Integrating measurement of control and affiliation in studies of physician-patient interaction: the interpersonal circumplex

Nurses' models of spiritual care: Predictors of spiritual care competence

OBJECTIVES

Previous studies have shown that nurses' spiritual care competence is related to characteristics of personal spirituality, training adequacy, and comfort, confidence, and frequency of provision of spiritual care. However, these studies assumed that all participants understood spiritual care in the same way, and used self-ratings of spiritual care competence, which are problematic. Our previous study found that spiritual care was understood in 4 qualitatively different ways that can be arranged in order of competence. This study aimed to re-examine the relationships between nurse characteristics and spiritual care competence, using spiritual care understanding as a proxy for competence.

METHODS

Data was collected from a convenience sample of nurses who completed an anonymous, online survey. The survey provided qualitative data about what spiritual care means for them. The survey also provided quantitative data regarding nurse characteristics. This study created sub-groups of nurses based on their understanding of spiritual care, and used the quantitative data to construct a profile of nurse characteristics for each sub-group. Kruskal-Wallis statistical tests determined whether nurse characteristics differed across the 4 sub-groups.

RESULTS

Spiritual care competence was not related to confidence or comfort in providing spiritual care. Relationships with spirituality, training adequacy, and frequency of provision of spiritual care were not linear; i.e., higher competence did not always correspond with higher scores of these characteristics.

SIGNIFICANCE OF RESULTS

The results raise concerns about the construct validity of using comfort and confidence as estimates of spiritual care competence. That the relationships between competence and spirituality, training adequacy, and frequency of spiritual care provision was not as linear as portrayed in extant literature, suggests that outcomes of training may depend on the type of spiritual care understanding subscribed to by training participants. The findings offer insights about how nurses could achieve high levels of spiritual care performance.

Specific back pain - effective diagnosis and treatment from the radiologist's point of view

The diagnosis and treatment of specific back pain is important in radiology. Due to the high number of patients suffering from back pain, it is important to provide excellent diagnostic and therapeutic support.Based on a recent literature search and considering the relevant guidelines as well as expert opinions, the aspects of specific back pain important for radiologists in terms of pathogenesis, diagnosis, and treatment are presented.Clinical examination in combination with the medical history provides a valid suspected diagnosis. This should subsequently be verified radiologically. MRI is the most effective cross-sectional diagnostic method for investigating specific back pain. A conventional X-ray on two planes in a standing position can be a useful addition if postural causes are suspected. If the clinical symptoms match the morphological findings, radiological treatment can be carried out for nerve root involvement as well as for inflammatory changes of the facet joints. The improvement in symptoms after radiological therapy is considered good overall; at least a short-term improvement in symptoms can generally be achieved, but no reliable data is available regarding the long-term outcome. Using preparations containing triamcinolone, low dosages should be selected in accordance with the guidelines. Embedding in a multimodal pain therapy treatment concept should be considered.Radiology provides essential diagnostic findings regarding specific back pain. Interventional pain therapy is an effective and safe method of treating proven specific back pain. · First examine clinically, then confirm the suspected diagnosis radiologically.. · MRI is usually the method of choice.. · Interventional pain therapy should show success after a maximum of 2 interventions.. · The anti-inflammatory drug dose should be kept as low as possible.. · The individual course determines the number of interventions.. · Stueckle CA, Haage P. Specific back pain - effective diagnosis and treatment from the radiologist's point of view. Fortschr Röntgenstr 2024; DOI 10.1055/a-2371-1752.

Application of bilingual simulated patients in the medical history collection for international medical students in China

BACKGROUND

In all international medical student (IMS) programs in China, language barriers between IMSs and Chinese patients greatly reduced the learning in clinical practice and brought great challenges to IMSs in their transition from preclinical to clinical practice. This study aimed to investigate the role of bilingual simulated patients (B-SPs) in IMSs learning of medical history collection in China.

METHODS

48 IMSs of grade 4 between October 2020 to Jan 2021 were enrolled in this study. During the training of medical history collection, students were randomly arranged into two groups trained with either B-SPs (B-SP group) or English-speaking SP (E-SP group). All SPs in Objective Structured Clinical Exam station (OSCE) were trained in the Affiliated Hospital of Wuhan University. Clinical skills in medical history collection were assessed by instructors during pre-clinical, post-clinical OSCE and clinical rotations.

RESULTS

The scores of IMSs in each group were analyzed in terms of medical history collection including the ability to effectively consult for information and key communication skills related to patient care. Our results indicated that IMS in B-SP group obtained similar scores in preclinical training for history collection (67.3 ± 8.46 vs 67.69 ± 8.86, P < 0.05) compared to E-SP group, while obtaining significantly higher score improvements between pre- and post-OSCE (17.22 (95% CI 12.74 to 21.70) vs 10.84 (95% CI 3.53 to 18.15), P = 0.0007).

CONCLUSION

B-SPs are more conducive to doctor-patient communication and actually improve IMSs learning in medical history collection in China.

Physicians' Speech Complexity and Interrupting Behavior in Pediatric Consultations

Pediatricians' communication behavior affects a variety of outcomes in both children and their parents. This study analyzes how speech complexity and interruptions as indicators of accommodative behaviors relate to parental recall of medical information and to their satisfaction with the medical encounter. We recruited 19 pediatricians and 68 parents at pediatric inpatient and outpatient consultations in two Swiss clinics. All medical interactions were videotaped and transcripts were analyzed to assess pediatricians' speech complexity and interrupting behavior was coded from the videos. At the end of the encounter, parents rated their satisfaction with the medical encounter and were probed regarding their recall of medical information. Our results show recall of medical information to be unrelated to pediatricians' speech complexity and negatively associated with their interrupting behavior for parents who report low positive mood. We also found less educated parents to report lower satisfaction when pediatricians employed more complex language. Furthermore, parental satisfaction was negatively associated with pediatricians' interrupting behavior, especially when displayed by male pediatricians. Overall, these findings suggest that pediatricians' speech complexity and interruptions indicate a nonaccommodative stance reducing advantageous parent outcomes.

Employing Contemporary Integrative Interpersonal Theory to Understand Dysfunction in Those at Clinical High Risk for Psychosis

Poor social functioning is related to the development of psychosis; however, our current understanding of social functioning in those at-risk for psychosis is limited by (a) poor conceptual models of interpersonal behavior and (b) a reliance on comparisons to healthy controls (e.g., vs. clinical controls). In this study, we introduce Contemporary Integrated Interpersonal Theory (CIIT) and use its Interpersonal Circumplex (IPC) model to compare interpersonal behavior traits in those at clinical high-risk (CHR) for psychosis, clinical controls, and healthy controls. A community sample (N = 3460) was used to derive estimates of IPC dimensions (i.e., affiliation and dominance), which were then compared among a large subsample that completed diagnostic interviews (N = 337), which included a CHR group, as well as several control groups ranging on degree of psychosis vulnerability and internalizing disorders. CHR individuals were distinguished from healthy controls by low affiliation (d = -1.31), and from internalizing disorder groups by higher dominance (d = 0.64). Negative symptoms were consistently associated with low affiliation and low dominance, whereas positive symptoms were related primarily to coldness. These results connect social functioning in psychosis risk to a rich theoretical framework and suggest a potentially distinct interpersonal signature for CHR individuals. More broadly, this study suggests that CIIT and the IPC may have utility for informing diagnostics and treatment development in psychosis risk research.

Non-verbal Adaptation to the Interlocutors' Inner Characteristics: Relevance, Challenges, and Future Directions

Human diversity cannot be denied. In our everyday social interactions, we constantly experience the fact that each individual is a unique combination of characteristics with specific cultural norms, roles, personality, and mood. Efficient social interaction thus requires an adaptation of communication behaviors to each specific interlocutor that one encounters. This is especially true for non-verbal communication that is more unconscious and automatic than verbal communication. Consequently, non-verbal communication needs to be understood as a dynamic and adaptive process in the theoretical modeling and study of social interactions. This perspective paper presents relevance, challenges, and future directions for the study of non-verbal adaptation in social interactions. It proposes that non-verbal adaptability is more pertinently studied as adaptation to interlocutor's inner characteristics (i.e., expectations or preferences) than to interlocutor's behaviors per se, because behaviors are communication messages that individuals interpret in order to understand their interlocutors. The affiliation and control dimensions of the Interpersonal Circumplex Model are proposed as a framework to measure both the interlocutors' inner characteristics (self-reported) and the individuals' non-verbal responses (external coders). These measures can then be compared across different interactions to assess an actual change in behavior tailored to different interlocutors. These recommendations are proposed in the hope of generating more research on the topic of non-verbal adaptability. Indeed, after having gathered the evidence on average effects of non-verbal behaviors, the field can go further than a “one size fits all” approach, by investigating the predictors, moderators, and outcomes of non-verbal adaptation to the interlocutors' inner characteristics.

The Shared Decision-Making Process in the Pharmacological Management of Depression

Shared decision making (SDM) is a model of interaction between doctors and patients in which both actors contribute to the medical decision-making process. There is an international consensus across medicine about the importance of SDM interventions, which have raised great interest in mental healthcare over the last decade. Yet SDM is not widely adopted, particularly in the field of psychiatry. The purpose of the present article is to examine, from a patient and physician perspective, the importance of SDM in the management of healthcare with a focus on mental health; it reviews the enablers and barriers (and how to overcome them) to implementing a SDM process in psychiatric practice. SDM models have been developed recently for involving patients with depression in the decision-making process, which could result in augmenting the proportion of patients who adhere to their antidepressant or other treatments for a duration that complies with the current recommendations. To implement this approach, more physicians need training in the SDM approach and access to appropriate tools that help engage in collaborative deliberation, and practice generally needs to be reorganized around the principles of patient engagement.

Simulated patient and role play methodologies for communication skills and empathy training of undergraduate medical students

BACKGROUND

Verbal and non-verbal communication, as well as empathy are central to patient-doctor interactions and have been associated with patients' satisfaction. Non-verbal communication tends to override verbal messages. The aim of this study was to analyze how medical students use verbal and non-verbal communication using two different educational approaches, student role play (SRP) and actor simulated patient (ASP), and whether the non-verbal behaviour is different in the two different poses.

METHODS

Three raters evaluated 20 students playing the doctor role, 10 in the SRP group and 10 in the ASP group. The videos were analyzed with the Calgary-Cambridge Referenced Observation Guide (CCG) and, for a more accurate evaluation of non-verbal communication, we also evaluated signs of nervousness, and posture. Empathy was rated with the CARE questionnaire. Independent Mann Whitney U tests and Qhi square tests were performed for statistical analysis.

RESULTS

From the 6 main tasks of the CCG score, we obtained higher scores in the ASP group for the task 'Gathering information' (p = 0.0008). Concerning the 17 descriptors of the CCG, the ASP group obtained significantly better scores for 'Exploration of the patients' problems to discover the biomedical perspective' (p = 0.007), 'Exploration of the patients' problems to discover background information and context' (p = 0.0004) and for 'Closing the session - Forward planning' (p = 0.02). With respect to non-verbal behaviour items, nervousness was significantly higher in the ASP group compared to the SRP group (p < 0.0001). Concerning empathy, no differences were found between the SRP and ASP groups.

CONCLUSIONS

Medical students displayed differentiated verbal and non-verbal communication behaviour during the two communication skills training methodologies. These results show that both methodologies have certain advantages and that more explicit non-verbal communication training might be necessary in order to raise students' awareness for this type of communication and increase doctor-patient interaction effectiveness.

Power and social information processing

We review the scientific evidence concerning the relation between power and social information processing. Does having or obtaining power affect how we perceive and judge our social interaction partners and how accurately we do this? High power individuals perceive others as more agentic and tend to project characteristics of themselves onto others. People in power tend to stereotype others more and see them as less human and generally in a more negative way. Powerholders are not more or less accurate in assessing others; rather, the way they understand their power (as responsibility or opportunity) seems to make the difference: Power as responsibility results in better interpersonal accuracy. Our analysis shows that it is not so much being high or low in power that explains how we perceive others, but rather how we understand our power, whether our high power position is stable, and what our current interaction goals are.

Psychological Treatment Strategy for Chronic Low Back Pain

Studies have indicated that chronic low back pain (LBP) should be approached according to its morphological basis and in consideration of biopsychosocial interventions. This study presents an updated review on available psychological assessments and interventions for patients with chronic LBP. Psychosocial factors, including fear-avoidance behavior, low mood/withdrawal, expectation of passive treatment, and negative pain beliefs, are known as risk factors for the development of chronic LBP. The Örebro Musculoskeletal Pain Questionnaire, STarT Back Screening Tool, and Brief Scale for Psychiatric Problems in Orthopaedic Patients have been used as screening tools to assess the development of chronicity or identify possible psychiatric problems. The Pain Catastrophizing Scale, Pain Self-Efficacy Questionnaire, and Injustice Experience Questionnaire are also widely used to assess psychosocial factors in patients with chronic pain. With regard to interventions, the placebo effect can be enhanced by preferable patient-clinician relationship. Reassurance to patients with non-specific pain is advised by many guidelines. Cognitive behavioral therapy focuses on restructuring the negative cognition of the patient into realistic appraisal. Mindfulness may help improve pain acceptance. Self-management strategies with appropriate goal setting and pacing theory have proved to improve long-term pain-related outcomes in patients with chronic pain.

Professional Boundaries of Nursing Staff in Secure Mental Health Services: Impact of Interpersonal Style and Attitude Toward Coercion

The current study explored the impact of nursing staff members' interpersonal style and attitudes toward coercion on the management of their professional boundaries. Researchers predicted that a combination of a particular interpersonal style, a specific attitude toward coercion, and self-reported engagement in boundary-crossing behavior would be associated with particular styles of boundary management as outlined by Hamilton's Boundary Seesaw Model. Sixty-three nursing staff members in secure inpatient mental health services completed measures of boundary management, boundary crossings, attitude toward coercion, and interpersonal style. Regression analyses showed that a submissive interpersonal style and fewer boundary-crossing behaviors were associated with a pacifier boundary management style. In contrast, a pragmatic attitude toward coercion predicted a negotiator style of boundary management. The regression model for controller boundary management style was not significant. Findings are explored, along with their impact and implications for research and practice. [Journal of Psychosocial Nursing and Mental Health Services, 57(2), 16-24.].

Verbal and non-verbal communication skills including empathy during history taking of undergraduate medical students

BACKGROUND

Verbal and non-verbal aspects of communication as well as empathy are known to have an important impact on the medical encounter. The aim of the study was to analyze how well final year undergraduate medical students use skills of verbal and non-verbal communication during history-taking and whether these aspects of communication correlate with empathy and gender.

METHODS

During a three steps performance assessment simulating the first day of a resident 30 medical final year students took histories of five simulated patients resulting in 150 videos of physician-patient encounters. These videos were analyzed by external rating with a newly developed observation scale for the verbal and non-verbal communication and with the validated CARE-questionnaire for empathy. One-way ANOVA, t-tests and bivariate correlations were used for statistical analyses.

RESULTS

Female students showed signicantly higher scores for verbal communication in the case of a female patient with abdominal pain (p < 0.05), while male students started the conversations significantly more often with an open question (p < 0.05) and interrupted the patients significantly later in two cases than female students (p < 0.05). The number of W-questions asked by all students was significantly higher in the case of the female patient with abdominal pain (p < 0.05) and this patient was interrupted after the beginning of the interview significantly earlier than the patients in the other four cases (p < 0.001). Female students reached significantly higher scores for non-verbal communication in two cases (p < 0.05) and showed significantly more empathy than male students in the case of the female patient with abdominal pain (p < 0.05). In general, non-verbal communication correlated significantly with verbal communication and with empathy while verbal communication showed no significant correlation with empathy.

CONCLUSIONS

Undergraduate medical students display differentiated communication behaviour with respect to verbal and non-verbal aspects of communication and empathy in a performance assessment and special differences could be detected between male and female students. These results suggest that explicit communication training and feedback might be necessary to raise students' awareness for the different aspects of communication and their interaction.

Consumer satisfaction with antipsychotic medication-monitoring appointments: the role of consumer-prescriber communication patterns

OBJECTIVE

The study was designed to explore patterns of prescriber communication behaviors as they relate to consumer satisfaction among a serious mental illness sample.

METHODS

Recordings from 175 antipsychotic medication-monitoring appointments between veterans with psychiatric disorders and their prescribers were coded using the Roter Interaction Analysis System (RIAS) for communication behavioral patterns.

RESULTS

The frequency of prescriber communication behaviors (i.e., facilitation, rapport, procedural, psychosocial, biomedical, and total utterances) did not reliably predict consumer satisfaction. The ratio of prescriber to consumer utterances did predict consumer satisfaction.

CONCLUSIONS

Consistent with client-centered care theory, antipsychotic medication consumers were more satisfied with their encounters when their prescriber did not dominate the conversation.

PRACTICE IMPLICATIONS

Therefore, one potential recommendation from these findings could be for medication prescribers to spend more of their time listening to, rather than speaking with, their SMI consumers.

Patient-Centeredness as Physician Behavioral Adaptability to Patient Preferences

A physician who communicates in a patient-centered way is a physician who adapts his or her communication style to what each patient needs. In order to do so, the physician has to (1) accurately assess each patient's states and traits (interpersonal accuracy) and (2) possess a behavioral repertoire to choose from in order to actually adapt his or her behavior to different patients (behavioral adaptability). Physician behavioral adaptability describes the change in verbal or nonverbal behavior a physician shows when interacting with patients who have different preferences in terms of how the physician should interact with them. We hypothesized that physician behavioral adaptability to their patients' preferences would lead to better patient outcomes and that physician interpersonal accuracy was positively related to behavioral adaptability. To test these hypotheses, we recruited 61 physicians who completed an interpersonal accuracy test before being videotaped during four consultations with different patients. The 244 participating patients indicated their preferences for their physician's interaction style prior to the consultation and filled in a consultation outcomes questionnaire directly after the consultation. We coded the physician's verbal and nonverbal behavior for each of the consultations and compared it to the patients' preferences to obtain a measure of physician behavioral adaptability. Results partially confirmed our hypotheses in that female physicians who adapted their nonverbal (but not their verbal) behavior had patients who reported more positive consultation outcomes. Moreover, the more female physicians were accurate interpersonally, the more they showed verbal and nonverbal behavioral adaptability. For male physicians, more interpersonal accuracy was linked to less nonverbal adaptability.

A Preliminary Probe of Personality Predicting Psychotherapy Outcomes: Perspectives from Therapists and Their Clients

BACKGROUND

It is widely established that personality disorder has as broad negative impact on psychotherapy outcomes. Given the increased emphasis on dimensional traits for personality pathology in the DSM-5 and the proposal for the ICD-11, it is important to understand how traits are linked to treatment outcomes. Building on past research with general traits, we hypothesized that more nuanced and specific relations would be apparent. Furthermore, much of the past research has relied upon self-reports of personality and little is known about how ratings from therapists might be related to outcomes.

SAMPLING AND METHODS

The present paper examined how dimensional traits from the Five-Factor Model predicted outcomes in a case series of 54 therapist-client dyads within a doctoral training clinic. Importantly, this extends past research as dimensional traits were rated by both therapists and clients at intake as well as sequentially over the course of therapy.

RESULTS

Correlations and regression analyses indicated that traits predicted a variety of outcomes including initial engagement in treatment as well as overall symptom reduction across therapy. Specifically, preliminary evidence suggests that therapist-rated conscientiousness at intake was positively related to clients' early engagement in therapy. In addition, openness to experience after the 4th session - particularly as rated by the client - was predictive of long-term therapy outcomes.

CONCLUSIONS

Broadly, these results provided preliminary information about the promise of dimensional models for improving the clinical utility of personality disorder diagnoses. More specifically, these results reinforced the relevance of personality assessment during therapy and indicated the potential predictive value of ratings by therapists and their clients.

The Impact of Interpersonal Style on Ruptures and Repairs in the Therapeutic Alliance Between Offenders and Therapists in Sex Offender Treatment

The therapeutic relationship is a critical component of psychological treatment. Strain can occur in the relationship, particularly when working with offenders, and more specifically, those offenders with interpersonal difficulties; strain can lead to a rupture, which may affect treatment participation and performance. This study examined ruptures in the therapeutic relationship in sexual offenders participating in offense-focused group treatment. Fifty-four sex offenders rated the therapeutic alliance at the commencement and completion of treatment; at the completion of treatment, they also reported on the occurrence of ruptures and whether they believed these ruptures were repaired. Ruptures were separated by type, according to severity-Each relationship was therefore characterized as experiencing no rupture, a minor rupture, or a major rupture. Offender characteristics including interpersonal style (IPS) and psychopathy were assessed at the commencement of treatment; their relationship with ruptures was examined. Results revealed that more than half of the offenders (approximately 55%) experienced a rupture in the therapeutic alliance, with one in four of these ruptures remaining unresolved. Offenders who did not report a rupture rated the therapeutic alliance significantly higher at the end of treatment compared with those offenders who reported a rupture that was not repaired. Offenders who reported a major rupture in the therapeutic relationship were higher in interpersonal hostility and hostile-dominance. No interpersonal or offense-specific factors affected the likelihood of a rupture repair.

Can images of pain enhance patient-clinician rapport in pain consultations?

A variety of treatment outcomes in chronic pain are influenced by patient-clinician rapport. Patients often report finding it difficult to explain their pain, and this potential obstacle to mutual understanding may impede patient-clinician rapport. Previous research has argued that the communication of both patients and clinicians is facilitated by the use of pain-related images in pain assessments. This study investigated whether introducing pain-related images into pain assessments would strengthen various components of patient-clinician rapport, including relative levels of affiliation and dominance, and interpersonal coordination between patient and clinician behaviour. Videos of 35 pain assessments in which pain images were present or absent were used to code behavioural displays of patient and clinician rapport at fixed intervals across the course of the assessment. Mixed modelling was used to examine patterns of patient and clinician affiliation and dominance with consultation type (Image vs Control) as a moderator. When pain images were present, clinicians showed more affiliation behaviour over the course of the consultation and there was greater correspondence between the affiliation behaviour of patient and clinician. However, relative levels of patient and clinician dominance were unaffected by the presence of pain images in consultations. Additional analyses revealed that clinicians responded directly to patients' use of pain images with displays of affiliation. Based on the results of this study, we recommend further investigation into the utility and feasibility of incorporating pain images into pain assessments to enhance patient-clinician communication.

The Impact of Interpersonal Style and Interpersonal Complementarity on the Therapeutic Alliance Between Therapists and Offenders in Sex Offender Treatment

Therapist and treatment process variables affect the effectiveness of offender rehabilitation programs. This study examined the influence of therapists' and offenders' interpersonal styles (IPSs) and interpersonal complementarity on therapeutic alliance (TA). Seventy-five sex offenders and their therapists evaluated each other's IPSs and the TA after 3 weeks of treatment. Offenders evaluated the TA more positively than therapists. Regarding the impact of IPS, therapist affiliation was positively correlated and therapist control was negatively correlated with offenders' ratings of the TA; in other words, offenders evaluated the TA more strongly when therapists were perceived as affiliative, and weaker when therapists were viewed as controlling. Offender affiliation was positively correlated with therapists' ratings of TA; in other words, therapists evaluated the TA more strongly when offenders were viewed as more affiliative; perceptions of offender control were unrelated to offenders' ratings of TA. Complementarity in IPS between offenders and therapists did not affect TA.

Medical student empathy: interpersonal distinctions and correlates

Attention to interpersonal behaviors, communication, and relational factors is taking on increasing importance in medical education. Medical student empathy is one aspect of the physician-patient relationship that is often involved in beneficial interactions leading to improved clinical outcomes and patient satisfaction. As an interpersonal quality, empathy is a social behavior well-suited to be examined from an interpersonal perspective. The present study used the interpersonal theory of clinical, personality, and social psychology to examine the construct of empathy and theorize about likely interpersonal correlates. One hundred and sixty-three students from an academic health center in the southeastern United States participated in this study. The medical student version of the Jefferson Scale of Empathy was used to assess empathy and its factors: Perspective taking, compassionate care, and walking in the patient's shoes. Interpersonal assessments included the International Personality Item Pool-Interpersonal Circumplex, the Interpersonal Support Evaluation List, and the UCLA Loneliness Scale. Distinct interpersonal styles and correlates emerged among empathy and its factors. While all factors of empathy were related to interpersonal warmth, perspective taking and compassionate care were also associated with submissiveness. Of note, only walking in the patient's shoes was correlated with both social support and less loneliness. These findings are discussed in light of interpersonal theory with particular attention paid to the implications for medical education and professional development.

Beyond "One Size Fits All": Physician Nonverbal Adaptability to Patients' Need for Paternalism and Its Positive Consultation Outcomes

In this study, we tested whether physicians' ability to adapt their nonverbal behavior to their patients' preferences for a paternalistic interaction style is related to positive consultation outcomes. We hypothesized that the more physicians adapt their nonverbal dominance behavior to match their patients' preferences for physician paternalism, the more positively the patients perceive the medical interaction. We assessed the actual nonverbal dominance behavior of 32 general practitioners when interacting with two of their patients and compared it with each of their patients' preferences for paternalism to obtain a measure of adaptability. Additionally, we measured patient outcomes with a questionnaire assessing patient satisfaction, trust in the physician, and evaluation of physician competence. Results show that the more nonverbal dominance the physician shows toward the patient who prefers a more paternalistic physician, as compared to toward the patient who prefers a less paternalistic physician (i.e., the more the physician shows nonverbal behavioral adaptability), the more positive the consultation outcomes are. This means that physicians' ability to adapt aspects of their nonverbal dominance behavior to their individual patients' preferences is related to better outcomes for patients. As this study shows, it is advantageous for patients when a physician behaves flexibly instead of showing the same behavior towards all patients. Physician training might want to focus more on teaching a diversity of different behavior repertoires instead of a given set of behaviors.

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.

Gender differences in irritable bowel syndrome: the interpersonal connection

BACKGROUND

While irritable bowel syndrome (IBS) affects women more than men, the reasons are unclear. Research on the female preponderance of IBS has focused on gender differences in sex-linked biological processes; much less attention has been paid to the role of psychosocial factors. Interpersonal difficulties may be one source of stress that may significantly impact on women with IBS. Because of the importance that women attach to relationships, we suspected they would be more reactive to interpersonal stress.

METHODS

A total of 283 (M age = 41 years, F = 80%), Rome III-diagnosed IBS patients completed a test battery that included the IBS Symptom Severity Scale, McGill Pain Questionnaire, Inventory of Interpersonal Problems (IIP), interpersonal support evaluation list (social support), Negative Interactions Scale, Brief Symptom Inventory (distress), Beck Depression Inventory, Anxiety Sensitivity Inventory, and IBS-Quality of Life as part of baseline assessment of an NIH trial.

KEY RESULTS

Males scored higher on two IIP scales reflecting a hostile-dominant interpersonal pattern, and reported less social support. The quality of relationship problems (more interpersonal difficulties, lower support) correlated with IBS symptom severity as measured mainly by gastroenterologists.

CONCLUSIONS & INFERENCES

Male, not female, IBS patients reported more interpersonal difficulties. Male patients-a population for whom little is known-are characterized by hostile-dominant interpersonal problems. This finding has clinical importance, given that relationship problems may influence MDs' estimation of IBS symptom severity and undermine the physician-patient relationship.

Trait-agreeableness influences individual reactions to a physician's affiliative behavior in a simulated bad news delivery

We tested whether the personality trait of agreeableness predicts different individual reactions to the level of nonverbal affiliativeness shown by a physician, in the context of a simulated bad news delivery. We predicted that individuals with high levels of agreeableness would react better to a physician adopting a highly affiliative communication style compared to individuals with low levels of agreeableness. We used an experimental design with analogue patients. Eighty participants (40 men/40 women) were randomly assigned to watch a video of a physician who communicated a bad diagnosis either in a highly affiliative or in a less affiliative way. Participants reported their reactions of anger and trust in the physician, and completed the agreeableness scale of the NEO Five-Factor Inventory (NEO-FFI). In accordance with our predictions, the higher the agreeableness score of the participants, the less anger and the more trust they reported after viewing the high as compared to the low affiliative physician. These results suggest that people with high levels of agreeableness may be especially sensitive to highly affiliative physician nonverbal behavior when receiving bad news.

Emergency physician's perception of cultural and linguistic barriers in immigrant care: results of a multiple-choice questionnaire in a large Italian urban emergency department

BACKGROUND

A poor communication with immigrants can lead to inappropriate use of healthcare services, greater risk of misdiagnosis, and lower compliance with treatment. As precise information about communication between emergency physicians (EPs) and immigrants is lacking, we analyzed difficulties in communicating with immigrants in the emergency department (ED) and their possible associations with demographic data, geographical origin and clinical characteristics.

METHODS

In an ED with approximately 85 000 visits per year, a multiple-choice questionnaire was given to the EPs 4 months after discharge of each immigrant in 2011.

RESULTS

Linguistic comprehension was optimal or partial in the majority of patients. Significant barriers were noted in nearly one fourth of patients, for only half of them compatriots who were able to translate. Linguistic barriers were mainly found in older and sicker patients; they were also frequently seen in patients coming from western Africa and southern Europe. Non-linguistic barriers were perceived by EPs in a minority of patients, more frequently in the elderly and frequent attenders. Factors independently associated with a poor final comprehension led to linguistic barriers, non-linguistic obstacles, the absence of intermediaries, and the presence of patient's fear and hostility. The latter probably is a consequence, not the cause, of a poor comprehension.

CONCLUSION

Linguistic and non-linguistic barriers, although quite infrequent, are the main factors that compromise communication with immigrants in the ED, with negative effects especially on elderly and more seriously ill patients as well as on physician satisfaction and appropriateness in using services.

Exploring the experiences of client involvement in medication decisions using a shared decision making model: results of a qualitative study

This qualitative study explored a newly introduced model of shared decision making (CommonGround) and how psychiatric medications were experienced by clients, prescribers, case managers and peer support staff. Of the twelve client subjects, six were highly engaged in shared decision-making and six were not. Five notable differences were found between the two groups including the presence of a goal, use of personal medicine, and the behavior of case managers and prescribers. Implications for a shared decision making model in psychiatry are discussed.

Real-time feedback on nonverbal clinical communication. Theoretical framework and clinician acceptance of ambient visual design

INTRODUCTION

This article is part of the focus theme of Methods of Information in Medicine on "Pervasive Intelligent Technologies for Health".

BACKGROUND

Effective nonverbal communication between patients and clinicians fosters both the delivery of empathic patient-centered care and positive patient outcomes. Although nonverbal skill training is a recognized need, few efforts to enhance patient-clinician communication provide visual feedback on nonverbal aspects of the clinical encounter.

OBJECTIVES

We describe a novel approach that uses social signal processing technology (SSP) to capture nonverbal cues in real time and to display ambient visual feedback on control and affiliation--two primary, yet distinct dimensions of interpersonal nonverbal communication. To examine the design and clinician acceptance of ambient visual feedback on nonverbal communication, we 1) formulated a model of relational communication to ground SSP and 2) conducted a formative user study using mixed methods to explore the design of visual feedback.

METHODS

Based on a model of relational communication, we reviewed interpersonal communication research to map nonverbal cues to signals of affiliation and control evidenced in patient-clinician interaction. Corresponding with our formulation of this theoretical framework, we designed ambient real-time visualizations that reflect variations of affiliation and control. To explore clinicians' acceptance of this visual feedback, we conducted a lab study using the Wizard-of-Oz technique to simulate system use with 16 healthcare professionals. We followed up with seven of those participants through interviews to iterate on the design with a revised visualization that addressed emergent design considerations.

RESULTS

Ambient visual feedback on non- verbal communication provides a theoretically grounded and acceptable way to provide clinicians with awareness of their nonverbal communication style. We provide implications for the design of such visual feedback that encourages empathic patient-centered communication and include considerations of metaphor, color, size, position, and timing of feedback.

CONCLUSIONS

Ambient visual feedback from SSP holds promise as an acceptable means for facilitating empathic patient-centered nonverbal communication.

Finding the right interactional temperature: do colder patients need more warmth in physician communication style?

Being aware of which communication style should be adopted when facing more difficult patients is important for physicians; it can help prevent patient reactions of dissatisfaction, mistrust, or non-adherence that can be detrimental to the process of care. Past research suggests that less agreeable patients are especially critical towards, and reactive to, their physician's communication style, compared to more agreeable patients. On the basis of the literature, we hypothesized that less agreeable patients would react more negatively than agreeable patients to lower levels of affiliativeness (i.e., warmth, friendliness) in the physicians, in terms of satisfaction with the physician, trust in the physician, and determination to adhere to the treatment. Thirty-six general practitioners (20 men/16 women) working in their own practice in Switzerland were filmed while interacting with 69 patients (36 men/33 women) of different ages (M = 50.7; SD = 18.19; range: 18-84) and presenting different medical problems (e.g., back pain, asthma, hypertension, diabetes). After the medical interview, patients filled in questionnaires measuring their satisfaction with the physician, their trust in the physician, their determination to adhere to the treatment, and their trait of agreeableness. Physician affiliativeness was coded on the basis of the video recordings. Physician gender and dominance, patient gender and age, as well as the gravity of the patient's medical condition were introduced as control variables in the analysis. Results confirmed our hypothesis for satisfaction and trust, but not for adherence; less agreeable patients reacted more negatively (in terms of satisfaction and trust) than agreeable patients to lower levels of affiliativeness in their physicians. This study suggests that physicians should be especially attentive to stay warm and friendly with people low in agreeableness because those patients' satisfaction and trust might be more easily lowered by a cold or distant physician communication style.

The Pragmatics of Emotions in Interlinguistic Healthcare Settings

Data-based studies on interlinguistic medical interaction show that frequently migrant patients encounter difficulties in expressing their emotions and concerns. Such difficulties are not always overcome through the intervention of an interpreter, as emotional expressions tend to “get missed” in translations which focus on problems and treatments in medical terms. The main question addressed here is: what types of interpreters’ actions cut out, or make relevant, migrant patients’ emotions? Our data is based on a corpus of 300 interlinguistic medical interactions in Arabic, Mandarin Chinese and Italian in two public hospitals in Italy. The conversations involve one Italian healthcare provider, an interpreter and a migrant patient. The corpus is analyzed drawing upon Conversation Analysis, studies on Dialogue Interpreting and Intercultural Pragmatics.

Predictors of consent in tissue donation: interpersonal aspects and information provision during requests by phone

OBJECTIVE

To examine whether interpersonal behavior and provision of key information by tissue requesters (TRs) during phone requests for tissue donation with initially undecided next-of-kin (NOK) predict consent/refusal to donate.

METHODS

The sample consisted of 102 TR-NOK dyads in which NOK reported that they were initially undecided about their intentions to donate their loved ones' tissue. Audiorecordings of requests, gathered from a national sample of tissue banks, were coded to assess for interpersonal behavior of each interactant. The effects of TR and NOK interpersonal behavior as well as information provision by the TR on consent/refusal were examined.

RESULTS

Expressions of disapproval by the TR strongly predicted NOK donation decision. Predictors of consent included fewer questions asked and more supportive statements made by the TR, as well as reassurance from the TR that donation would not lead to disfigurement or affect the appearance of the body.

CONCLUSION

Aspects of the communication process between TR and NOK during requests for tissue donation significantly predict consent to donate among initially undecided NOK.

PRACTICE IMPLICATIONS

TR trainings aimed at improving interpersonal skills and provision of key information could potentially increase tissue donation consent rates.

Agreeable patient meets affiliative physician: how physician behavior affects patient outcomes depends on patient personality

OBJECTIVE

This study tests whether the personality trait of agreeableness in simulated patients moderates their reactions to the physician's behavior. We predicted that the more agreeable the participants, the more positive the interaction outcomes when they see a high affiliative physician as compared to a low affiliative physician.

METHODS

Participants (60 students) watched videotaped excerpts (2 min each) of 4 physicians exhibiting a high affiliative behavior and of 4 physicians exhibiting a low affiliative behavior. Participants reported after each physician their satisfaction, trust, determination to adhere to the treatment recommendations, and their perception of the physician's competence. They also completed the agreeableness scale of the NEO-PI-R personality questionnaire.

RESULTS

The higher the agreeableness scores of the participants, the higher was their trust with the high affiliative physicians as compared to the low affiliative physicians, their perception of the physician's competence, and their determination to adhere to the treatment.

CONCLUSION

Results confirmed that the more agreeable the simulated patients were, the better they reacted to a physician behavior that was high rather than low in affiliativeness.

PRACTICE IMPLICATIONS

These results suggest that the more agreeable patients are, the more important it is that physicians adopt a high affiliative behavior.

Providers' roles in enhancing patients' adherence to pain self management

Practice guidelines and empirical research related to pain management encourage clinicians to take active roles in providing education about self management and promoting adoption of a self-management approach. The purpose of the study was to review the relevant literature, summarize aspects of the patient-provider interaction that influence patient engagement in self management for chronic pain, and outline practice recommendations in this area. Review of the literature on aspects of the patient-provider interaction that promote engagement in pain self-management was used. Findings are synthesized into recommendations for providers. Patients benefit from a biopsychosocial and patient-centered approach. Patients are more likely to fully disclose when providers respond empathically, which can improve conceptualization and treatment. Patient education and motivation play important roles in engaging patients in self management. Self management is influenced in part by the patient-provider communication process. Suggestions for communication strategies to facilitate patient engagement in self-management techniques, including empathic discussion of barriers and motivation enhancement, are provided.

The Interpersonal Process in Tissue Donation Requests with “Undecided” Next of Kin

Context

Although recent studies have demonstrated that tissue requesters' behavior during conversations about tissue donation affects consent rates, the link between requesters' behavior and consent rates remains unclear.

Objective

To examine whether positive/collaborative requester behaviors elicit complementary behaviors from next of kin who were initially undecided about their willingness to donate their deceased family member's tissues.

Design

Audio recordings of requests were coded to assess for interpersonal behavior of each interactant.

Setting

Audio recordings were gathered from a national sample of tissue banks.

Participants

One hundred and two requester–next-of-kin dyads, consisting of 102 relatives and 53 requesters.

Main Outcome Measures

Tissue requester and next-of-kin affiliation and interpersonal control were assessed. Tissue requesters' persuasion, confirmation (eg, approval, empathy, reassurance) and disapproval, as well as next-of-kin approval and disapproval, were examined.

Results

Tissue requesters and next of kin tended to match one another on affiliation and complement one another on interpersonal control. “Key topics,” which may affect the next of kin's decision, are discussed in only about one-third of requests. Next of kin were less affiliative and more disapproving when requesters were also more disapproving. Interpersonal behavior of the tissue requester, such as affiliation, statements of disapproval, and persuasion, as well as discussion of key topics, was a significant predictor of the interpersonal behavior of the next of kin.

Conclusions

Positive requester behaviors elicited a positive response from undecided next of kin. Because many next of kin have limited knowledge about tissue donation before the request, the communication process may affect the next of kin's perceptions of donation and thus affect the likelihood of consent. Findings could potentially inform communication skills training for tissue requesters; future research could examine effects of such training on consent rates.

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.

Implications for the prevention of aggressive behavior within psychiatric hospitals drawn from interpersonal communication theory

Although interpersonal style is a defining feature of personality and personality disorder and is commonly identified as an important influence on aggressive behavior, treatment completion, and the development of an effective therapeutic alliance, it is rarely considered in practice guidelines for preventing, engaging, and managing patients at risk of aggression. In this article, the authors consider three potential applications of interpersonal theory to the care and management of patients at risk of aggression during hospitalization: (a) preventing aggression through theoretically grounded limit setting and de-escalation techniques, (b) developing and using interventions to alter problematic interpersonal styles, and (c) understanding therapeutic ruptures and difficulties establishing a therapeutic alliance. Interpersonal theory is proposed to offer a unifying framework that may assist development of intervention and management strategies that can help to reduce the occurrence of aggression in institutional settings.

LUCAS: a theoretically informed instrument to assess clinical communication in objective structured clinical examinations

OBJECTIVES

We reviewed papers describing the development of instruments for assessing clinical communication in undergraduate medical students. The instruments had important limitations: most lacked a theoretical basis, and their psychometric properties were often poor or inadequately investigated and reported. We therefore describe the development of a new instrument, the Liverpool Undergraduate Communication Assessment Scale (LUCAS), which is intended to overcome some of these limitations. We designed LUCAS to reflect the theory that communication is contextually dependent, inherently creative and cannot be fully described within a conceptual framework of discrete skills.

METHODS

We investigated the preliminary psychometric properties of LUCAS in two studies. To assess construct and external validity, we examined correlations between examiners' LUCAS ratings and simulated patients' ratings of their relationships with students in Year 1 formative (n = 384) and summative (n = 347) objective structured clinical examination (OSCE) samples. Item-total correlations and item difficulty analyses were also performed. The dimensionality of LUCAS was examined by confirmatory factor analysis. We also assessed inter-rater reliability; four raters used LUCAS to rate 40 video-recorded encounters between Year 1 students and simulated patients.

RESULTS

Simulated patient ratings correlated with examiner ratings across two OSCE datasets. All items correlated with the total score. Item difficulty showed LUCAS was able to discriminate between student performances. LUCAS had a two-dimensional factor structure: we labelled Factor 1 creative communication and Factor 2 procedural communication. The intraclass correlation coefficient was 0.73 (95% confidence interval 0.54-0.85), indicating acceptable reliability.

CONCLUSIONS

We designed LUCAS to move the primary focus of examiners away from an assessment of students' enactment of behavioural skills to a judgement of how well students' communication met patients' needs. LUCAS demonstrated adequate reliability and validity. The instrument can be administered easily and efficiently and is therefore suitable for use in medical school examinations.

Patients' and observers' perceptions of involvement differ. Validation study on inter-relating measures for shared decision making

Objective

Patient involvement into medical decisions as conceived in the shared decision making method (SDM) is essential in evidence based medicine. However, it is not conclusively evident how best to define, realize and evaluate involvement to enable patients making informed choices. We aimed at investigating the ability of four measures to indicate patient involvement. While use and reporting of these instruments might imply wide overlap regarding the addressed constructs this assumption seems questionable with respect to the diversity of the perspectives from which the assessments are administered.

Methods

The study investigated a nested cohort (N = 79) of a randomized trial evaluating a patient decision aid on immunotherapy for multiple sclerosis. Convergent validities were calculated between observer ratings of videotaped physician-patient consultations (OPTION) and patients' perceptions of the communication (Shared Decision Making Questionnaire, Control Preference Scale & Decisional Conflict Scale).

Results

OPTION reliability was high to excellent. Communication performance was low according to OPTION and high according to the three patient administered measures. No correlations were found between observer and patient judges, neither for means nor for single items. Patient report measures showed some moderate correlations.

Conclusion

Existing SDM measures do not refer to a single construct. A gold standard is missing to decide whether any of these measures has the potential to indicate patient involvement.

Practice Implications

Pronounced heterogeneity of the underpinning constructs implies difficulties regarding the interpretation of existing evidence on the efficacy of SDM. Consideration of communication theory and basic definitions of SDM would recommend an inter-subjective focus of measurement.

Trial Registration

Controlled-Trials.com ISRCTN25267500.

Examining the validity of the unitary theory of clinical relationships: comparison of observed and experienced parent-doctor interaction

OBJECTIVE

We explored parent-doctor relationships in the care of children with leukaemia from three perspectives simultaneously: parents', doctors' and observers'. Our aim was to investigate convergence and divergence between these perspectives and thereby examine the validity of unitary theory of emotionality and authority in clinical relationships.

METHODS

33 audiorecorded parent-doctor consultations and separate interviews with parents and doctors, which we analysed qualitatively and from which we selected three prototype cases.

RESULTS

Across the whole sample doctors' sense of relationship generally converged with our observations of consultation, but parents' sense of relationship diverged strongly from each. Contrary to current assumptions, parents' sense of emotional connection with doctors did not depend on doctors' emotional behaviour, and parents did not feel disempowered by doctors' authority. Moreover, authority and emotionality were not conceptually distinct for parents, who gained emotional support from doctors' exercise of authority.

CONCLUSIONS

The relationships looked very different from the three perspectives. These divergences indicate weaknesses in current ideas of emotionality and authority in clinical relationships and the necessity of multisource datasets to develop these ideas in a way that characterises clinical relationships from all perspectives.

PRACTICE IMPLICATIONS

Methodological development will be needed to address the challenges posed by multisource datasets.

Discussion of sexual risk behavior in HIV care is infrequent and appears ineffectual: a mixed methods study

Consensus guidelines in HIV care call for clinicians to provide a brief sexual risk behavioral intervention in each visit. Studies based on participant reports find this occurs infrequently, but studies based on direct observation of clinical encounters are lacking. We conducted a mixed method study that used audio recordings of 116 routine outpatient visits by 58 different patients with HIV, in five different practice sites. Transcripts of the visits were coded and analyzed using a quantitative system. In addition, we conducted a qualitative analysis of the dialogue segments in which sexual risk behaviors arose as a topic. Discussion of sexual risk behavior occurred in 10 visits, and was generally quite brief. Two visits featured substantial counseling about sexual risk reduction; two others included substantial discussion which was not evidently directed at the patient's changing behavior. Cues suggesting a need or opportunity for such discussion that physicians did not follow up on occurred in seven additional visits. Interactions about sexual risk had less patient engagement than interactions about other health behaviors. Physicians seldom provide sexual risk reduction counseling in HIV care, even where specific indications are present.

Turning signals into meaning--'shared decision making' meets communication theory

Shared decision making (SDM) is being increasingly challenged for promoting an innovative role model while adhering to an archaic approach to patient-clinician communication, both in clinical practice and the research field. Too often, SDM has been studied at the individual level, which ignores the interpersonal system between patients and physicians. We aimed to encourage debate by reflecting on the essentials of SDM in terms of epistemology. We operationalized the SDM core concept of information exchange in terms of social systems theory. An epistemological analysis of the term information refers to its inherent process character. Exchange of information thereby becomes synonymous with social sense construction, indicating that, rather than just being a vehicle, the act of communication itself is the information. We plead for the adoption of existing dyadic analytical methods such as those offered by the interpersonal paradigm. Implications of an updated concept of information for the use of SDM-evaluation methods, for SDM-goal setting, and for clinical practice of SDM are described.

Shared decision-making: increases autonomy in substance-dependent patients

This study examines the effect of a shared decision-making intervention (SDMI) on patients' and clinicians' self-perceived interpersonal behavior. Clinicians (n = 34) in three addiction treatment centers in the Netherlands were randomly assigned to SDMI or treatment decision-making as usual. Patients receiving inpatient treatment in 2005-2006 were included (n = 212). Baseline characteristics were measured by the European Addiction Severity Index (EuropASI) and the Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM). Treatment goals were assessed using the Goals of Treatment Questionnaire (GoT-Q) plus a Q-sort ranking procedure. Interpersonal behavior was measured by Interpersonal Checklist-Revised (ICL-R) at baseline, end of treatment, and 3-month follow-up. Repeated measures analyses of variance and multiple hierarchical linear regression analysis were used. The key finding of this study was that SDMI is associated with an increase of patient autonomy (independent behavior) and control behavior. The study limitations have been noted.

Stereotyping of medical disability claimants' communication behaviour by physicians: towards more focused education for social insurance physicians

BACKGROUND

Physicians who hold medical disability assessment interviews (social insurance physicians) are probably influenced by stereotypes of claimants, especially because they have limited time available and they have to make complicated decisions. Because little is known about the influences of stereotyping on assessment interviews, the objectives of this paper were to qualitatively investigate: (1) the content of stereotypes used to classify claimants with regard to the way in which they communicate; (2) the origins of such stereotypes; (3) the advantages and disadvantages of stereotyping in assessment interviews; and (4) how social insurance physicians minimise the undesirable influences of negative stereotyping.

METHODS

Data were collected during three focus group meetings with social insurance physicians who hold medical disability assessment interviews with sick-listed employees (i.e. claimants). The participants also completed a questionnaire about demographic characteristics. The data were qualitatively analysed in Atlas.ti in four steps, according to the grounded theory and the principle of constant comparison.

RESULTS

A total of 22 social insurance physicians participated. Based on their responses, a claimant's communication was classified with regard to the degree of respect and acceptance in the physician-claimant relationship, and the degree of dominance. Most of the social insurance physicians reported that they classify claimants in general groups, and use these classifications to adapt their own communication behaviour. Moreover, the social insurance physicians revealed that their stereotypes originate from information in the claimants' files and first impressions. The main advantages of stereotyping were that this provides a framework for the assessment interview, it can save time, and it is interesting to check whether the stereotype is correct. Disadvantages of stereotyping were that the stereotypes often prove incorrect, they do not give the complete picture, and the claimant's behaviour changes constantly. Social insurance physicians try to minimise the undesirable influences of stereotypes by being aware of counter transference, making formal assessments, staying neutral to the best of their ability, and being compassionate.

CONCLUSIONS

We concluded that social insurance physicians adapt their communication style to the degree of respect and dominance of claimants in the physician-claimant relationship, but they try to minimise the undesirable influences of stereotypes in assessment interviews. It is recommended that this issue should be addressed in communication skills training.

Shared decision-making in the primary care treatment of late-life major depression: a needed new intervention?

OBJECTIVE

We suggest that clinicians consider models of shared decision-making (SDM) for their potential ability to improve the treatment of major depression in the primary care setting and overcome limitations of collaborative care and other interventions.

METHODS

We explore the characteristics and techniques of patient-clinician SDM, with particular emphasis on this model's relevance to the unique treatment concerns of depressed older adults.

RESULTS

We describe a SDM intervention to engage older adults in depression treatment in the primary care sector.

CONCLUSIONS

It is timely to examine SDM models for elderly depressed primary care patients given their potential ability to improve treatment adherence and clinical outcomes.

[Shared decision-making and communication theory: grounding the tango]

Shared decision-making (SDM) has the potential to overcome outdated social role models in the health care system. The concept, however, adheres to archaic epistemological assumptions as can be inferred from the rudimentary stage of the measurement methods used and from the information monopoly that the physician still holds in this concept. Advantages of an up-to-date model of knowledge for understanding and operationalising SDM are outlined. To this purpose, essential definitions of the concept are reflected in terms of epistemology. Accordingly, information emerges through a process of social construction. Likewise, interpersonal relations do not represent a static condition; rather, they develop anew with each interaction. Therefore, constructs suitable to focus on dyadic interaction processes can be used as indicators of sharing in SDM. Theories and methods of the interpersonal paradigm are advocated.