This document discusses doctor-patient communication and interactions. It provides an overview of some of the most cited authors on this topic, including DiMatteo, Hall, Kaplan, and Roter. It describes the Roter Interaction Analysis System (RIAS), a method for coding doctor-patient interactions. The document also lists some of the most cited journals on this subject and discusses lay information mediaries, models of mediary behavior, and methods used to study doctor-patient communication such as observational scales.

1. Examining Doctor- Patient Interactions and Communication Dorothy Gallop, Ian Parsells, Mary Chu 1

2. 2 Some of the Most Cited Authors: DiMatteo, R. Hall, J.A. Kaplan, S.H., Greenfield, S. Levinson, W. Ong, L.M.L. Roter, D.L. The Roter Interaction Analysis System (RIAS) Stewart, M. Stiles, W.B., Putnam, S.M., Wolf M.H., James, S.A. Waitzkin, H.

3. 3 The Roter Interaction Analysis System (RIAS) is a method of coding doctor-patient interaction during the medical visit. The system is broadly derived from the seminal work of Robert Bales for assessing patterns of small group interaction during problem-solving and decision-making (Interaction Process Analysis, Cambridge, Mass.: Addison-Wesley, 1950). The RIAS differs substantially from the original Bale's Process Analysis in four ways: • The coding approach is tailored to dyadic exchange specific to the medical encounter. All patient and physician dialogue is coded into categories that may be applied to each speaker, although some categories may be more common to a particular speaker. • Categories are tailored to directly reflect the content and context of the routine dialogue between patients and doctors during medical exchanges. • Identification and classification of verbal events are coded directly from videotapes or audiotapes and not transcripts. • Since coding is done directly from video or audiotapes, rather than transcripts, assessment of the tonal qualities of interaction is possible. These tonal qualities transmit the emotional context of the visit beyond the significance of the words spoken. Based on a general affective impression, coders rate both the patient and physician on global affective dimensions such as anger, anxiety, dominance, friendliness and interest. 55 page paper explaining the Roter method http://www.rias.org/manual.pdf

4. 4 Some of the most cited journals Annals of Family Medicine British Medical Journal Information Research Journal of the American Board of Family Practice Journal of the American Medical Association Journal of Health Communication Journal of Health Economics Journal of the Medical Library Association Patient Education and Counseling Social Science & Medicine Sociology of Health & Illness

5. 5 So Many Choices, So Little Time…

6. 6 Lay Information Mediaries Parents Spouse Other Family Members

7. 7 Figure 1: View 1 of the lay information mediarybehaviour Model

8. 8 Figure 2: View 2 of the lay information mediarybehaviour Model

9. 9 The rise of the e-patient Susannah Fox from the Pew Internet and American Life Project discusses the latest research on e-patients, including now many people are engaging in social media for health. Fox also gives advice for how patients can avoid information overload when going online. http://www.icyou.com/topics/politics-policy/health-2-0-meets-ix-susannah-fox

10. 10 RCS-O Relational Communication Scale for Observational Measurement

11. 11 Immediacy/affection The physician was intensely involved in the conversation with the patient The physician did not want a deeper relationship with the patient The physician was not attracted to the patient The physician found the conversation stimulating The physician communicated coldness rather than warmth The physician created a sense of distance between he/she and the patient The physician acted as if he/she was bored The physician was interested in talking to the patient The physician showed enthusiasm while talking with the patient Similarity/depth The physician made the patient feel that they were similar to he/she The physician tried to move the conversation to a deeper level The physician acted like he/she and the patient were good friends The physician seemed to desire further communication with the patient The physician seemed to care if the patient liked him/her or not Receptivity/trust The physician was sincere The physician was interested in talking with the patient The physician wanted the patient to trust him/her The physician was willing to listen to the patient The physician was open to the patient’s ideas The physician was honest in communicating with the patient

12. 12 Composure The physician felt very tense talking with the patient The physician was calm and posed with the patient The physician felt very relaxed talking with the patient The physician seemed nervous The physician was comfortable interacting with the patient Formality The physician made the interaction very formal The physician wanted the discussion to be casual The physician wanted the discussion to be informal Dominance The physician attempted to persuade the patient The physician did not attempt to influence the patient The physician tried to control the interaction The physician tried to gain the approval of the patient The physician did not try to win the patient’s favor The physician had the upper hand in the conversation

13. 13 Domains of communication in the provider-patient relationship

14. 14 House demonstrates how to not engender trust… http://www.youtube.com/watch?v=pZsICYJ1tW4 first minute and 8 seconds

15. 15

17. 'Because I was going against his advice he was difficult, but finally agreed'.

18. 'The doctor obviously felt that it was not the correct method of treating the problem'.

19. 'The doctor thought I was trying to self diagnose'.

21. 18 What are some of the methods used to study these communications?

22. 19 “Towards a theoretical framework” L.M.L. Ong, et al (1995)

23. Nonverbal Behavior and Communication What do we say when we’re not talking? What’s hidden underneath when we are? Are words the only means of information transfer? 20

24. Nonverbal Behavior and Communication When did we start discussing Nonverbal Behavior? What we recognize as Nonverbal Behavior began with Charles Darwin back in 1872. According to Darwin, earlier in our evolutionary history, Nonverbal Behaviors had specific functions that now have lost their initial meanings. Over time, these behaviors have gained a communicative value as they provide others with external evidence of someone’s internal state. (Krauss et al., 1996) 21

26. Smiling/Frowning

27. Eye Contact

28. Head Nodding

29. Hand Gestures

30. Posture and Body Leaning

31. Position

32. Appearance

33. Speech Rate

34. Loudness

35. Pitch

36. Pauses

37. Interruptions

38. Tone“An estimated 60-65% of the meaning in a social encounter is communicated nonverbally,” (Griffith et al., 2003). 22

39. Nonverbal Behavior and Communication Confused? Then let’s begin with some visual examples! http://www.youtube.com/watch?v=cEkT5uspE3c 23

41. Emotion-related communication skills, mostly nonverbal, are critical for high-quality care and influence patient satisfaction, adherence, and outcomes. (Roter et al., 2005)24

42. Nonverbal Behavior and Communication How does this apply to Physician-Patient interaction? (cont.) Nonverbal behaviors contribute to the development of trust and rapport, as well as the establishment and maintenance of relationships with patients. (Ambady et al., 2002) Nonverbal behavior is the most essential way to convey empathy with patients. (Bensing et al., 1995) 25

43. Nonverbal Behavior and Communication Specific Examples: Head nods, open arm positions, and forward leans are thought to convey encouragement and interest. Body position has been related to patients’ perception of warmth and empathy. Smiles convey approval or agreement, frowns disapproval. Blank expressions may convey boredom, aloofness, or dismissal. 26

44. Nonverbal Behavior and Communication More Specific Examples: An aggressive or hostile tone can negatively affect the patient’s willingness to follow through with recommendations. However, negative tones (such as anxiety) coupled with positive words can actually increase patient satisfaction and better appointment keeping. High, though not excessive, eye contact/gaze has been linked to increased comfort. 27

45. Nonverbal Behavior and Communication What kinds of patient behavior affect physicians? Many nonverbal clues indicate a patient’s state of illness such as physical pain, which can be difficult to express in words. Other nonverbal clues provide “leaks” into psychological issues, such as depression. Some may be deliberately conveyed to show the patient’s experience with symptoms and suffering. 28

46. Nonverbal Behavior and Communication Now let’s steer clear of diagnostic reasons, and get personal: A frustrating, antagonistic patient can anger a physician. On the flip side of the coin, a pleasant, cooperative patient may be liked more than others. An unkempt, dirty patient may receive hastened, inattentive consultation. Whereas, a clean, well-groomed patient may have their views received more readily with fewer interruptions. 29

47. Nonverbal Behavior and Communication Summary 30

48. Library’s Role 31

49. Doctor- Patient Communication: The Role of Gender Let’s check in with the doctors at Seattle Grace: http://www.youtube.com/watch?v=sG0uqWvLcEo&feature=related So what did you notice about the behavior of the female vs. the male doctor? 32

51. Technical language

52. Emotional support (through explicit statements of empathy, reassurance)

54. used more partnership language

55. asked more questions about medical and psychosocial issues –

56. positive nonverbal cues (smiled & nodded more)

57. received more medical information from patients. 33

59. Systematically examined the effects of gender in doctor patient interactions over 23 observational studies and 3 large physician report studies.

60. Results: Female primary care physicians engaged the patient in more communication

61. Psychosocial (the way an individual perceives his/her reality)

62. Asking questions- “question tags” (don’t you?)

63. Positive talk- agreement, encouragement, reassurance

64. Non-verbal communication- smiling and head nods.

65. Length of visit

66. Findings on OBGYN studies34

69. Doctor’s perceptions of patients influenced by socio-demographics.

71. Even when factors (like actual education level) was adjusted for.36

73. On the flip side, a well-liked patient is better engaged by the doctor, and receives more medical information. 37

74. What human behavioral theories comes to mind when thinking about these studies? 38

76. Lung cancer and exposure to air ( unawareness of information, reliance on myth)

78. Information constructed internally

79. “female doctors are nicer.”

80. “white doctors don’t care about my health”

81. Human communication is important for bridging information gaps39

83. Their medical doctor was the preferred source of information (63.3%) and also considered the most believable source (74.4%)40

85. Nearly all the participants had positive opinions about the public library. 38% thought it was likely that the library would have the health information that could help them. And 60% thought it was very likely.

86. But only 75.6% said they “hardly used” the library.

87. This might be an accessibility issue. 41

89. Communication vs. Library & Information Science

90. best way to communicate to an audience vs. best way to inform a single person

91. Both assume that there is a “best” or “right method for transmitting information

92. Examined three in-depth literature reviews (her own research: )

93. 25 key points on what librarians can do to engage their users42 #4: “Top down information transmission has ignored the realities of lay person’s lives […] it blames the victims and is received as irrelevant at best and prejudicial and oppressive at worse. #5 The information environment marked by decreasing trust in expert and institutional sources

94. Questions? Comments? 43