The Provider’s Voice: Patient Satisfaction and the Content-filtered Speech of Nurses and Physicians in Primary Medical Care

A systematic scoping review of patient and caregiver self-report measures of satisfaction with clinicians' communication

OBJECTIVE

We conducted a systematic scoping review of self-report tools used to measure patient and/or caregiver satisfaction with clinician communication. Aims included identifying: 1) instruments that have been used to measure communication satisfaction, and 2) content of the communication items on measures.

METHODS

Two databases (PubMed and CINAHL) were searched for relevant studies. Eligibility included patient or caregiver self-report tools assessing satisfaction with clinicians' communication in a biomedical healthcare setting; and the stated purpose for using the measurement involved evaluating communication satisfaction and measures included more than one question about this. All data were charted in a form created by the authors.

RESULTS

Our search yielded a total of 4531 results screened as title and abstracts; 228 studies were screened in full text and 85 studies were included in the review. We found 53 different tools used to measure communication satisfaction among those 85 studies, including 29 previously used measures (e.g., FS-ICU-24, CAHPS), and 24 original measures developed by authors. Content of communication satisfaction items included satisfaction with content-specific communication, interpersonal communication skills of clinicians, communicating to set the right environment, and global communication satisfaction items.

CONCLUSION

There was high variability in the number of items and types of content on measures. Communication satisfaction should be better conceptualized to improve measurement, and more robust measures should be created to capture complex factors of communication satisfaction.

PRACTICE IMPLICATIONS

Creating a rigorous evaluation of satisfaction with clinician communication may help strengthen communication research and the assessment of communication interventions.

It's not what you said, it's how you said it: An analysis of therapist vocal features during psychotherapy

Psychotherapy is a conversation, whereby, at its foundation, many interventions are derived from the therapist talking. Research suggests that the voice can convey a variety of emotional and social information, and individuals may change their voice based on the context and content of the conversation (e.g., talking to a baby or delivering difficult news to patients with cancer). As such, therapists may adjust aspects of their voice throughout a therapy session depending on if they are beginning a therapy session and checking in with a client, conducting more therapeutic "work," or ending the session. In this study, we modeled three vocal features-pitch, energy, and rate-with linear and quadratic multilevel models to understand how therapists' vocal features change throughout a therapy session. We hypothesized that all three vocal features would be best fit with a quadratic function - starting high and more congruent with a conversational voice, decreasing during the middle portions of therapy where more therapeutic interventions were being administered, and increasing again at the end of the session. Results indicated a quadratic model for all three vocal features was superior in fitting the data, as compared to a linear model, suggesting that therapists begin and end therapy using a different style of voice than in the middle of a session.

Outcomes of Physicians' Communication Goals During Patient Interactions

During healthcare visits, physicians may set communication goals such as providing their patient with information about treatment; however, no recommendations exist regarding which goals physicians should prioritize during their often-brief interactions with patients. Two studies examined five communication goals (providing information, reducing distress, increasing patient satisfaction, increasing patient adherence, and encouraging hope) in the context of physician-patient interactions and their relationship with patient and physician outcomes. In Study 1, audio-recordings of physician-patient interactions were coded by research assistants for goal-related content. In Study 2, patients reported their physician's use of each goal during the interaction. In both studies, patients and physicians reported visit outcomes. Within-study meta-analyses suggested that the goal of reducing distress, but not the other goals, was consistently related to improved outcomes in Study 1. All goals were related to improved outcomes in Study 2. We then computed sample-size-weighted meta-analytic effects of each goal on each outcome across both studies. These results suggested that all of the goals had similar-sized positive relationships with patient and physician outcomes across studies. These findings suggest that physicians should generally approach consultations with communication goals in mind, but prioritizing efforts to reduce distress may be particularly beneficial.

Measuring nonverbal behavior in clinical interactions: A pragmatic guide

OBJECTIVE

Understanding nonverbal behavior is key to the research, teaching, and practice of clinical communication. However, the measurement of nonverbal behavior can be complex and time-intensive. There are many decisions to make and factors to consider when coding nonverbal behaviors.

METHODS

Based on our experience conducting nonverbal behavior research in clinical interactions, we developed practical advice and strategies for coding nonverbal behavior in clinical communication, including a checklist of questions to consider for any nonverbal coding project.

RESULTS

We provide suggestions for beginning the nonverbal coding process, operationalizing the coding approach, and conducting the coding.

CONCLUSION

A key to decision-making around nonverbal behavior coding is establishing clear research questions and using these to guide the process.

PRACTICE IMPLICATIONS

The field needs more coding of nonverbal behavior to better describe what happens in clinical interactions, to understand why nonverbal behaviors occur, and to determine the predictors and consequences of nonverbal behaviors in clinical interactions. A larger evidence base can inform better teaching practices and communication interventions.

Medical communication: the views of simulated patients

CONTEXT

Simulated patients (SPs) are extensively used in the teaching of medical communication, both for students and doctors. They occupy a unique middle ground between patients and physicians: although free from the prejudices that medical training brings, they work closely with clinical tutors to promote the principles of patient-centred consulting. Despite this, there is relatively little research around their views on what makes for good communication practice. This study aims to address this gap in the literature through a qualitative analysis of SPs' opinions, especially in the context of medical student communication.

METHODS

Eighteen SPs from two medical schools, Hull York Medical School and Durham, were interviewed, using an in-depth, one-to-one, semi-structured approach. Data, transcribed verbatim, were thematically analysed.

RESULTS

Three global themes were identified: (i) listening and empathy and showing it, (ii) continual human connection and (iii) information flow from the patient. These three themes, termed the communication triad, form a type of virtuous circle, each facilitating the other. Listening and empathy were facilitated through attributes, including attentive non-verbal communication, and through responding to cues, including making effective empathetic statements. Continual human connection was facilitated through successful beginnings, including preferring open questions to 'robotic' tick-list questions and allowing patients time to have their say. Mirroring, professional appearance, appropriate physical contact and a human approach were amongst other factors facilitating connection with patients. Information flow was encouraged by factors including showing an interest in the patient and use of silence; flow was curtailed by undesirable attributes, including interrupting, dismissive communication and making assumptions about aspects such as sexuality.

CONCLUSION

This first in-depth study of SPs' views on medical consulting identifies a communication triad that both affirms and builds on the current literature base. Five novel teaching points emerge, with clear relevance for best practice communication teaching and curricula design.

Patient satisfaction and alliance as a function of the physician's self-regulation, the physician's stress, and the content of consultation in cancer care

OBJECTIVE

To investigate which characteristics of the physician and of the consultation are related to patient satisfaction with communication and working alliance.

METHODS

Real-life consultations (N = 134) between patients (n = 134) and their physicians (n = 24) were audiotaped. All of the patients were aware of their cancer diagnosis and consulted their physician to discuss the results of tests (CT scans, magnetic resonance imaging, or tumor markers) and the progression of their cancer. The consultations were transcribed and coded with the "Defense Mechanisms Rating Scale-Clinician." The patients and physicians completed questionnaires about stress, satisfaction, and alliance, and the data were analyzed using robust linear modeling.

RESULTS

Patient satisfaction with communication and working alliance was high. Both were significantly (negatively) related to the physician's neurotic and action defenses-in particular to the defenses of displacement, self-devaluation, acting out, and hypochondriasis-as well as to the physician's stress level. The content of the consultation was not significantly related to the patient outcomes.

CONCLUSIONS

Our study shows that patient satisfaction with communication and working alliance is not influenced by the content of the consultation but is significantly associated with the physician's self-regulation (defense mechanisms) and stress. The results of this study might contribute to optimizing communication skills training and to improving communication and working alliance in cancer care.

Emergency medical triage decisions are swayed by computer-manipulated cues of physical dominance in caller's voice

In humans as well as other animals, displays of body strength such as power postures or deep masculine voices are associated with prevalence in conflicts of interest and facilitated access to resources. We conduct here an ecological and highly critical test of this hypothesis in a domain that, on first thought, would appear to be shielded from such influences: access to emergency medical care. Using acoustic manipulations of vocal masculinity, we systematically varied the perceived level of physical dominance of mock patients calling a medical call center simulator. Callers whose voice were perceived as indicative of physical dominance (i.e. those with low fundamental and formant frequency voices) obtained a higher grade of response, a higher evaluation of medical emergency and longer attention from physicians than callers with strictly identical medical needs whose voice signaled lower physical dominance. Strikingly, while the effect was important for physician participants, it was virtually non-existent when calls were processed by non-medically-trained phone operators. This finding demonstrates an unprecedented degree of vulnerability of telephone-based medical decisions to extra-medical factors carried by vocal cues, and shows that it may not simply be assumed that more medical training will shield decisions from such influences.

Using music[al] knowledge to represent expressions of emotions

OBJECTIVE

Being able to identify expressions of emotion is crucial to effective clinical communication research. However, traditional linguistic coding systems often cannot represent emotions that are expressed nonlexically or phonologically (i.e., not through words themselves but through vocal pitch, speed/rhythm/tempo, and volume).

METHODS

Using audio recording of a palliative care consultation in the natural hospital setting, two experienced music scholars employed Western musical notation, as well as the graphic realization of a digital audio program (Piano roll visualization), to visually represent the sonic features of conversation where a patient has an emotional "choke" moment.

RESULTS

Western musical notation showed the ways that changes in pitch and rate correspond to the patient's emotion: rising sharply in intensity before slowly fading away. Piano roll visualization is a helpful supplement.

CONCLUSIONS

Using musical notation to illustrate palliative care conversations in the hospital setting can render visible for analysis several aspects of emotional expression that researchers otherwise experience as intuitive or subjective. Various forms and formats of musical notation techniques and sonic visualization technologies should be considered as fruitful and complementary alternatives to traditional coding tools in clinical communications research.

PRACTICE IMPLICATIONS

Musical notation offers opportunity for both researchers and learners to "see" how communication evolves in clinical encounters, particularly where the lexical and phonological features of interpersonal communication are concordant and discordant with one another.

Physician eye contact and elder patient perceptions of understanding and adherence

OBJECTIVE

To Examine physician eye contact (EC), patient understanding and adherence.

METHODS

Secondary analysis of National Institute of Aging videotapes (N=52) of physician-elder patients in two visit types: (1) routine (n=20); (2) anxiety-provoking (n=32) was conducted. Self-reports of understanding and adherence were used. History-taking segments were qualitatively and quantitatively analyzed for relationships between EC, understanding and adherence.

RESULTS

Qualitative analysis showed: (1) two salient EC elements--frequency, type (brief or sustained)--and verbal synchronicity were commonly invoked; (2) conjoint unfolding of three communication elements--"looking, listening and talking"--may be salient for patient outcomes; (3) despite differing EC patterns in routine and anxiety provoking visits, statistical analyses showed patient understanding and adherence ratings were similar in the sample population comprising two visit types; no significant correlations between EC elements and understanding and adherence were found.

CONCLUSIONS

Salience of EC for patient-centered communication is shown in prior research. Present findings broaden the significance of EC by including verbal synchronicity. Methodological limitations may account for no significant correlations between EC and patient outcomes.

PRACTICE IMPLICATIONS

Using suggested framework for operationalizing EC elements, including verbally synchronous communication, may facilitate patient-centeredness and have positive implications for patient understanding and adherence.

Clinician styles of care: Transforming patient care at the intersection of leadership and medicine

A key role of clinicians is to motivate their patients to initiate and maintain beneficial health behaviors. This article integrates research on transformational leadership, clinician–patient communication, and health behavior to introduce a novel approach to understanding and improving clinicians’ effectiveness as motivators. We describe three dominant clinician styles or patterned approaches to patient care that derive from leadership theory (in order of least to most effective): laissez-faire, transactional, and transformational. Additionally, we suggest potential mediators and effects of the transformational style of care. Finally, we discuss future research directions for the study of clinician styles of care.

Pain assessment: the roles of physician certainty and curiosity

Undertreatment of pain is common even when caused by serious illness. We examined whether physician-patient communication (particularly language indicating physician certainty) was associated with incomplete (i.e., premature closure) of pain assessment among patients with serious illness. Standardized patients (SPs) trained to portray patients with serious illness conducted unannounced, covertly audio-recorded visits to 20 consenting family physicians and 20 medical specialists. We coded extent of pain assessment, physician voice tone, and a measure of the degree to which physicians explored and validated patient concerns. To assess physician certainty, we searched transcripts for use of words that conveyed certainty using the Linguistic Inquiry and Word Count program. SP role fidelity was 94%, and few physicians were suspicious that they had seen an SP (14% of visits). Regression analyses showed that physicians who used more certainty language engaged in less thorough assessment of pain (β = -0.48, p < .05). Conversely, physicians who engaged in more exploring and validating of patient concerns (β = 0.27, p < .05) had higher ratings on anxiety/concerned voice tone (β = 0.25, p <.01) and engaged in more thorough assessment of pain. Together, these three factors accounted for 38% of the variance in pain assessment. Physicians who convey certainty in discussions with patients suffering from pain may be more likely to close prematurely their assessment of pain. We found that expressions of physician concern and responsiveness (curiosity) were associated with superior pain assessment. Further study is needed to determine whether these associations are causal and mutable.

Association between nonverbal communication during clinical interactions and outcomes: a systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis of studies reporting associations between patients' and clinicians' nonverbal communication during real clinical interactions and clinically relevant outcomes.

METHODS

We searched 10 electronic databases, reference lists, and expert contacts for English-language studies examining associations between nonverbal communication measured through direct observation and either clinician or patient outcomes in adults. Data were systematically extracted and random effects meta-analyses were performed.

RESULTS

26 observational studies met inclusion criteria. Meta-analysis was performed for patient satisfaction, which was assessed in 65% of studies. Mental and physical health status were evaluated in 23% and 19% of included studies, respectively. Both clinician warmth and clinician listening were associated with greater patient satisfaction (p<0.001 both). Physician negativity was not related to patient satisfaction (p=0.505), but greater nurse negativity was associated with less patient satisfaction (p<0.001). Substantial differences in study design and nonverbal measures existed across studies.

CONCLUSION

Greater clinician warmth, less nurse negativity, and greater clinician listening were associated with greater patient satisfaction. Additional studies are needed to evaluate the impact of nonverbal communication on patients' mental and physical health.

PRACTICE IMPLICATIONS

Communication-based interventions that target clinician warmth and listening and nurse negativity may lead to greater patient satisfaction.

Communication about patient pain in primary care: development of the Physician-Patient Communication about Pain scale (PCAP)

OBJECTIVE

This paper describes the development of the 47-item Physician-Patient Communication about Pain (PCAP) scale for use with audiotaped medical visit interactions.

METHODS

Patient pain was assessed with the Medical Outcomes Study SF-36 Bodily Pain Scale. Four raters assessed 181 audiotaped patient interactions with 68 physicians. Descriptive statistics of PCAP items were computed. Principal components analyses with 20 scale items were used to reduce the scale to composite variables for analyses. Validity was assessed through (1) comparing PCAP composite scores for patients with high versus low pain and (2) correlating PCAP composites with a separate communication rating scale.

RESULTS

Principal components analyses yielded four physician and five patient communication composites (mean alpha=.77). Some evidence for concurrent validity was provided (5 of 18 correlations with communication validation rating scale were significant). Paired-sample t tests showed significant differences for 4 patient PCAP composites, showing the PCAP scale discriminates between high and low pain patients' communication.

CONCLUSION

The PCAP scale shows partial evidence of reliability and two forms of validity.

PRACTICE IMPLICATIONS

More research with this scale (developing more reliable and valid composites) is needed to extend these preliminary findings before this scale is applicable for use in practice.

Voice analysis during bad news discussion in oncology: reduced pitch, decreased speaking rate, and nonverbal communication of empathy

PURPOSE

This study was designed to determine if differences exist in the speaking rate and pitch of healthcare providers when discussing bad news versus neutral topics, and to assess listeners' ability to perceive voice differences in the absence of speech content.

METHODS

Participants were oncology healthcare providers seeing patients with cancer of unknown primary. The encounters were audio recorded; the information communicated by the oncologist to the patient was identified as neutral or bad news. At least 30 seconds of both bad news and neutral utterances were analyzed; provider voice pitch and speaking rate were measured. The same utterances were subjected to low pass filtering that maintained pitch contours and speaking rate, but eliminated acoustic energy associated with consonants making the samples unintelligible, but with unchanged intonation. Twenty-seven listeners (graduate students in a voice disorders class) listened to the samples and rated them on three features: caring, sympathetic, and competent.

RESULTS

All but one provider reduced speaking rate, the majority also reduced pitch in the bad news condition. Listeners perceived a significant difference between the nonverbal characteristics of the providers' voice when performing the two tasks and rated speech produced with the reduced rate and lower pitch as more caring and sympathetic.

CONCLUSIONS

These results suggest that simultaneous assessment of verbal content and multiparameter prosodic analysis of speech is necessary for a more thorough understanding of the expression and perception of empathy. This information has the potential to contribute to the enhancement of communication training design and of oncologists' communication effectiveness.

Patients' perceptions of GP non-verbal communication: a qualitative study

BACKGROUND

During doctor-patient interactions, many messages are transmitted without words, through non-verbal communication.

AIM

To elucidate the types of non-verbal behaviours perceived by patients interacting with family GPs and to determine which cues are perceived most frequently.

DESIGN OF STUDY

In-depth interviews with patients of family GPs.

SETTING

Nine family practices in different regions of Poland.

METHOD

At each practice site, interviews were performed with four patients who were scheduled consecutively to see their family doctor.

RESULTS

Twenty-four of 36 studied patients spontaneously perceived non-verbal behaviours of the family GP during patient-doctor encounters. They reported a total of 48 non-verbal cues. The most frequent features were tone of voice, eye contact, and facial expressions. Less frequent were examination room characteristics, touch, interpersonal distance, GP clothing, gestures, and posture.

CONCLUSION

Non-verbal communication is an important factor by which patients spontaneously describe and evaluate their interactions with a GP. Family GPs should be trained to better understand and monitor their own non-verbal behaviours towards patients.

Nonverbal sensitivity in medical students: implications for clinical interactions

BACKGROUND

Clinicians' accuracy in perceiving nonverbal cues has potentially important consequences, but has received insufficient research.

OBJECTIVE

To examine the relation of medical students' nonverbal sensitivity to their gender and personal traits, as well as to their communication and impressions made during a standardized patient (SP) visit.

DESIGN

Psychometric testing, questionnaire, and observation.

SETTING

One US medical school.

PARTICIPANTS

Two-hundred seventy-five third-year medical students.

MEASUREMENTS

Nonverbal sensitivity and attitudes were measured using standard instruments. Communication during the SP visit was measured using trained coders and analogue patients who viewed the videotapes and rated the favorability of their impressions of the student.

RESULTS

Nonverbal sensitivity was higher in female than male students (P < 0.001) and was positively correlated with self-reported patient-centered attitudes (P < 0.01) and ability to name one's own emotions (P < 0.05). It was also associated with less distressed (P < 0.05), more dominant (P < 0.001), and more engaged (P < 0.01) behavior by the SP, and with more liking of the medical student (P < 0.05) and higher ratings of compassion (P < 0.05) by the analogue patients. Correlations between nonverbal sensitivity and other variables were generally stronger and different for male than female students, but nonverbal sensitivity predicted analogue patients' impressions similarly for male and female students.

CONCLUSION

Medical students' nonverbal sensitivity was related to clinically relevant attitudes and behavioral style in a clinical simulation.

Development and Validation of the Physician—Patient Humor Rating Scale

The purpose of this study was the development of a rating instrument to assess the use of humor in physician— patient interactions, and to compare humor use as a function of patients’ socioeconomic status. The 46-item Physician—Patient Humor Rating Scale (PPHRS) was used to rate 246 audiotaped primary care interactions. Four subscales were reliable and valid, demonstrating correlations with patient satisfaction and reports of physician humor, with physician satisfaction and with separate affective communication ratings. There was a significant difference in use of humor as a function of patient socioeconomic status, such that there was greater mutual trust between physicians and high versus low income patients.