do faculty evaluate the interviewing skills of medical students? J Gen Intern Med 1992 Sep-Oct;7(5):499-505.
(Communication Skills Evaluation, United States)
OBJECTIVE: To study the reliability and validity of using medical school faculty in the evaluation of the interviewing skills of medical students. DESIGN: All second-year University of North Carolina medical students (n = 159) were observed interviewing standardized patients for 5 minutes by one of eight experienced clinical faculty. Interview quality was assessed by a faculty checklist covering questioning style, facilitative behaviors, and specific content. Twenty-one randomly chosen students were videotaped and rated: by the original rater as well as four other raters; by two nationally recognized experts; and according to Roter's coding dimensions, which have been found to correlate strongly with patient compliance and satisfaction. SETTING: Medical school at a state university in the southeastern United States. PARTICIPANTS: Faculty members who volunteered to evaluate second-year medical students during an annual Objective Structured Clinical Exam. INTERVENTIONS: Interrater reliability and intrarater reliability were tested using videotapes of medical students interviewing a standardized patient. Validity was tested by comparing the faculty judgment with both an analysis using the Roter Interactional Analysis System and an assessment made by expert interviewers. MEASUREMENTS AND MAIN RESULTS: Faculty mean checklist score was 80% (range 41-100%). Intrarater reliability was poor for assessment of skills and behaviors as compared with that for content obtained. Interrater reliability was also poor as measured by intraclass correlation coefficients ranging from 0.11 to 0.37. When compared with the experts, faculty raters had a sensitivity of 80% but a specificity of 45% in identifying students with adequate skills. The predictive value of faculty assessment was 12%. Analysis using Roter's coding scheme suggests that faculty scored students on the basis of likability rather than specific behavioral skills, limiting their ability to provide behaviorally specific feedback. CONCLUSIONS: To accurately evaluate clinical interviewing skills we must enhance rater consistency, particularly in assessing those skills that both satisfy patients and yield crucial data.

Kim YM, Figueroa ME, Martin A, Silva R, Acosta SF, Hurtado M, Richardson P, Kols A. Impact of supervision and self-assessment on doctor-patient communication in rural Mexico. Int J Qual Health Care. 2002 Oct;14(5):359-67.
(Primary Care, Communication Skills, Mexico)
OBJECTIVE: To determine whether supervision and self-assessment activities can improve doctor-patient communication. SETTING AND PARTICIPANTS: Six supervisors, 60 doctors in their last year of training, and 232 primary health care patients at rural health clinics in Michoacan, Mexico. DESIGN: The main evaluation compared post-intervention measures in control and intervention groups. A small panel study also examined changes from baseline to post-intervention rounds in both groups. INTERVENTION: Over a 4-month period, specially trained supervisors added 1 hour of supervision on interpersonal communication and counseling (IPC/C) to regular site visits. Doctors, who had received prior IPC/C training, periodically audiotaped and assessed their own consultations. MAIN OUTCOME MEASURES: These comprised frequency of doctors' facilitative communication, doctors' biomedical information-giving, and patients' active communication. RESULTS: The performance of all doctors improved markedly over the study period, but gains in facilitative communication and information-giving were significantly greater in the intervention than the control group. No single component of the intervention was responsible for the improvement; it resulted from the combination of activities. The doctors appreciated the more supportive relationship with supervisors that resulted from the intervention and found listening to themselves on audiotape a powerful, although initially stressful, experience. CONCLUSION: Supportive supervision and self-assessment activities can reinforce IPC/C training, prompt reflection and learning, and help novice doctors improve their interpersonal communication skills.

Kindler CH, Szirt L, Sommer D, Hausler R, Langewitz W. A quantitative analysis of anaesthetist-patient communication during the pre-operative visit. Anaesthesia. 2005 Jan; 60(1):53-9.
(Communication Skills, Anesthesia, Switzerland)
Previous communication research in general medical practice has shown that effective communication enhances patient compliance, satisfaction and medical outcome. It is expected that communication is equally important in anaesthesia, since patients often suffer from anxiety and lack of knowledge about anaesthetic procedures. However, little is known about the nature of communication during routine anaesthetic visits. The present study of 57 authentic anaesthetic visits provides the first results on the structure and content of communication in the pre-operative setting using the Roter Interaction Analysis System (RIAS). Patient-centred communication behaviours of anaesthetists and the extent of patient involvement were particularly investigated. From the 57 pre-operative visits, 18 267 utterances were coded. The mean (SD) [range] duration of the visit was 16.1 (7.8) [3.7-42.7] min. Anaesthetists provided 169 (68) and patients 153 (82) utterances per visit (53.5% vs. 46.5%). Physician and patient gender had no impact on the distribution of utterances and the duration of the visit. Conversation mainly focussed on biomedical issues with little psychosocial discussion (< 0.1% of all anaesthetist utterances). However, anaesthetists quite frequently used emotional comments toward patients (7%) and involved them in the conversation. The use of facilitators, open questions and emotional statements by the anaesthetist correlated with high patient involvement. The amount of patient participation in anaesthetic decisions was assessed with the Observing Patient Involvement Scale (OPTION). Compared with general practitioners, anaesthetists offered more opportunities to discuss treatment options (mean (SD) OPTION score 26.8 (16.8) vs. 16.8 (7.7)).

Kinsman H, Roter D, Berkenblit G, Saha S, Korthuis PT, Wilson I, Eggly S, Sankar A, Sharp V, Cohn J, Moore RD, Beach MC. "We'll do this together": the role of the first person plural in fostering partnership in patient-physician relationships. J Gen Intern Med. 2010 Mar;25(3):186-93. Epub 2009 Dec 22.

(Communication Skills, HIV/AIDS, United States)
BACKGROUND: Partnership is integral to therapeutic relationships, yet few studies have examined partnership-fostering communication behaviors in the clinic setting. We conducted this study to better understand how statements in which physicians use the first person plural might foster partnership between patient and provider. METHODS: We audio-recorded encounters between 45 HIV providers and 418 patients in the Enhancing Communication and HIV Outcomes (ECHO) Study. We used the Roter Interaction Analysis System (RIAS) to code for statements made by the physician that used the first person plural to refer to themselves and their patient. Using multiple logistic regression, we examined the associations between the occurrence of one or more first person plural statements with patient ratings of provider communication. To better understand the meaning of first person plural statements, we conducted a qualitative analysis. MAIN RESULTS: Providers were mostly white (69%) and Asian (24%); 57% were female. Patients were black (60%), white (25%), and Hispanic (15%); 33% were female. One or more first person plural statements occurred in 92/418 (22%) of encounters. In adjusted analyses, encounters with first person plural statements were associated with younger patient age (OR 0.97, 95% CI 0.94-0.99), higher patient depression scores (highest tertile compared to lowest tertile: OR 1.89, 95% CI 1.01-3.51), the patient not being on anti-retroviral therapy (OR 0.53, 95% CI 0.29-0.93), and older provider age (OR 1.05, 95% CI 1.00-1.09). After adjustment, patients were less likely to highly rate their provider's communication style if first person plural statements were used (AOR 0.57, 95% CI 0.33-0.96). There were 167 first person plural statements made by physicians in the 418 encounters. Qualitative analysis revealed that many first person plural features had at least one negative feature such as being overtly persuasive ("That's going to be our goal"), indirect ("What can we do to improve your diet?"), or ambiguous ("Let's see what we can do"), although there were also positive statements that involved patients in the health-care process, contributed to a mutual understanding, and addressed the patients' goals. CONCLUSIONS: Contrary to our hypotheses, use of first person plural was not associated with higher ratings of provider communication, probably because some of these statements were overtly persuasive, indirect, or ambiguous. Physicians should become aware of benefits and pitfalls of using the first person plural with patients. Further research is needed to determine the most effective methods through which providers can build alliances with patients.

Krupat E, Frankel R, Stein T, Irish J. The Four Habits Coding Scheme: Validation of an instrument to assess clinicians' communication behavior. Patient Educ. Couns. 2006 Jul;62(1):38-45.
(Communication Skills, United States)
OBJECTIVE: To present preliminary evidence for the reliability and validity of the Four Habits Coding Scheme (4HCS), an instrument based on a teaching model used widely throughout Kaiser Permanente to improve clinicians' communication skills. METHODS: One hundred videotaped primary care visits were coded using the 4HCS, and the data were assessed against a previously available data set for these visits, including the Roter Interaction Analysis System (RIAS), back channel responses, measures of nonverbal behavior, length of visit, and patients' post-visit assessments. RESULTS: Levels of inter-rater reliability were acceptable, and the distribution of ratings across items indicated that physicians' modal responses varied widely. Correlations between 4HCS ratings, RIAS, back channel responses, and non-verbal measures provided evidence of the instrument's construct validity. CONCLUSIONS: The Four Habits Coding Scheme, an instrument that combines both evaluative and descriptive elements of physician communication behavior and is derived from a conceptually based teaching model, has the potential to be of utility to researchers and evaluators as well as educators and clinicians. PRACTICE IMPLICATIONS: The Four Habits Coding Scheme provides a template for both guiding and measuring physician communication behaviors.

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. Epub 2010 Jul 16.
(Communication Skills Training, Oncology, Switzerland)
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.

Kubota Y, Yano Y, Seki S, Takada K, Sakuma M, Morimoto T, Akaike A, Hiraide A. Assessment of pharmacy students' communication competence using the Roter Interaction Analysis System during objective structured clinical examinations. Am J Pharm Educ. 2011 Apr 11;75(3):43.
(Pharmacy, Communication Skills, Japan)
OBJECTIVE: To determine the value of using the Roter Interaction Analysis System during objective structured clinical examinations (OSCEs) to assess pharmacy students' communication competence. METHODS: As pharmacy students completed a clinical OSCE involving an interview with a simulated patient, 3 experts used a global rating scale to assess students' overall performance in the interview, and both the student's and patient's languages were coded using the Roter Interaction Analysis System (RIAS). The coders recorded the number of utterances (ie, units of spoken language) in each RIAS category. Correlations between the raters' scores and the number and types of utterances were examined. RESULTS: There was a significant correlation between students' global rating scores on the OSCE and the number of utterances in the RIAS socio-emotional category but not the RIAS business category. CONCLUSIONS: The RIAS proved to be a useful tool for assessing the socio-emotional aspect of students' interview skills.

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.

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.

Newes-Adeyi G, Heliter DL, Roter DL, Caulfield LE. Improving client-provider communication: evaluation of a training program for women, infants and children (WIC) professionals in New York State. Patient Educ Couns 2004 Nov;55(2):210-7.
(Communication Skills Training, United States)
Results are presented from evaluation of an intensive 1 day training program to improve the growth monitoring counseling skills of Special Supplemental Nutrition Program for Women, Infant and Children (WIC) providers. The training was framed by the patient-centered approach, and focused on a seven-step technique that emphasized eliciting client perspective on the child’s health and negotiating follow-up strategies. Changes in skill were assessed during audio taped mock counseling sessions with simulated clients. Observed intervention effects were moderate but encouraging for future training programs. After the training, more providers elicited client perspective, and provider level of engagement in negotiating with the client increased. At post-test providers asked more open-ended questions that at pre-test, and provider-to-client talk ratio decreased. Increases in provider total and competence-related satisfaction paralleled improvements in counseling proficiency. Study results suggest that counseling skills of non-physician health providers can change after a 1 day focused training: providers were more client-centered in their discussions.

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.

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 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, 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, 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 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, 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.

Shaw JR, Barley GE, Hill AE, Larson S, Roter DL. Communication skills education onsite in a veterinary practice. Patient Educ Couns. 2010 Sep;80(3):337-44. Epub 2010 Jul 6.
(Veterinary Medicine, Communication Skills Training, United States)
OBJECTIVE: To provide communication skills education to veterinary professionals in the practice setting and evaluate the training by measuring veterinarian communication pre- and post-intervention. METHODS: This is a case-based pre-test/post-test intervention study of a veterinary practice in Denver, CO. Four veterinarians from a single practice and 48 clients (selected to represent wellness and problem visits) were recruited to the study. The veterinarians took part in a training intervention consisting of a year-long curriculum, including interactive communication modules, individual coaching and communication laboratories. Six visit interactions were measured for each of the 4 veterinarians pre- and post-skill training. The Roter interaction analysis system (RIAS) was used to analyze the study's 48 videotapes. RESULTS: Compared to the pre-training visits, veterinarians gathered twice as much lifestyle-social data (p < 0.02), and used 1.5 times more partnership building (p < 0.03) and positive rapport-building (p < 0.01) communication. Clients provided 1.4 times more lifestyle/social information (p < 0.02) and expressed 1.7 times more emotional statements (p < 0.01) in post-training visits. CONCLUSION: The training intervention promoted a more client-centered approach to veterinarian-client communication. PRACTICE IMPLICATIONS: Practice-based communication training is novel to veterinary practice. As a case study, generalization of the findings are limited, however the findings support the efficacy of the communication intervention and enhanced utilization of veterinarian-client communication skills by these veterinarians.

Shaw JR, Barley GE, Hill AE, Larson S, Roter DL. Communication skills education onsite in a veterinary practice. Patient Educ Couns. 2010 Sep;80(3):337-44. Epub 2010 Jul 6.
(Communication Skills Training, Veterinary Medicine, United States)
OBJECTIVE: To provide communication skills education to veterinary professionals in the practice setting and evaluate the training by measuring veterinarian communication pre- and post-intervention. METHODS: This is a case-based pre-test/post-test intervention study of a veterinary practice in Denver, CO. Four veterinarians from a single practice and 48 clients (selected to represent wellness and problem visits) were recruited to the study. The veterinarians took part in a training intervention consisting of a year-long curriculum, including interactive communication modules, individual coaching and communication laboratories. Six visit interactions were measured for each of the 4 veterinarians pre- and post-skill training. The Roter interaction analysis system (RIAS) was used to analyze the study's 48 videotapes. RESULTS: Compared to the pre-training visits, veterinarians gathered twice as much lifestyle-social data (p < 0.02), and used 1.5 times more partnership building (p < 0.03) and positive rapport-building (p < 0.01) communication. Clients provided 1.4 times more lifestyle/social information (p < 0.02) and expressed 1.7 times more emotional statements (p < 0.01) in post-training visits. CONCLUSION: The training intervention promoted a more client-centered approach to veterinarian-client communication. PRACTICE IMPLICATIONS: Practice-based communication training is novel to veterinary practice. As a case study, generalization of the findings are limited, however the findings support the efficacy of the communication intervention and enhanced utilization of veterinarian-client communication skills by these veterinarians.

Shaw WS, Pransky G, Roter DL, Winters T, Tveito TH, Larson SM. The effects of patient-provider communication on 3-month recovery from acute low back pain. J Am Board Fam Med. 2011 Jan-Feb;24(1):16-25.
(Work-Related Health, Communication, United States)
BACKGROUND: patient-provider communication has been indicated as a key factor in early recovery from acute low back pain (LBP), one of the most common maladies seen in primary care; however, associations between communication and LBP outcomes have not been studied prospectively. METHODS: working adults (n = 97; 64% men; median age, 38 years) with acute LBP completed baseline surveys, agreed to audio recording of provider visits, and were followed for 3 months. Using the Roter Interaction Analysis System, 10 composite indices of communication were compared with 1- and 3-month patient outcomes. RESULTS: patients (n = 30) with significant pain and dysfunction persisting at 3 months provided more biomedical information (t[75], 2.61; P < .05) and engaged in more negative rapport building (t[75], 2.33; P < .05) but showed no increase in psychosocial/lifestyle communication during the initial visit (P > .05). Providers asked these patients more biomedical questions (r = 0.35 with dysfunction), more psychosocial/lifestyle questions (r = 0.30), made more efforts to engage the patient (t[75], 4.49; P < .05), and did more positive rapport building (t[75], 2.13; P < .05). CONCLUSIONS: providers adapt their communication patterns to collect more information and establish greater rapport with high-risk patients, but patients focus more on biomedical than coping concerns. To better elicit psychosocial concerns from patients, providers may need to administer brief self-report measures or adopt more structured interviewing techniques.

Wissow L, Gadomski A, Roter D, Larson S, Lewis B, Brown J. Aspects of mental health communication skills training that predict parent and child outcomes in pediatric primary care. Patient Educ Couns. 2011 Feb;82(2):226-32. Epub 2010 May 5.
(Communication Skills/ Training, Pediatrics, Adolescent Medicine, Mental Health, United States)
OBJECTIVE: Training in communication can change clinician behaviors, but brief training may function by altering attitudes rather than teaching new skills. We used data from a trial of mental health training for office-based primary care to determine indicators of uptake that predicted parent and child outcomes. METHODS: Clinicians (n=50) were randomized to be controls or receive training. Uptake was determined comparing pre- and post-training visits with standardized patients (SPs) coded for skills and patient centeredness. Clinical outcomes were assessed by recruiting and following 403 children/youth ages 5-16 making visits to participants. At 6 months, change in mental health was assessed by parent and youth reports using the Strengths and Difficulties Questionnaire. RESULTS: Trained clinicians used more agenda setting, time, and anger management skills than controls and showed increased patient centeredness toward SP parents, but not adolescents. Increased patient-centeredness toward parents predicted improvement in child/youth symptoms and functioning (rated by parents), and improvement in youth-rated symptoms. Increased skills alone were not associated with improvement, but patients of clinicians above the mean for both skill and patient-centeredness change improved most.

Wissow LS, Roter D, Larson SM, Wang MC, Hwang WT, Johnson R, Luo X. Mechanisms behind the failure of residents' longitudinal primary care to promote disclosure and discussion of psychosocial issues. Arch Pediatr Adolesc Med. 2002 Jul;156(7):685-92.
(Communication Skills/Training, Pediatrics, Patient Distress/Cues, United States)
CONTEXT: Longitudinality (care by a single physician over time) and continuity (receipt of most care from a single physician) are believed to enhance patient-physician relationships and facilitate disclosure of emotional distress, but some studies suggest this potential goes unrealized. OBJECTIVES: To determine whether care in a pediatric residents' continuity clinic promotes, over time, increased discussion, disclosure, and detection of parents' social and emotional distress and to understand physicians' communication behaviors underlying changes with time. DESIGN: Longitudinal, observational study of parent-physician interaction over the course of 1 year. PARTICIPANTS: One hundred ninety parents (90% African American) and their infants' primary care physicians (31 [4 Asians and 27 whites] first- and second-year pediatric residents). MAIN OUTCOME MEASURES: Frequency with which parents and physicians raised topics related to parental mood and family or social functioning; proportion of distressed parents discussing mood or functioning; and physicians' detection of parent distress. RESULTS: Physician initiation of psychosocial topics fell in the course of longitudinal relationships (odds of initiation in visits > or =6 vs odds of initiation in visits 1-5 = 0.46 [95% confidence limits, 0.31%, 0.67%]); parent initiation did not change over time nor was it increased by greater levels of continuity. Length of relationship was not associated with increased physician detection of parental distress or with increased rates of disclosure by distressed parents. Physicians' positively framed leading questions, and their avoidant responses to prior parental disclosures were significantly associated with decreased odds of problem disclosure. In contrast, visits in which parents or physicians raised psychosocial topics were characterized, on average, by 40% higher levels of physicians' "patient-centeredness" (increases of about 100 utterances per visit [95% confidence limits, 65.7%, 133.9%]). CONCLUSIONS: Longitudinal relationships between residents and patients may not be sufficient to promote the discussion, disclosure, and detection of psychosocial issues. Training in communication skills may help residents achieve the potential and goals of longitudinal care.

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