[The Verona Medical Interview Classification System/Patient (VR-MICS/P): the tool and its reliability]

A meta-narrative review of coding tools for healthcare interactions and their applicability to written communication

Background

Although healthcare professionals (HCP) undergo communicative skills training, these are sometimes unsatisfactory for patients (empathy, discussion managing). Existing coding tools overlook the interaction and patients' responses. Meanwhile, remote consultations are redefining communication channels. While some researchers adapt those tools to telehealth, few investigate written interactions.

Objective

To identify and evaluate coding tools for healthcare interactions and examine their suitability for written interactions.

Methods

We conducted a meta-narrative review in PubMed, PsycINFO, Embase, Web of Science, CINAHL, and Scopus databases up to December 2022 with Communicati* AND Human* AND Linguistic* AND Professional-Patient Relation* as search terms. We extracted data regarding methodology, unit of analysis (UoA), coding categories, reliability, strengths, weaknesses, and inter-rater reliability (IRR).

Results

We identified 11 mixed-methods tools. Qualitatively, coding dimension was focused (n = 6) or comprehensive (n = 5). Main quantitative methods were descriptive statistics (n = 4) and cross-tabulations (n = 4). Main UoA was utterance (n = 7). Relevant categories were processes (n = 4), content (n = 3), emotional expressions and responses (n = 3), and grammatical format (n = 2). IRR ranged from 0.68 to 0.85 for coding categories.

Conclusion

Despite similarities, category terminologies were inconsistent, one-sided, and mostly covered conversation topics and behaviours. A tool with emotional and grammar categories could bridge the gap between a speaker's intended meaning and the receiver's interpretation to enhance patient-HCP communication. Furthermore, we need empirical research to determine whether these tools are suitable for written interactions.

Innovation

This review presents a comprehensive and state-of-the-art overview of healthcare interactions' coding tools and identifies their barriers. Our findings will support communication researchers in selecting appropriate coding tools for evaluating health interactions and enhancing HCP training.

Measurement of physician-patient communication--a systematic review

BACKGROUND

Effective communication with health care providers has been found as relevant for physical and psychological health outcomes as well as the patients' adherence. However, the validity of the findings depends on the quality of the applied measures. This study aimed to provide an overview of measures of physician-patient communication and to evaluate the methodological quality of psychometric studies and the quality of psychometric properties of the identified measures.

METHODS

A systematic review was performed to identify psychometrically tested instruments which measure physician-patient communication. The search strategy included three databases (EMBASE, PsycINFO, PubMed), reference and citation tracking and personal knowledge. Studies that report the psychometric properties of physician-patient communication measures were included. Two independent raters assessed the methodological quality of the selected studies with the COSMIN (COnsensus based Standards for the selection of health status Measurement INtruments) checklist. The quality of psychometric properties was evaluated with the quality criteria of Terwee and colleagues.

RESULTS

Data of 25 studies on 20 measures of physician-patient communication were extracted, mainly from primary care samples in Europe and the USA. Included studies reported a median of 3 out of the nine COSMIN criteria. Scores for internal consistency and content validity were mainly fair or poor. Reliability and structural validity were rated mainly of fair quality. Hypothesis testing scored mostly poor. The quality of psychometric properties of measures evaluated with Terwee et al.'s criteria was rated mainly intermediate or positive.

DISCUSSION

This systematic review identified a number of measures of physician-patient communication. However, further psychometric evaluation of the measures is strongly recommended. The application of quality criteria like the COSMIN checklist could improve the methodological quality of psychometric property studies as well as the comparability of the studies' results.

How Do medical students respond to emotional cues and concerns expressed by simulated patients during OSCE consultations?--a multilevel study

Objectives

How medical students handle negative emotions expressed by simulated patients during Objective Structured Clinical Examinations (OSCE) has not been fully investigated. We aim to explore (i) whether medical students respond differently to different types of patients’ emotional cues; and (2) possible effects of patients’ progressive disclosure of emotional cues on students’ responses.

Methods

Forty OSCE consultations were video recorded and coded for patients’ expressions of emotional distress and students’ responses using a validated behavioural coding scheme (the Verona Coding Definitions of Emotional Sequence). Logistic multilevel regression was adopted to model the probability of the occurrence of student reducespace response behaviour as a function of the number of patients’ expressions of emotional cues.

Results

We found that medical students offered responses that differed to emotional cue types expressed by simulated patients. Students appeared to providespace to emotional cues when expressed in vague and unspecific words and reducespace to cues emphasizing physiological or cognitive correlates. We also found that medical students were less likely to explore patients’ emotional distress nearer the end of the consultation and when the duration of a patient speech turn got larger. Cumulative frequency of patients’ emotional cues also predicted students’ reducespace behaviour.

Practical Implications

Understanding how medical students manage negative emotions has significant implications for training programme development focusing on emotion recognition skills and patient-centred communication approach. In addition, the statistical approaches adopted by this study will encourage researchers in healthcare communication to search for appropriate analytical techniques to test theoretical propositions.

Empathy in general practice consultations: A qualitative analysis

Aims — Empathy is an important basis of all provider-patient interaction, including general practice. Little has been known about the details of how general practitioners express empathy to their patients. In the present study, it was a main aim to carry out a detailed qualitative study of actual sequences through which empathy was achieved, by focusing on the form, function, and categorisation of such sequences. Methods — The study drew on the qualitative method of conversation analysis. Transcriptions of 77 British general-practitioner-patient interactions were analysed in detail in order to identify and characterise sequences in which empathy was achieved. Results — Four types of empathy were identified, described, and analysed: cognitive empathy, affective empathy, sharing empathy, and nurturant empathy. Although sequences involving empathy typically were brief and occurred relatively rarely, the analyses demonstrated that the sequences often concerned matters of great importance to the interactants. Conclusions — The study underlined the need to focus also on phenomena that occur relatively rarely in consultations. For this purpose, the method of conversation analysis was a useful tool.

Declaration of Interest: there was no conflict of interest.

Sequence analysis in multilevel models. A study on different sources of patient cues in medical consultations

The aims of the study were to explore the importance of macro (patient, physician, consultation) and micro (doctor-patient speech sequences) variables in promoting patient cues (unsolicited new information or expressions of feelings), and to describe the methodological implications related to the study of speech sequences. Patient characteristics, a consultation index of partnership and doctor-patient speech sequences were recorded for 246 primary care consultations in six primary care surgeries in Verona, Italy. Homogeneity and stationarity conditions of speech sequences allowed the creation of a hierarchy of multilevel logit models including micro and macro level variables, with the presence/absence of cues as the dependent variable. We found that emotional distress of the patient increased cues and that cues appeared among other patient expressions and were preceded by physicians' facilitations and handling of emotion. Partnership, in terms of open-ended inquiry, active listening skills and handling of emotion by the physician and active participation by the patient throughout the consultation, reduced cue frequency.

Communication skills in psychiatry residents-- how do they handle patient concerns? An application of sequence analysis to interviews with simulated patients

BACKGROUND

The main focus of the training of psychiatrists is on diagnosis and treatment based on the traditional doctor-centered approach to the psychiatric interview. Less attention is given to the correct handling of patients' emotional concerns, which is crucial for the patient-physician relationship, but also for improving diagnostic and treatment decisions. The aim of this study is to assess psychiatrists' responses to patients' concerns and worries.

METHOD

118 consultations, conducted by 10 residents in psychiatry with 20 simulated patients, have been coded using the Verona Psychiatric Interview Classification System. Lag1 sequential analysis and a multinomial logit regression analysis were performed to investigate the relationship between patients' expressions of concern and psychiatrists' subsequent interventions in terms of patient-centered skills.

RESULTS

Compared to doctor-centered interventions, all patients' expressions of concern increased the probability of passive listening (odds ratios between 2.4 and 4.2). They also increased the occurrence of emotion focusing interventions (odds ratios between 3.3 and 1.7), which however remained rare (4% of residents' total responses). A small although significant increase in the likelihood of active listening expressions was observed as a response to two types of patient expressions of concern: statements of feelings (odds ratio 1.4) and expression of opinions regarding problematic psychosocial issues (odds ratio of 1.7).

CONCLUSIONS

Young psychiatrists are good passive listeners but need to improve active listening skills which, together with emotion focusing skills, should be a major learning target in psychiatry. These patient-centered interviewing skills should integrate those traditionally used for attributing ICD-10 and/or DSM-IV categories.

The English version of the Verona medical interview classification system (VR-MICS). An assessment of its reliability and a comparative cross-cultural test of its validity

OBJECTIVE

This study aimed to assess the inter-rater and intra-rater reliability of the English translation of the original Italian version of the VR-MICS and to evaluate its sensitivity by comparing the coding of English and Italian general practice consultations with emotionally distressed and non-distressed patients, as defined by the 12-item General Health Questionnaire (GHQ-12).

METHOD

Six male GPs from Manchester (UK) and six from Verona (Italy) each contributed five consultations, which were coded using the VR-MICS. Intra-rater and inter-rater reliability were assessed both for the division of interviews into speech units and the speech unit coding. Interaction and main effects of GHQ-12 status and nationality on patient and GP expressions were assessed by two-way ANOVA.

RESULTS

Agreement indices for the division of speech units varied between 88-96 and 87-93% for GP and patient speech, respectively; those for coding categories between 88-91 and 82-86%, with Cohen's Kappa values between 0.86-0.91 and 0.80-0.85 for GP and patient speech, respectively. Cross-cultural comparisons of patient and GP speech showed no interaction effects between GHQ-12 status and nationality. The Italian GPs were more 'doctor-centred', while the UK GPs tended to use a more 'sharing' consulting style. Independent of nationality, distressed patients talked more, gave more psychosocial cues and increased amounts of positive talk compared to non-distressed patients. GPs in both settings, when interviewing distressed patients, reduced social conversation and increased psychosocial information-giving, checking questions and reassurance.

CONCLUSION

The English translation of the VR-MICS showed satisfactory reliability indices and similar sensitivity to patients' verbal behaviours in relation to their emotional state in the two settings.

PRACTICE IMPLICATIONS

The VR-MICS may be an useful coding instrument to support collaborative research on doctor-patient communication between the two countries.

Information-giving sequences in general practice consultations

RATIONALE, AIMS AND OBJECTIVE

Most patients want to be involved in the decision-making process regarding their health and doctors need to improve their ability to meet these needs. Before implementing educational interventions, a better understanding of how information is provided in routine clinical practice is necessary. Aim of this study was to analyse the information-giving sequence of general practice consultations.

METHODS

This is an observational study that involved six general practitioners (GPs) in single-handed practices and patients (aged between 16 and 74) who consulted over a 2-month period for a new illness episode. Transcripts of 252 consultations were coded using the Verona Medical Interview Classification System that provides three categories for information giving (information on illness management; instructions on illness management and information and instructions on psychosocial aspects). Lag1 and lag2 sequential analyses were performed.

RESULTS

Information represented about one-third of the average consultation length. Medical and psychosocial information were preceded most often by patients' replies to previous questions (36% and 41%, respectively) and by listening and agreement (21% and 23%, respectively), less frequently by expression of opinions (10% and 6%, respectively). Listening and agreement were the most likely patient response after information (36%). GPs rarely tried to find out patients' view before and after the delivery of information or an instruction (<1%).

CONCLUSION

The low frequency of expressions of opinions and questions immediately before and after GPs' information and instructions, and the lack of facilitating questions indicate a limited degree of patient involvement in the information-giving sequence.

The unexpected in primary care: a multicenter study on the emergence of unvoiced patient agenda

PURPOSE

Within the time constraints of a typical physician-patient encounter, the full patient agenda will rarely be voiced. Unexpectedly revealed issues that were neither on the patient's list of items for discussion nor anticipated by the physician constitute an emerging agenda. We aimed to quantify the occurrence rate of emerging agendas in primary care practices and to explain the variation between patients and practices.

METHODS

This observational cross-sectional study involved 182 primary care practices in 9 European cultural regions. Consecutive primary care consultations were videotaped and rated. Patients completed preconsultation and postconsultation questionnaires assessing their expectations and perceived care. Emerging agenda, determined by using 11-item preconsultation and postconsultation questionnaires, was defined as care perceived by the patient to be in addition to expected care, after adjustment for cultural variations of patient expectations.

RESULTS

For consultations involving 2,243 patients (mean age, 44.8 years, 58.4% women), every sixth (15.8%) consultation revealed emerging psychosocial agenda. Biomedical agenda emerged in 14.5% of the consultations. Rates for unmet expectations were 13.6% and 10.3%, respectively, for psychosocial and biomedical problems. Practices showed considerable heterogeneity of occurrence of emerging agenda (biomedical, median 13%, range 0%-67%; psychosocial, median 14%, range 0%-53%). After controlling for region and patient baseline characteristics, variables significantly related to emerging agenda were patient expectations and biomedical or psychosocial discourse content, but not consultation time or sex of the patient. A large proportion of the variance attributable to physicians remained concealed in a practice dummy variable (explaining up to 8% of the variance).

CONCLUSION

Unexpected agenda emerges in every sixth to seventh consultation in outpatient primary care visits.

The biopsychosocial domains and the functions of the medical interview in primary care: construct validity of the Verona Medical Interview Classification System

Factor analysis (FA) is a powerful method of testing the construct validity of coding systems of the medical interview. The study uses FA to test the underlying assumptions of the Verona Medical Interview Classification System (VR-MICS). The relationship between factor scores and patient characteristics was also examined. The VR-MICS coding categories consider the three domains of the biopsychosocial model and the main functions of the medical interview-data gathering, relationship building and patient education. FA was performed on the frequencies of the VR-MICS categories based on 238 medical interviews. Seven factors (62.5% of variance explained) distinguished different strategies patients and physicians use to exchange information, build a relationship and negotiate treatment within the domains of the biopsychosocial model. Three factors, Psychological, Social Inquiry and Management of Patient Agenda, were related to patient data: sociodemographic (female gender, age and employment), social (stressful events), clinical (GHQ-12 score), personality (chance external health locus of control) and clinical characteristics (psychiatric history, chronic illness, attributed presence of emotional distress).

A patient-centred approach to defining and assessing interviewing competency

The inclusion of communication skills as a core competency in health care curricula, has led to the need to define adequacy in this area. Developments in the field of interview analysis have meant that robust and objective ways of assessing interview behaviours are now available; however, these systems in themselves do not provide a model for assessing competency. As adequacy in interviewing is contextually driven, this paper discusses the potential of using patient centeredness to address the issue. It suggests two ways in which patient centeredness may be operationally defined, permitting data available from current rating systems, and from a new system shortly to be available, to be used to assess interviewing competency.

Patient cues and medical interviewing in general practice: examples of the application of sequential analysis

AIMS

To illustrate how sequence analysis may be applied to the medical interview to: 1. explore how physicians without formal training in communication skills elicit and respond to patient cues and expression of expectations and opinions; and 2. test the hypothesis that physicians' closed ended questions determine the use of subsequent closed ended questions.

METHODS

238 consultations in primary care, coded with the Verona Medical Interview Classification System, were analysed. Lag 1 analysis was applied to study which physician behaviour precedes and follows patient cues. Pattern recognition analysis for five lag sequences was performed to test the occurrence of predefined specific code chains, where a closed and an open ended question were followed either by two closed-ended questions or by two patient facilitating interventions

RESULTS

Patients' cue offers were most likely after facilitative interventions, but not after open-ended questions; physicians were most likely to respond to these expressions with facilitation. Physicians' tendency to use closed ended questions increased after previous closed questions and decreased after an open-ended question.

CONCLUSIONS

Lag sequential analysis and pattern recognition analysis are useful methods to study exploratory and theory driven hypotheses and allow an initial approach to validate the supposed appropriateness of specific physician interventions.

Inter and intra individual variations in physicians' verbal behaviour during primary care consultations

It is well established that most medical interviews in primary care are characterised by a scarcity of patient-centred interventions and a predominance of doctor-centred behaviours. Less information is available on the intra- and inter-individual variability between the physicians' use of these categories. The study aimed to examine the impact of physician, physician's attribution of emotional distress, patients' GHQ-12 status and gender on the frequency of doctor and patient-centred verbal behaviours. A matched pair design involved six General Practitioners (GPs) and 238 patients. GPs'speech was classified using nine main categories derived from the Verona medical interview classification system (VR-MICS/D). Frequencies of the behaviours were calculated as percentages of total utterances per interview. Parametric and non-parametric ANOVAs were performed with GHQ-12 score, GP attribution of psychological distress, gender, and the six GPs as main factors. GPs varied in their use of the various interviewing behaviours. GHQ-12 status had no impact on GPs' interview behaviour, while GPs' distress attribution was associated with an increase of closed psychosocial questions and a decrease of closed medical questions. Within comparisons showed that each GP tended to change very little and only as a function of attribution: four out of six GPs increased closed psychosocial questions with patients they thought to be distressed. Patients' gender did not significantly alter GPs' interviewing behaviour. The variability in the use of specific verbal behaviours among GPs indicates a highly individualised approach and the lack of a common interview strategy. The fact that GPs' interviewing styles did not change according to patient characteristics, such as emotional distress, but only according to attribution further indicates that GPs untrained in communication techniques tend to use a predominant doctor-centred approach to the medical interview.

[Psychosocial problem disclosure during primary care consultations]

OBJECTIVE

To examine how primary care patients with psychosocial problems actually introduce and present these topics. To examine the influence of some personality traits (emotional dependency and health locus of control) on psychosocial problem disclosure.

DESIGN

"Case control". Cases had a GHQ-12 score equal or higher than three. Controls were matched with cases according to GP, GPs' attribution of absence or presence of emotional distress sex, age and presence of chronic illness.

SETTING

Six single handed primary care practices.

MEASURES

Clinical and Socio-demographic data, Social Problems List, List of 12 Threatening Life Events, GHQ-12, Multidimensional Health Locus of Control, Interpersonal Dependency Inventory and a Social Support Index.

RESULTS

The introduction of psychosocial topics by patients is related to the attribution of emotional distress by GP. Patients identified correctly as not distressed present less often psychosocial topics compared to patients recognised as distressed. Distressed patients not recognised as such more often than the others did not offer any psychosocial cue. The personality measures did not influence the presentation of psychosocial problems.

CONCLUSIONS

The lack of psycho-social cues from patients and of patient-centred skills contributed to the non recognition of emotional distressed patients. GPs' active facilitation of the presentation of psychosocial topics in such patients would improve the recognition of emotional distress.