Patient-directed gaze as a tool for discovering and handling psychosocial problems in general practice

The Importance of Gender-Sensitive Health Care in the Context of Pain, Emergency and Vaccination: A Narrative Review

So far, health care has been insufficiently organized in a gender-sensitive way, which makes the promotion of care that meets the needs of women and men equally emerge as a relevant public health problem. The aim of this narrative review was to outline the need for more gender-sensitive medical care in the context of pain, emergency care and vaccinations. In this narrative review, a selective search was performed in Pubmed, and the databases of the World Health Organization (WHO), the European Institute for Gender Equality and the German Federal Ministry of Health were searched. Study data indicate that there are differences between men and women with regard to the ability to bear pain. On the other hand, socially constructed role expectations in pain and the communication of these are also relevant. Studies indicate that women receive adequate pain medication less often than men with a comparable pain score. Furthermore, study results indicate that the female gender is associated with an increased risk of inadequate emergency care. In terms of vaccine provision, women are less likely than men to utilize or gain access to vaccination services, and there are gender-sensitive differences in vaccine efficacy and safety. Sensitization in teaching, research and care is needed to mitigate gender-specific health inequalities.

Observable indicators of person-centred care: an interview study with patients, relatives and professionals

OBJECTIVE

To identify key observable indicators of person-centred care (PCC) from interviews with patients, relatives and professionals with experience of receiving or working with PCC.

DESIGN

A qualitative interview study using deductive content analysis.

SETTING

Primary and hospital care settings in Western Sweden.

PARTICIPANTS

Twelve participants with extensive experience of receiving or working with PCC were interviewed: two patients, two patients representative with long-term conditions, one relative and informal carer, three registered nurses, one physician, two occupational therapists and one social worker/researcher.

RESULTS

Nine observable indicators were identified and subsumed under three predetermined categories: initiating, working and safeguarding the partnership. The first category comprised three subcategories: welcoming, interested and courteous reception; agreeing on structure and aims of the conversation; and eliciting patients' wishes for involvement of significant others. The second category comprised four subcategories: attentive, empathic and encouraging manner; promoting mutual understanding; promoting patient engagement; and encouraging and friendly body language. The last category consisted of two subcategories: collaboration and transparency in documentation and verifying that patient's and professional's views, goals and wants are correctly documented.

CONCLUSION

Our results underline the need for health professionals to actively and conscientiously convey to patients their interest in and respect for the patient as a person and their willingness to collaborate as partners in their care from the very outset of the interaction. Non-verbal behaviours were seen to play a major role in shaping patients' impressions of health professionals. Given that patients' first impressions were considered to impact the content, course and outcomes of the interaction, more research attention should be given to their implications for the effective delivery of PCC.

What are patients' first-time experiences with video consulting? A qualitative interview study in Danish general practice in times of COVID-19

OBJECTIVE

To explore the experiences of Danish patients using video consultation (VC) to consult their general practitioner (GP) during COVID-19 lockdown and their attitudes towards continued use beyond COVID-19.

DESIGN

A qualitative design was employed, consisting of individual semi-structured interviews where participants were asked to retrospectively describe their experiences and reflections. Data were analysed using thematic analysis.

SETTING

Capital and Southern Regions of Denmark.

PARTICIPANTS

27 patients (17 women and 10 men) aged between 23 and 76 years who had used VC once or more during the COVID-19 pandemic participated. The data were collected from February to October 2020. We used a convenience sampling technique and sample size was based on the principle of information power.

RESULTS

Three overarching themes, each containing subthemes, were developed. Participants described pre-use reactions and concerns relating to VC as being 'better than nothing' given the COVID-19 circumstances, and preferred VC over a telephone consultation. Salient pre-use concerns related to whether the technology 'would work' and whether VC would influence consultation length and GP behaviour. Overall, participants reported positive experiences of VC use and communication attributing these mainly to 'knowing the GP' and 'feeling seen and heard'. Participants were interested in future VC use for many needs as a natural consequence of an increasingly digitalised society, not least due to COVID-19.

CONCLUSIONS

Our findings contribute with knowledge about first-user experiences of VC against the background of COVID-19. Participants showed positive attitudes towards future use of VC as either a supplementary or alternative consultation form in general practice.

Key considerations for the implementation of clinically focused Prescription Drug Monitoring Programs to avoid unintended consequences

Prescription Drug Monitoring Programs (PDMP) are electronic databases that are used to track and monitor the prescribing and dispensing of controlled substances, including opioid analgesics and benzodiazepines. PDMP have been widely implemented throughout North America and are currently being introduced in Australia and some parts of Europe. PDMP were originally developed by and for law enforcement, however many jurisdictions have now shifted use toward clinical care and harm reduction through early identification of prescription dependence and extra-medical use, and to ensure appropriate supply of controlled substances to the community through monitoring health care provider prescribing and dispensing patterns (Deloitte, 2018; Picco et al., 2021a; CDC, 2021a, U.S Department of Justice, 2018). Clinically-motivated PDMP highlight medication-related risk, based on the patient's prescribing and dispensing history. Health care professionals can use this information to aid or inform clinical decision-making and provide opportunities for intervention and treatment (Deloitte, 2018) . However, a number of harms have been associated with the use of PDMP, including increased stigma and discrimination, untreated pain and mental illness, and denial of appropriate health care for those identified as 'high risk'. In this article we examine these harms and potential mitigating factors. We conclude with some suggestions and future directions for research to address some of the current uncertainties regarding PDMP use. We highlight the need for mixed methods research to better understand the personal impacts of PDMP policy on the populations they were designed to aid.

Impact of Telemedicine on Patient Satisfaction and Perceptions of Care Quality in Radiation Oncology

BACKGROUND

The COVID-19 pandemic has transformed cancer care with the rapid expansion of telemedicine, but given the limited use of telemedicine in oncology, concerns have been raised about the quality of care being delivered. We assessed the patient experience with telemedicine in routine radiation oncology practice to determine satisfaction, quality of care, and opportunities for optimization.

PATIENTS AND METHODS

Patients seen within a multistate comprehensive cancer center for prepandemic office visits and intrapandemic telemedicine visits in December 2019 through June 2020 who completed patient experience questionnaires were evaluated. Patient satisfaction between office and telemedicine consultations were compared, patient visit-type preferences were assessed, and factors associated with an office visit preference were determined.

RESULTS

In total, 1,077 patients were assessed (office visit, n=726; telemedicine, n=351). The telemedicine-consult survey response rate was 40%. No significant differences were seen in satisfaction scores between office and telemedicine consultations, including the appointment experience versus expectation, quality of physician's explanation, and level of physician concern and friendliness. Among telemedicine survey respondents, 45% and 34% preferred telemedicine and office visits, respectively, and 21% had no preference for their visit type. Most respondents found their confidence in their physician (90%), understanding of the treatment plan (88%), and confidence in their treatment (87%) to be better or no different than with an office visit. Patients with better performance status and who were married/partnered were more likely to prefer in-person office visit consultations (odds ratio [OR], 1.04 [95% CI, 1.00-1.08]; P=.047, and 2.41 [95% CI, 1.14-5.47]; P=.009, respectively). Patients with telephone-only encounters were more likely to report better treatment plan understanding with an office visit (OR, 2.25; 95% CI, 1.00-4.77; P=.04).

CONCLUSIONS

This study is the first to assess telemedicine in routine radiation oncology practice, and found high patient satisfaction and confidence in their care. Optimization of telemedicine in oncology should be a priority, specifically access to audiovisual capabilities that can improve patient-oncologist communication.

Are clinicians' self-reported empathic concern and perspective-taking traits associated with their response to patient emotions?: Communication Studies

OBJECTIVE

To understand whether clinicians' empathic concern and perspective-taking traits are associated with their response to patient emotions.

METHODS

We audio-recorded 41 HIV clinician interactions with 342 patients at two academic medical centers. We assessed clinicians' self-reported empathic concern and perspective-taking traits using the Interpersonal Reactivity Index and coded emotional communication using the Verona Coding Definitions of Emotional Sequences. We used random effects models to assess associations between clinician traits and clinician responses to patients' negative emotions, accounting for clustering of emotions within encounters and patients within clinicians.

RESULTS

Clinicians with more self-reported empathic concern received fewer emotional expressions from their patients (β -0.06; 95% CI -0.10, -0.01) and had greater odds of responding to emotions by giving information/advice (OR 1.10; 95% CI 1.01, 1.20). There were no associations between empathic concern or perspective-taking and any other clinician responses.

CONCLUSION

Clinicians with higher levels of empathic concern respond to patient emotions by giving information and advice, a response traditionally thought of as a missed empathic opportunity, not by exploring emotions or providing empathy. Whether this is helpful to patients is unknown.

PRACTICE IMPLICATIONS

Clinicians should be aware of their tendency to give information to patients with emotional distress, and consider whether this response is helpful to patients.

Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter

IMPORTANCE

Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.

OBJECTIVE

To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.

EVIDENCE REVIEW

Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.

FINDINGS

The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions).

CONCLUSIONS AND RELEVANCE

This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

Evaluating Pharmacy Student Consultations with Standardized Patients on Opioid Medication Use and Opioid-Specific Risks

Objective. To assess third-year pharmacy students' entry-level verbal and nonverbal communication skills when addressing sensitive topics during opioid consultations with standardized patients. Methods. Seventy-one students were video-taped while consulting with standardized patients who were receiving a one-month supply of oxycodone for lower back pain. Consults were coded quantitatively for the topics students discussed with the patient, terms used, eye contact, and filler words. Results. The majority of pharmacy students discussed common and severe opioid side effects, such as respiratory depression. However, only 30% explained that the medication being dispensed was an opioid or narcotic, and only 23% of students initiated a conversation regarding dependence, addiction, or overdose risk. Students used more filler words when discussing dependence, addiction, or overdose risk as compared to the rest of the consult. Afterwards, students expressed discomfort and the need for additional training and resources for communicating with patients about opioids. Conclusion. Many students lacked confidence with regards to educating patients about opioid-specific risks. This necessitates expanding education regarding discussing sensitive information about opioids at this school of pharmacy. Other schools of pharmacy would benefit from an evaluation of their curriculum to assess the necessity for additional education and training.

Keystrokes, Mouse Clicks, and Gazing at the Computer: How Physician Interaction with the EHR Affects Patient Participation

BACKGROUND

Evidence is mixed regarding how physicians' use of the electronic health record (EHR) affects communication in medical encounters.

OBJECTIVE

To investigate whether the different ways physicians interact with the computer (mouse clicks, key strokes, and gaze) vary in their effects on patient participation in the consultation, physicians' efforts to facilitate patient involvement, and silence.

DESIGN

Cross-sectional, observational study of video and event recordings of primary care and specialty consultations.

PARTICIPANTS

Thirty-two physicians and 217 patients.

MAIN MEASURES

Predictor variables included measures of physician interaction with the EHR (mouse clicks, key strokes, gaze). Outcome measures included active patient participation (asking questions, stating preferences, expressing concerns), physician facilitation of patient involvement (partnership-building and supportive talk), and silence.

KEY RESULTS

Patients were less active participants in consultations in which physicians engaged in more keyboard activity (b = -0.002, SE = 0.001, p = 0.02). More physician gaze at the computer was associated with more silence in the encounter (b = 0.21, SE = 0.09, p = 0.02). Physicians' facilitative communication, which predicted more active patient participation (b = 0.65, SE = 0.14, p < 0.001), was not related to EHR activity measures.

CONCLUSIONS

Patients may be more reluctant to actively participate in medical encounters when physicians are more physically engaged with the computer (e.g., keyboard activity) than when their behavior is less demonstrative (e.g., gazing at EHR). Using easy to deploy communication tactics (e.g., asking about a patient's thoughts and concerns, social conversation) while working on the computer can help physicians engage patients as well as maintain conversational flow.

Exploring physicians' verbal and nonverbal responses to cues/concerns: Learning from incongruent communication

OBJECTIVES

Explore physicians' verbal and nonverbal responses to cues/concerns in consultations with older-patients.

METHODS

Two teams independently coded a sample of Norwegian consultations (n=24) on verbal and nonverbal dimensions of communication using VR-CoDES and NDEPT instruments. Consultations exploring older-patients' verbal emotional expressions were labeled 'Acknowledging of patients' emotional expressions', and 'Distancing from patients' emotional expressions.' Based on type and extent of nonverbal expressiveness, consultations were labeled 'Affective' and 'Prescriptive.' Congruency of verbal and nonverbal communication was assessed and categorized into four types. Incongruent consultations were qualitatively analyzed.

RESULTS

Types 1 and 2 consultations were described as 'Congruent,' i.e. both verbal and nonverbal behaviors facilitate or inhibit emotional expressions. Types 3 and 4 were considered 'Incongruent,' i.e. verbal inhibits, but nonverbal facilitates emotional expressions or vice versa. Type 3 incongruent encounters occurred most often when it was challenging to meet patients' needs.

CONCLUSIONS

Frequently physicians' display incongruent behavior in challenging situations. Older patients' may perceive this as either alleviating or increasing distress, depending on their needs.

PRACTICE IMPLICATIONS

Type 3 consultations may shed light on reasons for physicians' incongruent behavior; therefore, independent measurement and analyses of verbal and nonverbal communication are recommended. Older-patients' perceptions of incongruent communication should be further explored.

Automated Video Analysis of Non-verbal Communication in a Medical Setting

Non-verbal communication plays a significant role in establishing good rapport between physicians and patients and may influence aspects of patient health outcomes. It is therefore important to analyze non-verbal communication in medical settings. Current approaches to measure non-verbal interactions in medicine employ coding by human raters. Such tools are labor intensive and hence limit the scale of possible studies. Here, we present an automated video analysis tool for non-verbal interactions in a medical setting. We test the tool using videos of subjects that interact with an actor portraying a doctor. The actor interviews the subjects performing one of two scripted scenarios of interviewing the subjects: in one scenario the actor showed minimal engagement with the subject. The second scenario included active listening by the doctor and attentiveness to the subject. We analyze the cross correlation in total kinetic energy of the two people in the dyad, and also characterize the frequency spectrum of their motion. We find large differences in interpersonal motion synchrony and entrainment between the two performance scenarios. The active listening scenario shows more synchrony and more symmetric followership than the other scenario. Moreover, the active listening scenario shows more high-frequency motion termed jitter that has been recently suggested to be a marker of followership. The present approach may be useful for analyzing physician-patient interactions in terms of synchrony and dominance in a range of medical settings.

The influence of electronic medical record usage on nonverbal communication in the medical interview

This study examined nonverbal communication in relation to electronic medical record (EMR) use during the medical interview. Six physicians were videotaped during their consultations with 50 different patients at a single setting Veterans Administration Hospital. Three different office spatial designs were identified and named `open,' `closed' and `blocked'. The `open' arrangement put physicians in a position to establish better eye contact and physical orientation than did the alternative `closed' and `blocked' office configurations. Physicians who accessed the EMR and took `breakpoints' (short periods of no computer use and sustained eye contact with patients) used more nonverbal cues than physicians who tended to talk with their patients while continuously working on the computer. Long pauses in conversational turn taking associated with EMR use may have positively influenced doctor—patient communication. High EMR use interviews were associated with patients asking more questions than they did in low EMR use interviews. Implications for medical education and future research are discussed.

Clients' psychosocial communication and midwives' verbal and nonverbal communication during prenatal counseling for anomaly screening

OBJECTIVES

This study focuses on facilitation of clients' psychosocial communication during prenatal counseling for fetal anomaly screening. We assessed how psychosocial communication by clients is related to midwives' psychosocial and affective communication, client-directed gaze and counseling duration.

METHODS

During 184 videotaped prenatal counseling consultations with 20 Dutch midwives, verbal psychosocial and affective behavior was measured by the Roter Interaction Analysis System (RIAS). We rated the duration of client-directed gaze. We performed multilevel analyses to assess the relation between clients' psychosocial communication and midwives' psychosocial and affective communication, client-directed gaze and counseling duration.

RESULTS

Clients' psychosocial communication was higher if midwives' asked more psychosocial questions and showed more affective behavior (β=0.90; CI: 0.45-1.35; p<0.00 and β=1.32; CI: 0.18-2.47; p=0.025, respectively). Clients "psychosocial communication was not related to midwives" client-directed gaze. Additionally, psychosocial communication by clients was directly, positively related to the counseling duration (β=0.59; CI: 0.20-099; p=0.004).

CONCLUSIONS

In contrast with our expectations, midwives' client-directed gaze was not related with psychosocial communication of clients.

PRACTICE IMPLICATIONS

In addition to asking psychosocial questions, our study shows that midwives' affective behavior and counseling duration is likely to encourage client's psychosocial communication, known to be especially important for facilitating decision-making.

The link between perception of clinical empathy and nonverbal behavior: The effect of a doctor's gaze and body orientation

OBJECTIVES

Clinical empathy is considered to be one of the most important skills for medical professionals. It is primarily conveyed by nonverbal behavior; however, little is known about the importance of different types of cues and their relation to engagement and sincerity as possible correlates of perceived clinical empathy (PCE). In this study, we explored the effect of doctor's gaze and body orientation on PCE with the help of 32 video vignettes.

METHODS

Actors impersonating medical interns displayed different combinations of gaze and body orientation while uttering an empathetic verbal statement. The video vignettes were evaluated in terms of the perceived clinical and general empathy, engagement and sincerity.

RESULTS

A principal component analysis revealed a possible single-factor solution for the scales measuring the two types of empathy, engagement and sincerity; therefore, they were subsumed under general perceived empathy (GPE). An analysis of variance showed a main effect of gaze and body orientation, with a stronger effect of gaze, on GPE. We subsequently performed a linear random effects analysis, which indicated possible gender-related differences in the perception of gaze.

CONCLUSIONS

The outcomes of our experiment confirm that both gaze and body orientation have an influence on the GPE. The effect of gaze, however, appears to be gender-dependent: in the experiment, males were perceived as slightly more empathetic with patient-centered gaze, while for females averted gaze resulted in higher GPE scores.

PRACTICE IMPLICATIONS

The findings are directly relevant in the context of medical communication training. Perception of clinical empathy supports medical information transfer, diagnosis quality and other patient outcomes.

All eyes on the patient: the influence of oncologists' nonverbal communication on breast cancer patients' trust

Trust in the oncologist is crucial for breast cancer patients. It reduces worry, enhances decision making, and stimulates adherence. Optimal nonverbal communication by the oncologist, particularly eye contact, body posture, and smiling, presumably benefits patients’ trust. We were the first to experimentally examine (1) how the oncologist’s nonverbal behavior influences trust, and (2) individual differences in breast cancer patients’ trust. Analogue patients (APs) viewed one out of eight versions of a video vignette displaying a consultation about chemotherapy treatment. All eight versions varied only in the oncologist’s amount of eye contact (consistent vs. inconsistent), body posture (forward leaning vs. varying), and smiling (occasional smiling vs. no smiling). Primary outcome was trust in the observed oncologist (Trust in Oncologist Scale). 214 APs participated. Consistent eye contact led to stronger trust (β = −.13, p = .04). This effect was largely explained by lower educated patients, for whom the effect of consistent eye contact was stronger than for higher educated patients (β = .18, p = .01). A forward leaning body posture did not influence trust, nor did smiling. However, if the oncologist smiled more, he was perceived as more friendly (r_s = .31, p < .001) and caring (r_s = .18, p = .01). Older (β = .17, p = .01) and lower educated APs (β = −.25, p < .001) were more trusting. Trust was weaker for more avoidantly attached APs (β = −.16, p = .03). We experimentally demonstrated the importance of maintaining consistent eye contact for breast cancer patients’ trust, especially among lower educated patients. These findings need to be translated into training for oncologists in how to optimize their nonverbal communication with breast cancer patients while simultaneously managing increased time pressure and computer use during the consultation.

Provider interaction with the electronic health record: the effects on patient-centered communication in medical encounters

OBJECTIVE

The computer with the electronic health record (EHR) is an additional 'interactant' in the medical consultation, as clinicians must simultaneously or in alternation engage patient and computer to provide medical care. Few studies have examined how clinicians' EHR workflow (e.g., gaze, keyboard activity, and silence) influences the quality of their communication, the patient's involvement in the encounter, and conversational control of the visit.

METHODS

Twenty-three primary care providers (PCPs) from USA Veterans Administration (VA) primary care clinics participated in the study. Up to 6 patients per PCP were recruited. The proportion of time PCPs spent gazing at the computer was captured in real time via video-recording. Mouse click/scrolling activity was captured through Morae, a usability software that logs mouse clicks and scrolling activity. Conversational silence was coded as the proportion of time in the visit when PCP and patient were not talking. After the visit, patients completed patient satisfaction measures. Trained coders independently viewed videos of the interactions and rated the degree to which PCPs were patient-centered (informative, supportive, partnering) and patients were involved in the consultation. Conversational control was measured as the proportion of time the PCP held the floor compared to the patient.

RESULTS

The final sample included 125 consultations. PCPs who spent more time in the consultation gazing at the computer and whose visits had more conversational silence were rated lower in patient-centeredness. PCPs controlled more of the talk time in the visits that also had longer periods of mutual silence.

CONCLUSIONS

PCPs were rated as having less effective communication when they spent more time looking at the computer and when there was more periods of silence in the consultation. Because PCPs increasingly are using the EHR in their consultations, more research is needed to determine effective ways that they can verbally engage patients while simultaneously managing data in the EHR.

PRACTICE IMPLICATIONS

EHR activity consumes an increasing proportion of clinicians' time during consultations. To ensure effective communication with their patients, clinicians may benefit from using communication strategies that maintain the flow of conversation when working with the computer, as well as from learning EHR management skills that prevent extended periods of gaze at computer and long periods of silence. Next-generation EHR design must address better usability and clinical workflow integration, including facilitating patient-clinician communication.

Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor-patient communication and attention

OBJECTIVE

The aim of this study was to examine eye gaze patterns between patients and physicians while electronic health records were used to support patient care.

BACKGROUND

Eye gaze provides an indication of physician attention to patient, patient/physician interaction, and physician behaviors such as searching for information and documenting information.

METHODS

A field study was conducted where 100 patient visits were observed and video recorded in a primary care clinic. Videos were then coded for gaze behaviors where patients' and physicians' gaze at each other and artifacts such as electronic health records were coded using a pre-established objective coding scheme. Gaze data were then analyzed using lag sequential methods.

RESULTS

Results showed that there are several eye gaze patterns significantly dependent to each other. All doctor-initiated gaze patterns were followed by patient gaze patterns. Some patient-initiated gaze patterns were also followed by doctor gaze patterns significantly unlike the findings in previous studies. Health information technology appears to contribute to some of the new significant patterns that have emerged. Differences were also found in gaze patterns related to technology that differ from patterns identified in studies with paper charts. Several sequences related to patient-doctor-technology were also significant. Electronic health records affect the patient-physician eye contact dynamic differently than paper charts.

CONCLUSION

This study identified several patterns of patient-physician interaction with electronic health record systems. Consistent with previous studies, physician initiated gaze is an important driver of the interactions between patient and physician and patient and technology.

Negotiating last-minute concerns in closing Korean medical encounters: the use of gaze, body and talk

Although patients may raise new concerns during any time of the medical visit, the closing phase of the consultation is a critical locus for the negotiation of the topicalization of additional concerns. Using conversation analysis as the primary method of analysis, this study provides an analysis of the structure of consultation "closings" in Korean primary-care encounters and the way in which the organization of closings in this context discourages patients' presentation of additional concerns. Data are drawn from 60 videotaped primary-care encounters collected from Korea, between 2007 and 2008. The rare occasions in which last-minute concerns are raised are closely analyzed to reveal that the organization of gaze and body orientation play an important role in foreclosing the presentation of additional concerns. The results contribute to our understanding of closings in the primary-care interview by investigating a non-western setting that includes an investigation of an understudied subject--that of embodied resources--and shows how these closings serve the doctor's purpose of bringing closure in the face of last-minute concerns broached by the patient. The cultural meaning of gaze in the Korean medical care context is also discussed. The findings have implications for research on nonverbal communication, cultural differences, and interactions in medical care.

The role of non-verbal behaviour in racial disparities in health care: implications and solutions

CONTEXT

People from racial minority backgrounds report less trust in their doctors and have poorer health outcomes. Although these deficiencies have multiple roots, one important set of explanations involves racial bias, which may be non-conscious, on the part of providers, and minority patients' fears that they will be treated in a biased way. Here, we focus on one mechanism by which this bias may be communicated and reinforced: namely, non-verbal behaviour in the doctor-patient interaction.

METHODS

We review 2 lines of research on race and non-verbal behaviour: (i) the ways in which a patient's race can influence a doctor's non-verbal behaviour toward the patient, and (ii) the relative difficulty that doctors can have in accurately understanding the nonverbal communication of non-White patients. Further, we review research on the implications that both lines of work can have for the doctor-patient relationship and the patient's health.

RESULTS

The research we review suggests that White doctors interacting with minority group patients are likely to behave and respond in ways that are associated with worse health outcomes.

DISCUSSION

As doctors' disengaged non-verbal behaviour towards minority group patients and lower ability to read minority group patients' non-verbal behaviours may contribute to racial disparities in patients' satisfaction and health outcomes, solutions that target non-verbal behaviour may be effective. A number of strategies for such targeting are discussed.

Frequency of high-quality communication behaviors used by primary care providers of heterozygous infants after newborn screening

OBJECTIVE

To examine the quality of communication likely to be experienced by parents when being first informed about how newborn screening identified heterozygous "carrier" status for cystic fibrosis or sickle cell disease.

METHODS

Primary care providers (PCPs) of infants found to have carrier status were telephoned over a 48-month period, and asked to rehearse with a standardized patient how they would inform the infants' parent(s). 214 rehearsal transcripts were abstracted using explicit criteria methods to measure the frequency of five categories of high-quality communication behaviors.

RESULTS

Overall, PCPs used large amounts of jargon and failed to use high quality communication behaviors. On average, PCPs used 18.6 total jargon words (8.7 unique words), but explained 2.4 jargon words. The most frequent assessment of understanding was the close-ended version, although it was only seen in 129 of 214 transcripts. The most common organizing behavior was importance emphasis (121/214). Precautionary empathy was rare; the most frequent behavior was "instruction about emotion" (33/214).

CONCLUSION

The limited use of high-quality communication behaviors in rehearsals raises concern about parental understanding, decision-making, and psychosocial outcomes after newborn screening.

PRACTICE IMPLICATIONS

Measurement of specific behaviors may help PCPs to improve communication, and thereby improve the patient experience.

Engaging parents through gaze: speaker selection in three-party interactions in maternity clinics

OBJECTIVE

Describing and analyzing speaker selection in conversations between the health nurse and parents in maternity clinics.

METHODS

The data consisted of ten video-recorded encounters in maternity clinics. Using conversation analysis, we investigated 89 sequences of interaction in which the health nurse asks a question that is verbally addressed to both parents.

RESULTS

There was an observable pattern of selecting mothers as principal respondents by all participants of the encounters in maternity clinics. In a few deviant cases, fathers were selected as principal respondents. A typical practice of speaker selection was the gaze direction of the health nurse towards the recipient (usually the mother) at the closure of her question. Various situational elements also influenced which one of the parents answered the question. The deviant cases in which fathers were selected as principal respondents were mainly explainable by the use of the questionnaire designed to facilitate talking about psycho-social issues connected with the transition to parenthood.

CONCLUSION

Particular interactional circumstances and practices can break the pattern of selecting mothers as respondents to questions addressed to both parents.

PRACTICE IMPLICATIONS

Fathers could easily be engaged in conversations through gaze. Also the questionnaire seems promising in engaging fathers in conversations in clinics.

Assessing Patient and Doctor Eye Gaze Patterns Between Two Styles of Doctor Ehr Use in Primary Care Encounters

The purpose of this study is to understand the potential relationship between the ways primary care doctors interact with electronic health records (EHRs) and the eye gaze patterns of doctors and patients during primary care visits. Forty primary care encounters where doctors used two different EHR interaction styles were analyzed. This study used a lag analysis method to analyze the eye-gaze patterns between doctor and patient for each style. Differences and similarities in eye gaze behavior patterns were found between the two styles. The results of this study may inform guidelines for EHR design and implementation and inform EHR interaction training.

Non-verbal communication between primary care physicians and older patients: how does race matter?

BACKGROUND

Non-verbal communication is an important aspect of the diagnostic and therapeutic process, especially with older patients. It is unknown how non-verbal communication varies with physician and patient race.

OBJECTIVE

To examine the joint influence of physician race and patient race on non-verbal communication displayed by primary care physicians during medical interviews with patients 65 years or older.

DESIGN, SETTING, AND PARTICIPANTS

Video-recordings of visits of 209 patients 65 years old or older to 30 primary care physicians at three clinics located in the Midwest and Southwest.

MAIN MEASURES

Duration of physicians' open body position, eye contact, smile, and non-task touch, coded using an adaption of the Nonverbal Communication in Doctor-Elderly Patient Transactions form.

KEY RESULTS

African American physicians with African American patients used more open body position, smile, and touch, compared to the average across other dyads (adjusted mean difference for open body position = 16.55, p < 0.001; smile = 2.35, p = 0.048; touch = 1.33, p < 0.001). African American physicians with white patients spent less time in open body position compared to the average across other dyads, but they also used more smile and eye gaze (adjusted mean difference for open body position = 27.25, p < 0.001; smile = 3.16, p = 0.005; eye gaze = 17.05, p < 0.001). There were no differences between white physicians' behavior toward African American vs. white patients.

CONCLUSION

Race plays a role in physicians' non-verbal communication with older patients. Its influence is best understood when physician race and patient race are considered jointly.

The social gradient in doctor-patient communication

OBJECTIVE

In recent years, the importance of social differences in the physician-patient relationship has frequently been the subject of research. A 2002 review synthesised the evidence on this topic. Considering the increasing importance of social inequalities in health care, an actualization of this review seemed appropriate.

METHODS

A systematic search of literature published between 1965 and 2011 on the social gradient in doctor-patient communication. In this review social class was determined by patient's income, education or occupation.

RESULTS

Twenty original research papers and meta-analyses were included. Social differences in doctor-patient communication were described according to the following classification: verbal behaviour including instrumental and affective behaviour, non-verbal behaviour and patient-centred behaviour.

CONCLUSION

This review indicates that the literature on the social gradient in doctor-patient communication that was published in the last decade, addresses new issues and themes. Firstly, most of the found studies emphasize the importance of the reciprocity of communication.Secondly, there seems to be a growing interest in patient's perception of doctor-patient communication.

PRACTICE IMPLICATIONS

By increasing the doctors' awareness of the communicative differences and by empowering patients to express concerns and preferences, a more effective communication could be established.

Mobile health IT: the effect of user interface and form factor on doctor-patient communication

BACKGROUND

Introducing computers into primary care can have negative effects on the doctor-patient dialogue. Little is known about such effects of mobile health IT in point-of-care situations.

AIM

To assess how different mobile information devices used by physicians in point-of-care situations support or hinder aspects of doctor-patient communication, such as face-to-face dialogue, nonverbal communication, and action transparency.

METHOD

The study draws on two different experimental simulation studies where 22 doctors, in 80 simulated ward rounds, accessed patient-related information from a paper chart, a PDA, and a laptop mounted on a trolley. Video recordings from the simulations were analyzed qualitatively. Interviews with clinicians and patients were used to triangulate the findings and to verify the realism and results of the simulations.

RESULT

The paper chart afforded smooth re-establishment of eye contact, better verbal and non-verbal contact, more gesturing, good visibility of actions, and quick information retrieval. The digital information devices lacked many of these affordances; physicians' actions were not visible for the patients, the user interfaces required much attention, gesturing was harder, and re-establishment of eye contact took more time. Physicians used the devices to display their actions to the patients. The analysis revealed that the findings were related to the user interface and form factor of the information devices, as well as the personal characteristics of the physician.

CONCLUSION

When information is needed and has to be located at the point-of-care, the user interface and the physical form factor of the mobile information device are influential elements for successful collaboration between doctors and patients. Both elements need to be carefully designed so that physicians can use the devices to support face-to-face dialogue, nonverbal communication, and action visibility. The ability to facilitate and support the doctor-patient collaboration is a noteworthy usability factor in the design of mobile EPR systems. The paper also presents possible design guidelines for mobile point-of-care systems for improved doctor-patient communication.

Modeling eye gaze patterns in clinician-patient interaction with lag sequential analysis

OBJECTIVE

The aim of this study was to examine whether lag sequential analysis could be used to describe eye gaze orientation between clinicians and patients in the medical encounter. This topic is particularly important as new technologies are implemented into multiuser health care settings in which trust is critical and nonverbal cues are integral to achieving trust. This analysis method could lead to design guidelines for technologies and more effective assessments of interventions.

BACKGROUND

Nonverbal communication patterns are important aspects of clinician-patient interactions and may affect patient outcomes.

METHOD

The eye gaze behaviors of clinicians and patients in 110 videotaped medical encounters were analyzed using the lag sequential method to identify significant behavior sequences. Lag sequential analysis included both event-based lag and time-based lag.

RESULTS

Results from event-based lag analysis showed that the patient's gaze followed that of the clinician, whereas the clinician's gaze did not follow the patient's. Time-based sequential analysis showed that responses from the patient usually occurred within 2 s after the initial behavior of the clinician.

CONCLUSION

Our data suggest that the clinician's gaze significantly affects the medical encounter but that the converse is not true.

APPLICATION

Findings from this research have implications for the design of clinical work systems and modeling interactions. Similar research methods could be used to identify different behavior patterns in clinical settings (physical layout, technology, etc.) to facilitate and evaluate clinical work system designs.

Screening for distress and depression in cancer settings: 10 lessons from 40 years of primary-care research

OBJECTIVE

There has been at least 40 years of active research on screening for depression and distress in primary care. Both successes and failures have been documented. The purpose of this focussed narrative review was to summarise this research and present the key lessons for clinicians and researchers working in psychosocial oncology.

METHODS

We searched for studies assessing the utility of screening in primary care in seven electronic bibliographic databases (CENTRAL, CINAHL, Embase, HMIC, Medline, PsycINFO, Web of Knowledge) from inception to December 2010. Results were reviewed and summarised into key areas.

RESULTS

We found that research could be distilled into the following key learning points. (1) Primary care is an important partner in psychosocial care. (2) Both over and under detection are problematic. (3) Barriers to identification involve patient and clinician factors. (4) Acceptability of screening is critical to implementation. (5) Underserved groups need special attention in screening. (6) Patient-clinician trust is an important modifiable variable. (7) Greater contact influences detection. (8) Clinician confidence/skills influence screening success and subsequent action. (9) Training may improve confidence but effects upon long-term outcomes are modest. (10) Screening is generally ineffective without aftercare.

CONCLUSIONS

Primary care has shown largely what does not work in relation to screening. Namely relying on clinicians' unassisted judgement without infrastructural support, using over-complex scales with low acceptability, looking for depression alone, using screening without linked treatment, treating in the absence of follow-up and failing to engage patients in their own care. These pitfalls can and should be avoided in psychosocial oncology.

Eye contact in patient-centered communication

OBJECTIVE

To understand the relationship between eye contact and patient-centered communication (PC) in physician-elder patient interactions.

METHODS

Two instruments-Patient-centered Behavior Coding Instrument (PBCI) and Eurocommunication Global Ratings Scale-were used to measure PC in 22 National Institute of Aging videotapes. Eye contact was measured using a refined eye contact scale in NDEPT. Qualitative observational techniques were used to understand how eye contact can implicate communication.

RESULTS

'High' eye contact tapes were found to be 'high' in PC using both instruments. However, the majority of 'low' tapes were also found to be 'high' in PC. Physicians' behavior distinctly differed in two ways: (1) high tapes were characterized by more 'sustained' eye contact episodes; low tapes consisted of a greater number of 'brief' episodes; (2) brief episode tapes showed a greater focus on 'charts', i.e. 'listening' was bereft of 'looking'; sustained episodes showed a focus on 'patients', i.e. 'listening' was accompanied by 'looking' indicating patient-centered communication.

CONCLUSIONS

A comprehensive understanding of elder patient-physician interaction needs to include both-'listening' and 'looking'-components of patient-centered communication.

PRACTICE IMPLICATIONS

Eye contact serves as a salient factor in the expression of PC, making it imperative to incorporate as a nonverbal dimension in PC instruments.

The patient and the computer in the primary care consultation

OBJECTIVE

Studies of the doctor-patient relationship have focused on the elaboration of power and/or authority using a range of techniques to study the encounter between doctor and patient. The widespread adoption of computers by doctors brings a third party into the consultation. While there has been some research into the way doctors view and manage this new relationship, the behavior of patients in response to the computer is rarely studied. In this paper, the authors use Goffman's dramaturgy to explore patients' approaches to the doctor's computer in the consultation, and its influence on the patient-doctor relationship.

DESIGN

Observational study of Australian general practice. 141 consultations from 20 general practitioners were videotaped and analyzed using a hermeneutic framework.

RESULTS

Patients negotiated the relationship between themselves, the doctor, and the computer demonstrating two themes: dyadic (dealing primarily with the doctor) or triadic (dealing with both computer and doctor). Patients used three signaling behaviors in relation to the computer on the doctor's desk (screen watching, screen ignoring, and screen excluding) to influence the behavior of the doctor. Patients were able to draw the doctor to the computer, and used the computer to challenge doctor's statements.

CONCLUSION

This study demonstrates that in consultations where doctors use computers, the computer can legitimately be regarded as part of a triadic relationship. Routine use of computers in the consultation changes the doctor-patient relationship, and is altering the distribution of power and authority between doctor and patient.

Optimal nonverbal communications strategies physicians should engage in to promote positive clinical outcomes

This article discusses the importance of physician management of their nonverbal communication behavior during physician-patient interactions. This management is important because certain nonverbal behaviors are associated with clinical outcomes. The article outlines research findings involving various physicians' nonverbal behaviors, such as gaze orientation, head nodding, facial expressiveness, body orientation, proxemics, and paralinguistics. It also highlights the need to train physicians in nonverbal communications skills and provides a taxonomy of best practices or optimal nonverbal communications strategies that a physician should engage while interacting with patients.

A method to quantify and compare clinicians' assessments of patient understanding during counseling of standardized patients

OBJECTIVE

To introduce a method for quantifying clinicians' use of assessment of understanding (AU) questions, and to examine medicine residents' AU usage during counseling of standardized patients about prostate or breast cancer screening.

METHODS

Explicit-criteria abstraction was done on 86 transcripts, using a data dictionary for 4 AU types. We also developed a procedure for estimating the "load" of informational content for which the clinician has not yet assessed understanding.

RESULTS

Duplicate abstraction revealed reliability kappa=0.96. Definite criteria for at least one AU were found in 68/86 transcripts (79%). Of these, 2 transcripts contained a request for a teach-back ("what is your understanding of this?"), 2 contained an open-ended AU, 46 (54%) contained only a close-ended AU, and 18 (21%) only contained an "OK?" question. The load calculation identified long stretches of conversation without an AU.

CONCLUSION

Many residents' transcripts lacked AUs, and included AUs were often ineffectively phrased or inefficiently timed. Many patients may not understand clinicians, and many clinicians may be unaware of patients' confusion.

PRACTICE IMPLICATIONS

Effective AU usage is important enough to be encouraged by training programs and targeted by population-scale quality improvement programs. This quantitative method should be useful in population-scale measurement of AU usage.

Does burnout among doctors affect their involvement in patients' mental health problems? A study of videotaped consultations

Background

General practitioners' (GPs') feelings of burnout or dissatisfaction may affect their patient care negatively, but it is unknown if these negative feelings also affect their mental health care. GPs' available time, together with specific communication tools, are important conditions for providing mental health care. We investigated if GPs who feel burnt out or dissatisfied with the time available for their patients, are less inclined to encourage their patients to disclose their distress, and have shorter consultations, in order to gain time and energy. This may result in less psychological evaluations of patients' complaints.

Methods

We used 1890 videotaped consultations from a nationally representative sample of 126 Dutch GPs to analyse GPs' communication and the duration of their consultations. Burnout was subdivided into emotional exhaustion, depersonalisation and reduced accomplishment. Multilevel regression analyses were used to investigate which subgroups of GPs differed significantly.

Results

GPs with feelings of exhaustion or dissatisfaction with the available time have longer consultations compared to GPs without these feelings. Exhausted GPs, and GPs with feelings of depersonalisation, talk more about psychological or social topics in their consultations. GPs with feelings of reduced accomplishment are an exception: they communicate less affectively, are less patient-centred and have less eye contact with their patients compared to GPs without reduced accomplishment.

We found no relationship between GPs' feelings of burnout or dissatisfaction with the available time and their psychological evaluations of patients' problems.

Conclusion

GPs' feelings of burnout or dissatisfaction with the time available for their patients do not obstruct their diagnosis and awareness of patients' psychological problems. On the contrary, GPs with high levels of exhaustion or depersonalisation, and GPs who are dissatisfied with the available time, sometimes provide more opportunities to discuss mental health problems. This increases the chance that appropriate care will be found for patients with mental health problems. On the other hand, these GPs are themselves more likely to retire, or risk burnout, because of their dissatisfaction. Therefore these GPs may benefit from training or personal coaching to decrease the chance that the process of burnout will get out of hand.

Receiving treatment for common mental disorders

OBJECTIVE

Anxiety and depressive disorders are widely prevalent, but patients are only treated in a minority of cases. In this study, the explanation of receiving mental health treatment is sought in predisposing and enabling characteristics and indicators for objective and self-perceived need.

METHODS

Cross-sectional analysis of data collected in the Netherlands Study of Depression and Anxiety (NESDA) among 743 persons with an anxiety and/or depression diagnosis as assessed by the CIDI. Receipt of mental health treatment was assessed in the face-to-face interview, as well as indicators of predisposing and enabling factors and variables evaluating need for care.

RESULTS

Of the total sample, 57% received treatment in the past 6 months in the general practice setting (50%) or the mental health care setting (14%). Younger patients, patients who evaluated their providers better on communicative abilities and patients who perceived mental health problems themselves had greater odds of having professional mental health contacts in the primary care setting. Confidence in professional help and higher severity of mental problems were associated with greater odds of having specialized mental health care.

CONCLUSION

Receiving help for common mental disorders depends not only on the objective need of the patient but also at least as much on the patients' own recognition that their problems have a mental health origin. Furthermore, in primary care especially, the patients' judgment of their providers' affective abilities may be decisive for being treated. For receiving specialized care, patients are also directed by their confidence in professional help.

Ten steps to better communication

Good communication skills are the foundations on which a good doctor–patient relationship is established. They have a significant influence on patient satisfaction and are likely to lead to a more satisfying career in medicine. This article is aimed at medical students and trainees in the early stage of their career, and it focuses on the key ingredients of good communication (Table 1).

Audio-visual recording of patient-GP consultations for research purposes: a literature review on recruiting rates and strategies

OBJECTIVE

To identify ethical processes and recruitment strategies, participation rates of studies using audio or video recording of primary health care consultations for research purposes, and the effect of recording on the behaviour, attitudes and feelings of participants.

METHODS

A structured literature review using Medline, Embase, Cochrane Library, and Psychinfo. This was followed by extensive hand search.

RESULTS

Recording consultations were regarded as ethically acceptable with some additional safeguards recommended. A range of sampling and recruitment strategies were identified although specific detail was often lacking. Non-participation rates in audio-recording studies ranged from 3 to 83% for patients and 7 to 84% for GPs; in video-recording studies they ranged from 0 to 83% for patients and 0 to 93% for GPs. There was little evidence to suggest that recording significantly affects patient or practitioner behaviour.

CONCLUSIONS

Research involving audio or video recording of consultations is both feasible and acceptable. More detailed reporting of the methodical characteristics of recruitment in the published literature is needed.

PRACTICE IMPLICATIONS

Researchers should consider the impact of diverse sampling and recruitment strategies on participation levels. Participants should be informed that there is little evidence that recording consultations negatively affects their content or the decisions made. Researchers should increase reporting of ethical and recruitment processes in order to facilitate future reviews and meta-analyses.

Validation of the Health Care Communication Questionnaire (HCCQ) to measure outpatients' experience of communication with hospital staff

OBJECTIVE

All healthcare workers' communication skills are recognised as valuable indicators of quality of care from the patient's perspective. Most of the studies measure doctor-patient communication, giving scarce attention to other professionals. This study is aimed at developing and providing preliminary validation of a questionnaire to measure outpatients' experience of communication with hospital personnel other than doctors.

METHODS

Small groups of outpatients and hospital staffs were involved in identifying the domains and generating the items. A quantitative validation phase involving 401 outpatients followed in order to verify the hypothesised dimensionality of selected items and to measure reliability.

RESULTS

A 13-item questionnaire emerged, comprising four components of outpatients' experience in the healthcare communication domain: problem solving, respect, lack of hostility, and nonverbal immediacy. Psychometric tests were promising as regards factorial validity, evaluated with confirmatory factor analysis, and scales reliability. Factor scores were independent of patients' gender, age, and education.

CONCLUSION

The developed Health Care Communication Questionnaire (HCCQ) is a self-administered brief measure with good psychometric properties.

PRACTICE IMPLICATIONS

The HCCQ gives information that could be taken as an indirect and subjective indicator of the quality of hospital services as provided by non-medical staff. This aspect may have a role in local quality improvement initiatives.

The impact of assessing simulated bad news consultations on medical students' stress response and communication performance

Seventy second-year medical students volunteered to participate in a study with the aim of evaluating the impact of the assessment of simulated bad news consultations on their physiological and psychological stress and communication performance. Measurements were taken of salivary cortisol, systolic and diastolic blood pressure, heart rate, state anxiety and global stress using a Visual Analogue Scale. The subjects were asked to take three salivary cortisol samples on the assessment day as well as on a quiet control day, and to take all other measures 5 min before and 10 min after conducting the bad news consultation. Consultations were videotaped and analyzed using the information-giving subscale of the Amsterdam Attitude and Communication Scale (AACS), the Roter Interaction Analysis System (RIAS), and the additional non-verbal measures, smiling, nodding and patient-directed gaze. MANOVA repeated measurements were used to test the difference between the cortisol measurements taken on the assessment and the control day. Linear regression analysis was used to determine the association between physiological and psychological stress measures and the students' communication performance. The analyses were restricted to the sample of 57 students who had complete data records. In anticipation of the communication assessment, cortisol levels remained elevated, indicating a heightened anticipatory stress response. After the assessment, the students' systolic blood pressure, heart rate, globally assessed stress level and state anxiety diminished. Pre-consultation stress did not appear to be related to the quality of the students' communication performance. Non-verbal communication could be predicted by pre-consultation physiological stress levels in the sense that patient-directed gaze occurred more often the higher the students' systolic blood pressure and heart rate. Post-consultation heart rate remained higher the more often the students had looked at the patient and the more information they had provided. However, the heart rate appeared to diminish the more often the students had reassured the patient. These findings suggest that in evaluating students' communication performance there is a need to take their stress levels into account.

On the importance of nonverbal communication in the physician-patient interaction

OBJECTIVE

The goal of this paper is to show that nonverbal aspects in the physician-patient interaction play an important role. Interpersonal judgment relies mostly on nonverbal and appearance cues of the social interaction partner. This is also true for the physician-patient interaction. Moreover, physicians and patients tend to mirror some of their nonverbal behavior and complement each other on other aspects of their nonverbal behavior. Nonverbal cues emitted by the patient can contain important information for the doctor to use for treatment and diagnosis decisions.

CONCLUSION

The way the physician behaves nonverbally affects patient outcomes, such as, for instance, patient satisfaction. Affilliative nonverbal behavior (e.g., eye gaze and proximity) of the physician is related to higher patient satisfaction. However, how different physician nonverbal behaviors are related to patient satisfaction also depends on personal attributes of the physician such as gender, for instance.

PRACTICE IMPLICATIONS

Physician training could profit from incorporating knowledge about physician and patient nonverbal behavior.

The workload of general practitioners does not affect their awareness of patients' psychological problems

OBJECTIVE

To investigate if general practitioners (GPs) with a higher workload are less inclined to encourage their patients to disclose psychological problems, and are less aware of their patients' psychological problems.

METHODS

Data from 2095 videotaped consultations from a representative selection of 142 Dutch GPs were used. Multilevel regression analyses were performed with the GPs' awareness of the patient's psychological problems and their communication as outcome measures, the GPs' workload as a predictor, and GP and patient characteristics as confounders.

RESULTS

GPs' workload is not related to their awareness of psychological problems and hardly related to their communication, except for the finding that a GP with a subjective experience of a lack of time is less patient-centred. Showing eye contact or empathy and asking questions about psychological or social topics are associated with more awareness of patients' psychological problems.

CONCLUSION

Patients' feelings of distress are more important for GPs' communication and their awareness of patients' psychological problems than a long patient list or busy moment of the day. GPs who encourage the patient to disclose their psychological problems are more aware of psychological problems.

PRACTICE IMPLICATIONS

We recommend that attention is given to all the communication skills required to discuss psychological problems, both in the consulting room and in GPs' training. Additionally, attention for gender differences and stress management is recommended in GPs' training.

Does training general practitioners to elicit patients' illness representations and action plans influence their communication as a whole?

OBJECTIVE

To examine whether the discussion of illness representations and action plans during medical encounters affects the way patients and general practitioners (GPs) communicate.

METHODS

In a quasi-experimental design, 10 GPs first performed care-as-usual conversations with patients. After a 6 h training they performed consultations either emphasizing patients' illness representations or action plans. Data were collected from 70 videotaped consultations with hypertensive patients, which were analyzed using the Roter Interaction Analysis System.

RESULTS

Compared with care-as-usual consultations, communication in the action plan condition resulted in an increased discussion of lifestyle issues whereas communication in the illness representation condition resulted in more discussion of patient concerns. In both experimental conditions the proportion of affective GP utterances was higher while patients contributed more to the conversation. When GPs changed their communication style, patients did accordingly.

CONCLUSION

The explicit address of illness representations or action plans during consultations results in more attention to patient concerns and lifestyle issues and an overall improvement in patient-GP communication in terms of affective atmosphere and patient involvement.

PRACTICE IMPLICATIONS

These findings show that after a brief training GPs are able to change their communication style in a way that allows for a more thorough consideration of patient self-management.