Debra Roter - Academia.edu (original) (raw)

Papers by Debra Roter

Journal of General Internal Medicine, Feb 8, 2008

BACKGROUND: Physician communication style affects patients' perceptions and behaviors. Two aspect... more BACKGROUND: Physician communication style affects patients' perceptions and behaviors. Two aspects of physician communication style, caring and dominance, are often related in that a high caring physician is usually not dominant and vice versa. OBJECTIVE: This research was aimed at testing the sole or joint impact of physician caring and physician dominance on participant perceptions and behavior during the medical visit. PARTICIPANTS AND DESIGN: In an experimental design, analog patients (APs) (167 university students) interacted with a computer-generated virtual physician on a computer screen. Participants were randomly assigned to 1 of 4 experimental conditions (physician communication style: high dominance and low caring, high dominance and high caring, low dominance and low caring, or low dominance and high caring). The APs' verbal and nonverbal behavior during the visit as well as their perception of the virtual physician were assessed. RESULTS: Analog patients were able to distinguish dominance and caring dimensions of the virtual physician's communication. Moreover, APs provided less medical information, spoke less, and agreed more when interacting with a high-dominant compared to a lowdominant physician. They also talked more about emotions and were quicker in taking their turn to speak when interacting with a high-caring compared to a lowcaring physician. CONCLUSIONS: Dominant and caring physicians elicit different emotional and behavioral responses from APs. Physician dominance reduces patient engagement in the medical dialog and produces submissiveness, whereas physician caring increases patient emotionality.

Health Communication, 2014

The goal was to explore the clinical relevance of accurate understanding of patients' thoughts an... more The goal was to explore the clinical relevance of accurate understanding of patients' thoughts and feelings. Between 2010 and 2012, four groups of participants (nursing students, medical students, internal medicine residents, and undergraduate students) took a test of accuracy in understanding the thoughts and feelings of patients who were videorecorded during their actual medical visits and who afterward reviewed their video to identify their thoughts and feelings as they occurred (Test of Accurate Perception of Patients' Affect, or TAPPA). Participants' accuracy scores were then correlated with participants' attitudes toward

Journal of General Internal Medicine, 2008

BACKGROUND: Physician communication style affects patients' perceptions and behaviors. Two aspect... more BACKGROUND: Physician communication style affects patients' perceptions and behaviors. Two aspects of physician communication style, caring and dominance, are often related in that a high caring physician is usually not dominant and vice versa. OBJECTIVE: This research was aimed at testing the sole or joint impact of physician caring and physician dominance on participant perceptions and behavior during the medical visit. PARTICIPANTS AND DESIGN: In an experimental design, analog patients (APs) (167 university students) interacted with a computer-generated virtual physician on a computer screen. Participants were randomly assigned to 1 of 4 experimental conditions (physician communication style: high dominance and low caring, high dominance and high caring, low dominance and low caring, or low dominance and high caring). The APs' verbal and nonverbal behavior during the visit as well as their perception of the virtual physician were assessed. RESULTS: Analog patients were able to distinguish dominance and caring dimensions of the virtual physician's communication. Moreover, APs provided less medical information, spoke less, and agreed more when interacting with a high-dominant compared to a lowdominant physician. They also talked more about emotions and were quicker in taking their turn to speak when interacting with a high-caring compared to a lowcaring physician. CONCLUSIONS: Dominant and caring physicians elicit different emotional and behavioral responses from APs. Physician dominance reduces patient engagement in the medical dialog and produces submissiveness, whereas physician caring increases patient emotionality.

Social Science & Medicine, 2011

Older adults are commonly accompanied to routine physician visits, primarily by adult children an... more Older adults are commonly accompanied to routine physician visits, primarily by adult children and spouses. This is the first review of studies investigating the dynamics and consequences of patient accompaniment. Two types of evidence were examined: (1) observational studies of audio and/or videotaped medical visits, and (2) surveys of patients, families, or health care providers that ascertained experiences, expectations, and preferences for family companion presence and behaviors in routine medical visits. Meta-analytic techniques were used to summarize the evidence describing attributes of unaccompanied and accompanied patients and their companions, medical visit processes, and patient outcomes. The weighted mean rate of patient accompaniment to routine adult medical visits was 37.6% in 13 contributing studies. Accompanied patients were significantly older and more likely to be female, less educated, and in worse physical and mental health than unaccompanied patients. Companions were on average 63 years of age, predominantly female (79.4%), and spouses (54.7%) or adult children (32.2%) of patients. Accompanied patient visits were significantly longer, but verbal contribution to medical dialogue was comparable when accompanied patients and their family companion were compared with unaccompanied patients. When a companion was present, health care providers engaged in more biomedical information giving. Given the diversity of outcomes, pooled estimates could not be calculated: of 5 contributing studies 0 were unfavorable, 3 inconclusive, and 2 favorable for accompanied relative to unaccompanied patients. Study findings suggest potential practical benefits from more systematic recognition and integration of companions in health care delivery processes. We propose a conceptual framework to relate family companion presence and behaviors during physician visits to the quality of interpersonal health care processes, patient self management and health care.

Patient Education and Counseling, 2018

Objective-Apply turn analysis to family conferences in the pediatric intensive care unit. Methods... more Objective-Apply turn analysis to family conferences in the pediatric intensive care unit. Methods-We analyzed 39 audio-recorded family conferences using the Roter Interaction Analysis System. A turn was defined as a continuous block of uninterrupted statements by a speaker. Results-Opening turns by the healthcare team (HCT) averaged 207 seconds, compared to 28 seconds for families. Turn density (number of statements/turn) was 6 for the HCT versus 2 for families (p<0.0001). An average of 21 turns (26%) occurred between HCT members, resulting in substantial sections of dialogue excluding the family. Average HCT dialogue reflected a literacy demand of a 9 th grade level, whereas family dialogue averaged a 5 th grade level (p<0.0001). More HCT turns were related to higher reading level demand (r = 0.34; p=0.03) and lower levels of patient-centeredness (r = −0.35, p=0.03).

Patient Education and Counseling, 2017

Objective-We examined the prevalence and extent of informed decision-making (IDM) and patient-cen... more Objective-We examined the prevalence and extent of informed decision-making (IDM) and patient-centered decision-making (PCDM) in primary care visits of African Americans with depression. Methods-We performed a cross-sectional analysis of audiotaped clinical encounters and postvisit surveys of 76 patients and their clinicians. We used RIAS to characterize patient-centeredness of visit dialogue. IDM entailed discussion of 3 components: the nature of the decision, alternatives, and pros/cons. PCDM entailed discussion of: lifestyle/coping strategies, knowledge/ beliefs, or treatment concerns. We examined the association of IDM and PCDM with visit duration, overall patient-centeredness, and patient/clinician interpersonal ratings. Results-Approximately one-quarter of medication and counseling decisions included essential IDM elements and 40% included at least one PCDM element. In high patient-centered visits, IDM was associated with patients feeling respected in counseling and liking clinicians in medication decisions. IDM was not related to clinician ratings. In low patient-centered visits, PCDM in counseling decisions was positively associated with patients feeling respected and clinicians respecting patients.

Patient Education and Counseling, 2017

This study was designed to address significant gaps in the predominantly western-centric research... more This study was designed to address significant gaps in the predominantly western-centric research literature by examining the influence of gender concordance in medical communication and patient satisfaction within the Japanese context. Methods: New primary care patients (54 male and 49 female) were randomly assigned to study internists (6 males and 5 females). Recorded visits were coded with the Roter Interaction Analysis System (RIAS). Post-visit, patients completed a Japanese version of the Medical Interview Satisfaction Scale (MISS). Results: Female concordant visits showed higher levels of patient-centeredness than all other gender combinations. Female physicians substantially modified their communication based on patient gender while male physicians did not. Gender concordance was associated with higher female, but lower male patient satisfaction relative to gender discordant visits. Conclusion: Contrary to normative experience of medicine as a male dominated profession in Japan, and gender-based power differentials, male-gendered clinical communication is less likely to satisfy male than female patients, while female-gendered communication is positively associated with female patient satisfaction. Practice implications: Patient satisfaction ratings reflect greater gender flexibility in terms of acceptable physician behavior than Japanese norms would suggest.

Psycho-oncology, Jun 20, 2016

To investigate how cancer patients, family caregiver, and their treating oncologist, view the ris... more To investigate how cancer patients, family caregiver, and their treating oncologist, view the risks and benefits of family involvement in cancer treatment decision making (TDM) or the degree to which these perceptions may differ. A nationwide, multicenter survey was conducted with 134 oncologists and 725 of their patients and accompanying caregivers. Participant answered to modified Control Preferences Scale and investigator-developed questionnaire regarding family involvement in cancer TDM. Most participants (>90%) thought that family should be involved in cancer TDM. When asked if the oncologist should allow family involvement if the patient did not want them involved, most patients and caregivers (>85%) thought they should. However, under this circumstance only 56.0% of oncologists supported family involvement. Patients were significantly more likely to skew their responses toward patient rather than family decisional control than were their caregivers (P < 0.003); oncol...

Patient education and counseling, Jan 20, 2015

Attitudes towards patients may influence how clinicians interact. We investigated whether respect... more Attitudes towards patients may influence how clinicians interact. We investigated whether respect for patients was associated with communication behaviors during HIV care encounters. We analyzed audio-recordings of visits between 413 adult HIV-infected patients and 45 primary HIV care providers. The independent variable was clinician-reported respect for the patient and outcomes were clinician and patient communication behaviors assessed by the Roter Interaction Analysis System (RIAS). We performed negative binomial regressions for counts outcomes and linear regressions for global outcomes. When clinicians had higher respect for a patient, they engaged in more rapport-building, social chitchat, and positive talk. Patients of clinicians with higher respect for them engaged in more rapport-building, social chitchat, positive talk, and gave more psychosocial information. Encounters between patients and clinicians with higher respect for them had more positive clinician emotional tone [...

Psycho-oncology, Jan 13, 2015

We aimed to compare the views of cancer patients, family caregivers, and oncologists about the di... more We aimed to compare the views of cancer patients, family caregivers, and oncologists about the disclosure of side effects in respect to their probability of occurrence, severity, and treatment purpose. We also compared attitudes toward potential harm of side effect disclosure, patients' perceived ability to understand the risk of the side effects, and informed decision-making regarding side effects. A national survey was performed with 750 patient-caregiver dyads (75.5% participation rate) recruited by 134 oncologists in 13 cancer centers (93% participation rate). Attitudes toward communication of side effects were assessed in terms of drug purpose, severity of potential complications, and probability of harm. Most patients (82.1-87.0%) and caregivers (75.9-81.5%) thought they should be informed of all possible drug side effects regardless of risk, severity, or drug purpose and wanted these risks to be communicated explicitly. Patients and their caregivers believed that detailed...

Patient Education and Counseling, 2015

Introduction-Medication adherence is essential in HIV care, yet provider communication about adhe... more Introduction-Medication adherence is essential in HIV care, yet provider communication about adherence is often suboptimal. We designed this study to improve patient-provider communication about HIV medication adherence. Methods-We randomized 26 providers at three HIV care sites to receive or not receive a onehour communication skills training based on motivational interviewing principles applied to medication adherence. Prior to routine office visits, non-adherent patients of providers who received the training were coached to discuss adherence with their providers. Patients of providers who did not receive the training providers were not coached. We audio-recorded and coded patient-provider interactions using the Roter Interaction Analysis System (RIAS).

Patient Education and Counseling, 2011

Social characteristics (e.g. race, gender, age, education) are associated with health care dispar... more 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=0.61vs. OR=1.37, p=0.035). A graded-response was observed for social concordance with patient positive affect and patient perceptions of care.

Patient Education and Counseling, 2007

Objective: The present study aimed to investigate the effect of physician sex and physician commu... more Objective: The present study aimed to investigate the effect of physician sex and physician communication style on patient satisfaction. In real medical visits, physician sex and physician communication style are confounded variables. By using the virtual medical visit paradigm, we were able to disentangle the two variables and study their separate and/or joint effects on patient satisfaction. Method: In an experimental design, analogue patients (167 students) interacted with a computer-generated virtual physician on a computer screen. The patients' satisfaction during the visit was assessed. Results: Depending on the sex composition of the dyad, physician communication style affected analogue patients' satisfaction differently. For instance, in male-male dyads, physician communication style did not affect the patients' satisfaction, whereas in female-female dyads, analogue patients were more satisfied when the physician adopted a caring as opposed to a non-caring communication style. Conclusion: Sex of the physician and sex of the patient moderate how different physician communication styles affect patient satisfaction. In particular, a female-sex role congruent communication style leads to higher patient satisfaction when women see a female physician. Practice implications: Physician communication training cannot be one size fits all. Rather female and male physicians should obtain different training and they need to be made aware of the fact that female and male patients harbor different expectations toward them.

Psychiatric Services, 2011

Pediatrics, 2008

OBJECTIVE. The goal was to investigate the impact of a computer-based documentation tool on paren... more OBJECTIVE. The goal was to investigate the impact of a computer-based documentation tool on parent-health care provider communication during a pediatric health maintenance encounter. METHODS. We used a quasiexperimental study design to compare communication dynamics between clinicians and parents/children in health maintenance visits before and after implementation of the ClicTate system. Before ClicTate use, paper forms were used to create visit notes. The children examined were ≤18 months of age. All encounters were audiotaped or videotaped. A team of research assistants blinded to group assignment reviewed the audio portion of each encounter. Data from all recordings were analyzed, by using the Roter Interaction Analysis System, for differences in the open/closed question ratio, the extent of information provided by parents and providers, and other aspects of spoken and nonverbal communication (videotaped encounters). RESULTS. Computer-based documentation visits were slightly lon...

Patient Education and Counseling, 2009

This article appeared in a journal published by Elsevier. The attached copy is furnished to the a... more This article appeared in a journal published by Elsevier. The attached copy is furnished to the author for internal non-commercial research and education use, including for instruction at the authors institution and sharing with colleagues. Other uses, including reproduction and distribution, or selling or licensing copies, or posting to personal, institutional or third party websites are prohibited. In most cases authors are permitted to post their version of the article (e.g. in Word or Tex form) to their personal website or institutional repository. Authors requiring further information regarding Elsevier's archiving and manuscript policies are encouraged to visit: http://www.elsevier.com/copyright

Patient Education and Counseling, 2011

Objective-To determine the efficacy and effectiveness of training to improve primary care provide... more 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 three 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 two years after the training.

Patient Education and Counseling, 2006

Objective-To explore the domain of physician-reported respect for individual patients by investig... more Objective-To explore the domain of physician-reported respect for individual patients by investigating the following questions: How variable is physician-reported respect for patients? What patient characteristics are associated with greater physician-reported respect? Do patients accurately perceive levels of physician respect? Are there specific communication behaviors associated with physician-reported respect for patients? Methods-We audiotaped 215 patient-physician encounters with 30 different physicians in primary care. After each encounter, the physician rated the level of respect that s/he had for that patient using the following item: "Compared to other patients, I have a great deal of respect for this patient" on a five-point scale between strongly agree and strongly disagree. Patients completed a post-visit questionnaire that included a parallel respect item: "This doctor has a great deal of respect for me." Audiotapes of the patient visits were analyzed using the Roter Interaction Analysis System (RIAS) to characterize communication behaviors. Outcome variables included four physician communication behaviors: information-giving, rapport-building, global affect, and verbal dominance. A linear mixed effects modeling approach that accounts for clustering of patients within physicians was used to compare varying levels of physician-reported respect for patients with physician communication behaviors and patient perceptions of being respected. Results-Physician-reported respect varied across patients. Physicians strongly agreed that they had a great deal of respect for 73 patients (34%), agreed for 96 patients (45%) and were either neutral or disagreed for 46 patients (21%). Physicians reported higher levels of respect for older patients and for patients they knew well. The level of respect that physicians reported for ✩ Prior presentations-These results have been presented in part at the following meetings:

Patient Education and Counseling, 2006

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

Patient Education and Counseling, 2014

Effective clinicians need to be aware of their patients' emotions, personality, cultural and pers... more Effective clinicians need to be aware of their patients' emotions, personality, cultural and personal background, values, and expectations. An ability to ''read'' the patient plays a role in accurate diagnosis, predicting and recognizing nonadherence, relationship quality, and recognizing how the patient is reacting to the clinician. Accurate perception of patients is routinely acknowledged in discussions of patient-centered practice [1-5]. Yet, compared to the huge volume of research on what clinicians say and do, there has been much less research on clinicians' accuracy in perceiving patients, on clinicians' accuracy of interpersonal perception in general, and on the correlates and consequences of their accuracy [6]. There is, however, a great deal of research that provides a strong rationale for pursuing this topic in the clinical domain [7,8]. The present article presents a new test to assess clinicians' accuracy in understanding the thoughts and feelings of patients, called the Test of Accurate Perception of Patients' Affect (TAPPA). 1.1. Methods for studying clinicians' accuracy in interpersonal perception Some observation-based coding systems for evaluating clinicians' behavior include items describing the clinician's ability to perceive the patient accurately, thus relying on observers' impressions as an indicator of the clinician's interpersonal judgment accuracy. For example, an observer's impression of physician sensitivity to patients is included in the Medical Interaction Process System for evaluating oncologists' communication skill [9]. However, observers' impressions of skill in

Journal of General Internal Medicine, Feb 8, 2008

BACKGROUND: Physician communication style affects patients' perceptions and behaviors. Two aspect... more BACKGROUND: Physician communication style affects patients' perceptions and behaviors. Two aspects of physician communication style, caring and dominance, are often related in that a high caring physician is usually not dominant and vice versa. OBJECTIVE: This research was aimed at testing the sole or joint impact of physician caring and physician dominance on participant perceptions and behavior during the medical visit. PARTICIPANTS AND DESIGN: In an experimental design, analog patients (APs) (167 university students) interacted with a computer-generated virtual physician on a computer screen. Participants were randomly assigned to 1 of 4 experimental conditions (physician communication style: high dominance and low caring, high dominance and high caring, low dominance and low caring, or low dominance and high caring). The APs' verbal and nonverbal behavior during the visit as well as their perception of the virtual physician were assessed. RESULTS: Analog patients were able to distinguish dominance and caring dimensions of the virtual physician's communication. Moreover, APs provided less medical information, spoke less, and agreed more when interacting with a high-dominant compared to a lowdominant physician. They also talked more about emotions and were quicker in taking their turn to speak when interacting with a high-caring compared to a lowcaring physician. CONCLUSIONS: Dominant and caring physicians elicit different emotional and behavioral responses from APs. Physician dominance reduces patient engagement in the medical dialog and produces submissiveness, whereas physician caring increases patient emotionality.

Health Communication, 2014

The goal was to explore the clinical relevance of accurate understanding of patients' thoughts an... more The goal was to explore the clinical relevance of accurate understanding of patients' thoughts and feelings. Between 2010 and 2012, four groups of participants (nursing students, medical students, internal medicine residents, and undergraduate students) took a test of accuracy in understanding the thoughts and feelings of patients who were videorecorded during their actual medical visits and who afterward reviewed their video to identify their thoughts and feelings as they occurred (Test of Accurate Perception of Patients' Affect, or TAPPA). Participants' accuracy scores were then correlated with participants' attitudes toward

Journal of General Internal Medicine, 2008

BACKGROUND: Physician communication style affects patients' perceptions and behaviors. Two aspect... more BACKGROUND: Physician communication style affects patients' perceptions and behaviors. Two aspects of physician communication style, caring and dominance, are often related in that a high caring physician is usually not dominant and vice versa. OBJECTIVE: This research was aimed at testing the sole or joint impact of physician caring and physician dominance on participant perceptions and behavior during the medical visit. PARTICIPANTS AND DESIGN: In an experimental design, analog patients (APs) (167 university students) interacted with a computer-generated virtual physician on a computer screen. Participants were randomly assigned to 1 of 4 experimental conditions (physician communication style: high dominance and low caring, high dominance and high caring, low dominance and low caring, or low dominance and high caring). The APs' verbal and nonverbal behavior during the visit as well as their perception of the virtual physician were assessed. RESULTS: Analog patients were able to distinguish dominance and caring dimensions of the virtual physician's communication. Moreover, APs provided less medical information, spoke less, and agreed more when interacting with a high-dominant compared to a lowdominant physician. They also talked more about emotions and were quicker in taking their turn to speak when interacting with a high-caring compared to a lowcaring physician. CONCLUSIONS: Dominant and caring physicians elicit different emotional and behavioral responses from APs. Physician dominance reduces patient engagement in the medical dialog and produces submissiveness, whereas physician caring increases patient emotionality.

Social Science & Medicine, 2011

Older adults are commonly accompanied to routine physician visits, primarily by adult children an... more Older adults are commonly accompanied to routine physician visits, primarily by adult children and spouses. This is the first review of studies investigating the dynamics and consequences of patient accompaniment. Two types of evidence were examined: (1) observational studies of audio and/or videotaped medical visits, and (2) surveys of patients, families, or health care providers that ascertained experiences, expectations, and preferences for family companion presence and behaviors in routine medical visits. Meta-analytic techniques were used to summarize the evidence describing attributes of unaccompanied and accompanied patients and their companions, medical visit processes, and patient outcomes. The weighted mean rate of patient accompaniment to routine adult medical visits was 37.6% in 13 contributing studies. Accompanied patients were significantly older and more likely to be female, less educated, and in worse physical and mental health than unaccompanied patients. Companions were on average 63 years of age, predominantly female (79.4%), and spouses (54.7%) or adult children (32.2%) of patients. Accompanied patient visits were significantly longer, but verbal contribution to medical dialogue was comparable when accompanied patients and their family companion were compared with unaccompanied patients. When a companion was present, health care providers engaged in more biomedical information giving. Given the diversity of outcomes, pooled estimates could not be calculated: of 5 contributing studies 0 were unfavorable, 3 inconclusive, and 2 favorable for accompanied relative to unaccompanied patients. Study findings suggest potential practical benefits from more systematic recognition and integration of companions in health care delivery processes. We propose a conceptual framework to relate family companion presence and behaviors during physician visits to the quality of interpersonal health care processes, patient self management and health care.

Patient Education and Counseling, 2018

Objective-Apply turn analysis to family conferences in the pediatric intensive care unit. Methods... more Objective-Apply turn analysis to family conferences in the pediatric intensive care unit. Methods-We analyzed 39 audio-recorded family conferences using the Roter Interaction Analysis System. A turn was defined as a continuous block of uninterrupted statements by a speaker. Results-Opening turns by the healthcare team (HCT) averaged 207 seconds, compared to 28 seconds for families. Turn density (number of statements/turn) was 6 for the HCT versus 2 for families (p<0.0001). An average of 21 turns (26%) occurred between HCT members, resulting in substantial sections of dialogue excluding the family. Average HCT dialogue reflected a literacy demand of a 9 th grade level, whereas family dialogue averaged a 5 th grade level (p<0.0001). More HCT turns were related to higher reading level demand (r = 0.34; p=0.03) and lower levels of patient-centeredness (r = −0.35, p=0.03).

Patient Education and Counseling, 2017

Objective-We examined the prevalence and extent of informed decision-making (IDM) and patient-cen... more Objective-We examined the prevalence and extent of informed decision-making (IDM) and patient-centered decision-making (PCDM) in primary care visits of African Americans with depression. Methods-We performed a cross-sectional analysis of audiotaped clinical encounters and postvisit surveys of 76 patients and their clinicians. We used RIAS to characterize patient-centeredness of visit dialogue. IDM entailed discussion of 3 components: the nature of the decision, alternatives, and pros/cons. PCDM entailed discussion of: lifestyle/coping strategies, knowledge/ beliefs, or treatment concerns. We examined the association of IDM and PCDM with visit duration, overall patient-centeredness, and patient/clinician interpersonal ratings. Results-Approximately one-quarter of medication and counseling decisions included essential IDM elements and 40% included at least one PCDM element. In high patient-centered visits, IDM was associated with patients feeling respected in counseling and liking clinicians in medication decisions. IDM was not related to clinician ratings. In low patient-centered visits, PCDM in counseling decisions was positively associated with patients feeling respected and clinicians respecting patients.

Patient Education and Counseling, 2017

This study was designed to address significant gaps in the predominantly western-centric research... more This study was designed to address significant gaps in the predominantly western-centric research literature by examining the influence of gender concordance in medical communication and patient satisfaction within the Japanese context. Methods: New primary care patients (54 male and 49 female) were randomly assigned to study internists (6 males and 5 females). Recorded visits were coded with the Roter Interaction Analysis System (RIAS). Post-visit, patients completed a Japanese version of the Medical Interview Satisfaction Scale (MISS). Results: Female concordant visits showed higher levels of patient-centeredness than all other gender combinations. Female physicians substantially modified their communication based on patient gender while male physicians did not. Gender concordance was associated with higher female, but lower male patient satisfaction relative to gender discordant visits. Conclusion: Contrary to normative experience of medicine as a male dominated profession in Japan, and gender-based power differentials, male-gendered clinical communication is less likely to satisfy male than female patients, while female-gendered communication is positively associated with female patient satisfaction. Practice implications: Patient satisfaction ratings reflect greater gender flexibility in terms of acceptable physician behavior than Japanese norms would suggest.

Psycho-oncology, Jun 20, 2016

To investigate how cancer patients, family caregiver, and their treating oncologist, view the ris... more To investigate how cancer patients, family caregiver, and their treating oncologist, view the risks and benefits of family involvement in cancer treatment decision making (TDM) or the degree to which these perceptions may differ. A nationwide, multicenter survey was conducted with 134 oncologists and 725 of their patients and accompanying caregivers. Participant answered to modified Control Preferences Scale and investigator-developed questionnaire regarding family involvement in cancer TDM. Most participants (>90%) thought that family should be involved in cancer TDM. When asked if the oncologist should allow family involvement if the patient did not want them involved, most patients and caregivers (>85%) thought they should. However, under this circumstance only 56.0% of oncologists supported family involvement. Patients were significantly more likely to skew their responses toward patient rather than family decisional control than were their caregivers (P < 0.003); oncol...

Patient education and counseling, Jan 20, 2015

Attitudes towards patients may influence how clinicians interact. We investigated whether respect... more Attitudes towards patients may influence how clinicians interact. We investigated whether respect for patients was associated with communication behaviors during HIV care encounters. We analyzed audio-recordings of visits between 413 adult HIV-infected patients and 45 primary HIV care providers. The independent variable was clinician-reported respect for the patient and outcomes were clinician and patient communication behaviors assessed by the Roter Interaction Analysis System (RIAS). We performed negative binomial regressions for counts outcomes and linear regressions for global outcomes. When clinicians had higher respect for a patient, they engaged in more rapport-building, social chitchat, and positive talk. Patients of clinicians with higher respect for them engaged in more rapport-building, social chitchat, positive talk, and gave more psychosocial information. Encounters between patients and clinicians with higher respect for them had more positive clinician emotional tone [...

Psycho-oncology, Jan 13, 2015

We aimed to compare the views of cancer patients, family caregivers, and oncologists about the di... more We aimed to compare the views of cancer patients, family caregivers, and oncologists about the disclosure of side effects in respect to their probability of occurrence, severity, and treatment purpose. We also compared attitudes toward potential harm of side effect disclosure, patients' perceived ability to understand the risk of the side effects, and informed decision-making regarding side effects. A national survey was performed with 750 patient-caregiver dyads (75.5% participation rate) recruited by 134 oncologists in 13 cancer centers (93% participation rate). Attitudes toward communication of side effects were assessed in terms of drug purpose, severity of potential complications, and probability of harm. Most patients (82.1-87.0%) and caregivers (75.9-81.5%) thought they should be informed of all possible drug side effects regardless of risk, severity, or drug purpose and wanted these risks to be communicated explicitly. Patients and their caregivers believed that detailed...

Patient Education and Counseling, 2015

Introduction-Medication adherence is essential in HIV care, yet provider communication about adhe... more Introduction-Medication adherence is essential in HIV care, yet provider communication about adherence is often suboptimal. We designed this study to improve patient-provider communication about HIV medication adherence. Methods-We randomized 26 providers at three HIV care sites to receive or not receive a onehour communication skills training based on motivational interviewing principles applied to medication adherence. Prior to routine office visits, non-adherent patients of providers who received the training were coached to discuss adherence with their providers. Patients of providers who did not receive the training providers were not coached. We audio-recorded and coded patient-provider interactions using the Roter Interaction Analysis System (RIAS).

Patient Education and Counseling, 2011

Social characteristics (e.g. race, gender, age, education) are associated with health care dispar... more 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=0.61vs. OR=1.37, p=0.035). A graded-response was observed for social concordance with patient positive affect and patient perceptions of care.

Patient Education and Counseling, 2007

Objective: The present study aimed to investigate the effect of physician sex and physician commu... more Objective: The present study aimed to investigate the effect of physician sex and physician communication style on patient satisfaction. In real medical visits, physician sex and physician communication style are confounded variables. By using the virtual medical visit paradigm, we were able to disentangle the two variables and study their separate and/or joint effects on patient satisfaction. Method: In an experimental design, analogue patients (167 students) interacted with a computer-generated virtual physician on a computer screen. The patients' satisfaction during the visit was assessed. Results: Depending on the sex composition of the dyad, physician communication style affected analogue patients' satisfaction differently. For instance, in male-male dyads, physician communication style did not affect the patients' satisfaction, whereas in female-female dyads, analogue patients were more satisfied when the physician adopted a caring as opposed to a non-caring communication style. Conclusion: Sex of the physician and sex of the patient moderate how different physician communication styles affect patient satisfaction. In particular, a female-sex role congruent communication style leads to higher patient satisfaction when women see a female physician. Practice implications: Physician communication training cannot be one size fits all. Rather female and male physicians should obtain different training and they need to be made aware of the fact that female and male patients harbor different expectations toward them.

Psychiatric Services, 2011

Pediatrics, 2008

OBJECTIVE. The goal was to investigate the impact of a computer-based documentation tool on paren... more OBJECTIVE. The goal was to investigate the impact of a computer-based documentation tool on parent-health care provider communication during a pediatric health maintenance encounter. METHODS. We used a quasiexperimental study design to compare communication dynamics between clinicians and parents/children in health maintenance visits before and after implementation of the ClicTate system. Before ClicTate use, paper forms were used to create visit notes. The children examined were ≤18 months of age. All encounters were audiotaped or videotaped. A team of research assistants blinded to group assignment reviewed the audio portion of each encounter. Data from all recordings were analyzed, by using the Roter Interaction Analysis System, for differences in the open/closed question ratio, the extent of information provided by parents and providers, and other aspects of spoken and nonverbal communication (videotaped encounters). RESULTS. Computer-based documentation visits were slightly lon...

Patient Education and Counseling, 2009

This article appeared in a journal published by Elsevier. The attached copy is furnished to the a... more This article appeared in a journal published by Elsevier. The attached copy is furnished to the author for internal non-commercial research and education use, including for instruction at the authors institution and sharing with colleagues. Other uses, including reproduction and distribution, or selling or licensing copies, or posting to personal, institutional or third party websites are prohibited. In most cases authors are permitted to post their version of the article (e.g. in Word or Tex form) to their personal website or institutional repository. Authors requiring further information regarding Elsevier's archiving and manuscript policies are encouraged to visit: http://www.elsevier.com/copyright

Patient Education and Counseling, 2011

Objective-To determine the efficacy and effectiveness of training to improve primary care provide... more 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 three 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 two years after the training.

Patient Education and Counseling, 2006

Objective-To explore the domain of physician-reported respect for individual patients by investig... more Objective-To explore the domain of physician-reported respect for individual patients by investigating the following questions: How variable is physician-reported respect for patients? What patient characteristics are associated with greater physician-reported respect? Do patients accurately perceive levels of physician respect? Are there specific communication behaviors associated with physician-reported respect for patients? Methods-We audiotaped 215 patient-physician encounters with 30 different physicians in primary care. After each encounter, the physician rated the level of respect that s/he had for that patient using the following item: "Compared to other patients, I have a great deal of respect for this patient" on a five-point scale between strongly agree and strongly disagree. Patients completed a post-visit questionnaire that included a parallel respect item: "This doctor has a great deal of respect for me." Audiotapes of the patient visits were analyzed using the Roter Interaction Analysis System (RIAS) to characterize communication behaviors. Outcome variables included four physician communication behaviors: information-giving, rapport-building, global affect, and verbal dominance. A linear mixed effects modeling approach that accounts for clustering of patients within physicians was used to compare varying levels of physician-reported respect for patients with physician communication behaviors and patient perceptions of being respected. Results-Physician-reported respect varied across patients. Physicians strongly agreed that they had a great deal of respect for 73 patients (34%), agreed for 96 patients (45%) and were either neutral or disagreed for 46 patients (21%). Physicians reported higher levels of respect for older patients and for patients they knew well. The level of respect that physicians reported for ✩ Prior presentations-These results have been presented in part at the following meetings:

Patient Education and Counseling, 2006

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

Patient Education and Counseling, 2014

Effective clinicians need to be aware of their patients' emotions, personality, cultural and pers... more Effective clinicians need to be aware of their patients' emotions, personality, cultural and personal background, values, and expectations. An ability to ''read'' the patient plays a role in accurate diagnosis, predicting and recognizing nonadherence, relationship quality, and recognizing how the patient is reacting to the clinician. Accurate perception of patients is routinely acknowledged in discussions of patient-centered practice [1-5]. Yet, compared to the huge volume of research on what clinicians say and do, there has been much less research on clinicians' accuracy in perceiving patients, on clinicians' accuracy of interpersonal perception in general, and on the correlates and consequences of their accuracy [6]. There is, however, a great deal of research that provides a strong rationale for pursuing this topic in the clinical domain [7,8]. The present article presents a new test to assess clinicians' accuracy in understanding the thoughts and feelings of patients, called the Test of Accurate Perception of Patients' Affect (TAPPA). 1.1. Methods for studying clinicians' accuracy in interpersonal perception Some observation-based coding systems for evaluating clinicians' behavior include items describing the clinician's ability to perceive the patient accurately, thus relying on observers' impressions as an indicator of the clinician's interpersonal judgment accuracy. For example, an observer's impression of physician sensitivity to patients is included in the Medical Interaction Process System for evaluating oncologists' communication skill [9]. However, observers' impressions of skill in