RIAS Works - Resources by Subject

Patient Satisfaction / Patient Recall

Agha Z, Schapira RM, Laud PW, McNutt G, Roter DL. Patient satisfaction with physician-patient communication during telemedicine. Telemed J E Health. 2009 Nov;15(9):830-9.
(Telemedicine, Patient Satisfaction, United States)
The quality of physician-patient communication is a critical factor in treatment outcomes and patient satisfaction with care. To date, few studies have specifically conducted an in-depth evaluation of the effect of telemedicine (TM) on physician-patient communication in a medical setting. Our objective was to determine whether physical separation and technology used during TM have a negative effect on physician-patient communication. In this noninferiority randomized clinical trial, patients were randomized to receive a single consultation with one of 9 physicians, either in person (IP) or via TM. Patients (n = 221) were recruited from pulmonary, endocrine, and rheumatology clinics at a Midwestern Veterans Administration hospital. Physician-patient communication was measured using a validated self-report questionnaire consisting of 33 items measuring satisfaction with visit convenience and physician's patient-centered communication, clinical competence, and interpersonal skills. Satisfaction for physician's patient-centered communication was similar for both consultation types (TM = 3.76 versus IP = 3.61), and noninferiority of TM was confirmed (noninferiority t-test p = 0.002). Patient satisfaction with physician's clinical competence (TM = 4.63 versus IP = 4.52) and physician's interpersonal skills (TM = 4.79 versus IP = 4.74) were similar, and noninferiority of TM was confirmed (noninferiority t-test p = 0.006 and p = 0.04, respectively). Patients reported greater satisfaction with convenience for TM as compared to IP consultations (TM = 4.41 versus IP = 2.37, noninferiority t-test p < 0.001). Patients were equally satisfied with physician's ability to develop rapport, use shared decision making, and promote patient-centered communication during TM and IP consultations. Our data suggest that, despite physical separation, physician-patient communication during TM is not inferior to communication during IP consultations.

Bernhardt BA, Geller G, Doksum T, Larson SM, Roter D, Holtzman NA. Prenatal genetic testing: content of discussions between obstetric providers and pregnant women. Obstet Gynecol 1998 May;91(5 Pt 1): 648-55.
(Patient Satisfaction, United States)
OBJECTIVE: To document the content and accuracy of discussions about prenatal genetic testing between obstetric providers and pregnant women. METHODS: The first prenatal visits of 169 pregnant women with 21 obstetricians and 19 certified nurse-midwives were audiotaped and analyzed for whether a discussion of family history or genetic testing took place and if so, its length, content, and accuracy. RESULTS: Family history was discussed in 60% of visits, maternal serum marker screening in 60%, second-trimester ultrasonography for fetal anomalies in 34%, and for women at least 35 years old, amniocentesis or chorionic villus sampling (CVS) in 98%. The length of discussions of genetic testing averaged 2.5 minutes for women younger than 35 years of age and 6.9 minutes for older women. Topics discussed most often were the practical details of testing, the purpose of testing, and the fact that testing is voluntary. Discussions seldom were comprehensive. Obstetricians were more likely to make a recommendation about testing than were nurse-midwives and were less likely to indicate that testing is voluntary. Most women were satisfied with the amount of information, and the majority of women of advanced maternal age had made a decision about amniocentesis or CVS by the end of the visit. CONCLUSION: The information about genetic testing provided in the first prenatal visit is inadequate for ensuring informed autonomous decision-making. Guidelines addressing the content of these discussions should be developed with input from obstetricians, nurse-midwives, genetic counselors, and pregnant women.

Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract 1991 Feb; 32(2):175-81.
(Patient Recall and Satisfaction, Primary Care, United States)
The results of previous studies on the relationship between patient satisfaction and specific interviewing behaviors have been difficult to generalize because most studies have examined small samples of patients at one clinical location, and have used initial or acute care visits where the patient and physician did not have an established relationship. The present collaborative study of medical interviewing provided an opportunity to collect interviews from 550 return visits to 127 different physicians at 11 sites across the country. Tape recordings were analyzed using the Roter Interaction Analysis System, and postvisit satisfaction questionnaires were administered to patients. A number of significant relationships were found between communication during the visit and the various dimensions of patient satisfaction. Physician question asking about biomedical topics (both open- and closed-ended questions) was negatively related to patient satisfaction; however, physician question asking about psychosocial topics was positively related. Physician counseling for psychosocial issues was also positively related to patient satisfaction. Similarly, patient talk about biomedical topics was negatively related to satisfaction, while patient talk regarding psychosocial topics was positively related. Furthermore, patients were less satisfied when physicians dominated the interview by talking more or when the emotional tone was characterized by physician dominance. The findings suggest that patients are most satisfied by interviews that encourage them to talk about psychosocial issues in an atmosphere that is characterized by the absence of physician domination.

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.

Carter WB, Inui TS, Kukull WA, Haigh VH. Outcome-based doctor-patient interaction analysis: II.Identifying effective provider and patient behavior. Med Care 1982 Jun;20(6):550-66.
(Patient Recall or Satisfaction, Primary Care, United States)
Three interactional analysis (IA) systems (Bales', Roter’s modified Bales, and Stiles' "Verbal response modes") were used to characterize behavioral elements of provider-patient dialogues of 101 new-patient visits in a general medical clinic. In a previous article, the explanatory power of these IA systems was compared. In this article, specific provider and patient behaviors within segments of the encounter (introduction-history, physical examination and conclusion), which were shown to be related to encounter outcomes of knowledge, compliance and satisfaction, were examined. Review of interactional behaviors entering regression analysis with a significant F-to-enter (p less than or equal to 0.05) and supplementary contextual analyses suggested the importance of several categories of physician and patient behavior. Behaviors manifesting tension bear important and complex relationships to encounter outcomes. For example, patient and physician expressions of tension generally bear strong negative relationships to patient satisfaction, while patient expressions interpreted as tension release are positively related to both satisfaction and compliance. The timing of other behaviors appears to be critical to subsequent outcomes. If patient requests for medication occur early in the encounter, this behavior is positively related to subsequent patient satisfaction. However, if they occur in the concluding segment, a negative relationship results. Finally, several relationships taken together indicate that physician teaching in the concluding segment may be important. While useful observations may emerge from application of currently available IA techniques, the resulting information is best characterized as hypothesis-generating. These IA systems have many limitations, and research is needed to derived more clinically oriented systems that may permit more consistent demonstrations of critical process-outcome relationships.

Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003 Dec 2;139(11):907-15.
(Primary Care, Race-Concordance, Patient Satisfaction, United States)
BACKGROUND: African-American patients who visit physicians of the same race rate their medical visits as more satisfying and participatory than do those who see physicians of other races. Little research has investigated the communication process in race-concordant and race-discordant medical visits. Objectives: To compare patient-physician communication in race-concordant and race-discordant visits and examine whether communication behaviors explain differences in patient ratings of satisfaction and participatory decision making. DESIGN: Cohort study with follow-up using previsit and postvisit surveys and audiotape analysis. SETTING: 16 urban primary care practices. PATIENTS: 252 adults (142 African-American patients and 110 white patients) receiving care from 31 physicians (of whom 18 were African-American and 13 were white). MEASUREMENTS: Audiotape measures of patient-centeredness, patient ratings of physicians' participatory decision-making styles, and overall satisfaction. RESULTS: Race-concordant visits were longer (2.15 minutes [95% CI, 0.60 to 3.71]) and had higher ratings of patient positive affect (0.55 point, [95% CI, 0.04 to 1.05]) compared with race-discordant visits. Patients in race-concordant visits were more satisfied and rated their physicians as more participatory (8.42 points [95% CI, 3.23 to 13.60]). Audiotape measures of patient-centered communication behaviors did not explain differences in participatory decision making or satisfaction between race-concordant and race-discordant visits. CONCLUSIONS: Race-concordant visits are longer and characterized by more patient positive affect. Previous studies link similar communication findings to continuity of care. The association between race concordance and higher patient ratings of care is independent of patient-centered communication, suggesting that other factors, such as patient and physician attitudes, may mediate the relationship. Until more evidence is available regarding the mechanisms of this relationship and the effectiveness of intercultural communication skills programs, increasing ethnic diversity among physicians may be the most direct strategy to improve health care experiences for members of ethnic minority groups.

Eide H, Graugaard P, Holgersen K, Finset A. Physician communication in different phases of a consultation at an oncology outpatient clinic related to patient satisfaction. Patient Educ Couns. 2003 Nov;51(3):259-66.
(Oncology, Patient Satisfaction, Norway)
The aim of this study was to identify the relationship between content during the different phases of the consultation and overall patient satisfaction with regular follow-up consultations at a cancer outpatient clinic. Thirty-six consultations were analysed with Roter Interaction Analysis System (RIAS). In the statistical analysis, timed events of the RIAS categories were used. The regular follow-up consultations were rather short aiming at discussing medical and therapeutic aspects of the illness. There was a positive correlation between physician informal talk (IT) and patient satisfaction in the history-taking phase. Patients were found to be dissatisfied if the physician had focused on a great deal of psychosocial exchange (PE) during physical examination. Our study suggests that the physician should not initiate discussion of psychosocial topics during physical exam. This result should be studied further in other samples and designs.

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

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

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

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

Inui TS, Carter WB, Kukull WA, Haigh VH. Outcome-based doctor-patient interaction analysis: I Comparison of techniques. Med Care 1982 Jun;20(6):535-49.
(Patient Recall or Satisfaction, United States)
Interactional analysis (IA) systems have been devised and applied to doctor-patient dialogues to describe encounters and to relate process to outcomes. Prior work in this area has been typified by the use of a single taxonomy for classifying verbal behaviors and limited outcomes (compliance and/or satisfaction). We applied three different IA systems (Bales, Roter's modified Bales with affective ratings, and Stiles' "Verbal Response Modes") to 101 new-patient visits to a general medical clinic for which multiple outcomes had been determined: several measures of patient knowledge of problems at conclusion of visit; patient compliance with drugs (over the ensuing three months); and patient satisfaction with the visit (perceived technical, interpersonal and communication quality). Within IA systems, cross tabulations and multiple regressions were performed to relate encounter events to outcomes. Across IA systems, multiple regression R2 and R2 adjusted (R2a) for the number of independent variables entering were used to characterize strength of relationships. Roter's IA system showed stronger relationships to outcomes of knowledge (41% R2, 27% R2a) and compliance (44% R2, 28% R2a) than did Bales' or Stiles' systems. R2 for patient satisfaction was identical for Bales and Roter (35%), and greater than R2 for Stiles (14%). We conclude that choice of IA system for research or teaching purposes should be based on behaviors and outcomes of particular interest and importance to the user. Based on audioreview of tapes, Roter's approach is less time-consuming and may perform as well as more complex systems requiring transcript analysis.

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. 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, 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 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, 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.

Sala F, Krupat E, Roter D. Satisfaction and the use of humor by physicians and patients. Psychology and Health 2002:17(3):269-280.
(Patient Satisfaction, United States)
The current study investigated the extent to which various types of humor are associated with high- and low-satisfaction doctor visits and whether male and female physicians and patients differ in their use of humor. A humor coding scheme, capable of distinguishing three categories (negative, positive, and general) and ten sub-types of humor, was validated against 92 audiotaped physician-patient primary care visits, half rated high and half rated low in satisfaction. Results revealed that physicians and patients used more light humor, more humor that relieves tension, more self-effacing humor, and more positive-function humor in high satisfaction than in low-satisfaction visits. In addition, the patients of female physicians used more humor than the patients of male physicians across levels of satisfaction. The results indicate a strong association between humor and satisfaction, and suggest ways in which humor and laughter help to maintain rapport in the physician-patient relationship.

Thornton RL, Powe NR, Roter D, Cooper LA. Patient-physician social concordance, medical visit communication and patients' perceptions of health care quality. Patient Educ Couns. 2011 Dec;85(3):e201-8. Epub 2011 Aug 12.

(Race/Cross-Culture, Patient Satisfaction, United States)
Social characteristics (e.g. race, gender, age, education) are associated with health care disparities. We introduce social concordance, a composite measure of shared social characteristics between patients and physicians. OBJECTIVE: To determine whether social concordance predicts differences in medical visit communication and patients' perceptions of care. METHODS: Regression analyses were used to determine the association of patient-provider social concordance with medical visit communication and patients' perceptions of care using data from two observational studies involving 64 primary care physicians and 489 of their patients from the Baltimore, MD/Washington, DC/Northern Virginia area. RESULTS: Lower patient-physician social concordance was associated with less positive patient perceptions of care and lower positive patient affect. Patient-physician dyads with low vs. high social concordance reported lower ratings of global satisfaction with office visits (OR=0.64 vs. OR=1.37, p=0.036) and were less likely to recommend their physician to a friend (OR=0.61 vs. OR=1.37, p=0.035). A graded-response was observed for social concordance with patient positive affect and patient perceptions of care. CONCLUSION: Patient-physician concordance across multiple social characteristics may have cumulative effects on patient-physician communication and perceptions of care. PRACTICE IMPLICATIONS: Research should move beyond one-dimensional measures of patient-physician concordance to understand how multiple social characteristics influence health care quality.

van den Brink-Muinen A, Verhaak PF, Bensing JM, Bahrs O, Deveugele M, Gask L, Leiva F, Mead N, Messerli V, Oppizzi L, Peltenburg M, Perez A. Doctor-patient communication in different European health care systems: relevance and performance from the patients' perspective. Patient Educ Couns. 2000 Jan;39(1):115-27.
(Patient Recall or Satisfaction, Netherlands)
Our aim is to investigate differences between European health care systems in the importance attached by patients to different aspects of doctor-patient communication and the GPs' performance of these aspects, both being from the patients' perspective. 3658 patients of 190 GPs in six European countries (Netherlands, Spain, United Kingdom, Belgium, Germany, Switzerland) completed pre- and post-visit questionnaires about relevance and performance of doctor-patient communication. Data were analyzed by variance analysis and by multilevel analysis. In the non-gatekeeping countries, patients considered both biomedical and psychosocial communication aspects to be more important than the patients in the gatekeeping countries. Similarly, in the patients' perception, the non-gatekeeping GPs dealt with these aspects more often. Patient characteristics (gender, age, education, psychosocial problems, bad health, depressive feelings, GPs' assessment of psychosocial background) showed many relationships. Of the GP characteristics, only the GPs' psychosocial diagnosis was associated with patient-reported psychosocial relevance and performance. Talking about biomedical issues was more important for the patients than talking about psychosocial issues, unless the patients presented psychosocial problems to the GP. Discrepancies between relevance and performance were apparent, especially with respect to biomedical aspects. The implications for health policy and for general practitioners are discussed.

Wissow LS, Roter D, Bauman LJ, Crain E, Kercsmar C, Weiss K, Mitchel, H, Mohr B. Patient-provider communication during the emergency department care of children with asthma. The National Cooperative Inner-City Asthma Study. Med Care 1998 Oct;36(10):1439-50.
(Pediatrics, Patient Satisfaction or Recall, United States)
OBJECTIVES: Poor children's reliance on emergency facilities is one factor implicated in the rise of morbidity attributed to asthma. Although studies have examined doctor-patient communication during routine pediatric visits, little data are available about communication during emergency care. This study sought to describe communication during emergency treatment of childhood asthma to learn if a "patient-centered" provider style was associated with increased parent satisfaction and increased parent and child participation. METHODS: This cross-sectional, observational study examined 104 children aged 4 to 9 years and their guardian(s) attending emergency departments in seven cities. Quantitative analysis of provider-family dialogue was performed. Questionnaires measured satisfaction with care, provider informativeness, and partnership. RESULTS: Providers' talk to children was largely supportive and directive; parents received most counseling and information. Children spoke little to providers (mean: 20 statements per visit versus 156 by parents). Providers made few statements about psychosocial aspects of asthma care (mean: three per visit). Providers' patient-centered style with parents was associated with more talk from parents and higher ratings for informativeness and partnership. Patient-centered style with children was associated with five times the amount of talk from children and with higher parent ratings for "good care," but not for informativeness or partnership. CONCLUSIONS: Communication during emergency asthma care was overwhelmingly biomedical. Children took little part in discussions. A patient-centered style correlated with increased parent and child participation, but required directing conversation toward both parents and children.

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