Looking for trouble: the added value of sequence analysis in finding evidence for the role of physicians in patients' disclosure of cues and concerns.
BACKGROUND
Not knowing patient concerns can lead to misunderstandings, incomplete diagnoses, patient dissatisfaction, and nonadherence. Although many studies show relations between physician communication and patients' expression of cues or concerns, most of these studies are cross-sectional, thus limiting the interpretation of these relationships. Sequence analysis can show the immediate effects of physician communication behaviors.


OBJECTIVE
To show the added value of sequence analysis in finding evidence for the role of physician communication in patients' disclosure of cues and concerns.


OBJECTIVE
Which physician communication predicts patients' expression of cues or concerns when using 2 different types of analysis: sequence analysis and cross-sectional analysis?


METHODS
In a sample of 99 videotaped medical encounters with hypertensive patients in General Practice, we coded communication with Roter Interaction Analysis System and timed physician eye contact. For the cross-sectional analyses, we performed Poisson regression analyses to establish which physician communication is related to the total amount of patient cues and concerns. For the sequential analyses, we performed logistic regression analyses to establish which physician communication is directly followed by cues or concerns. We report incidence rate ratios and odds ratios (ORs), respectively.


RESULTS
Both methods show that physicians' facilitative communication (1.21 and 2.33, respectively), eye contact (1.02 and 1.51, respectively), and psychosocial questions (2.42 and 3.50, respectively) are related to more disclosure of cues and concerns. Moreover, sequence analysis shows that patients' expression of cues or concerns is less often preceded by physician social talk (OR = 0.49), giving instructions (OR = 0.38) and providing biomedical information (OR = 0.45) or counseling (OR = 0.39). In the cross-sectional analyses, these relations are absent or-before controlling for confounding variables-even in the opposite direction. All reported results are significant at P < 0.01 or P < 0.001.


CONCLUSIONS
Although cross-sectional analyses and sequence analyses show grossly the same results, sequence analysis is more precisely in demonstrating the direct influence of physician communication on subsequent cues and concerns by the patient. Physicians should avoid long monologues with medical information and should use facilitative communication, eye contact, and psychosocial questions to help patients express themselves.
Bensing
Jozien M
JM
NIVEL (Netherlands Institute for Health Services Research), Utrecht, The Netherlands. j.bensing@nivel.nl
Verheul
William
W
Jansen
Jesse
J
Langewitz
Wolf A
WA
D002983:Clinical Competence; D003142:Communication; D003430:Cross-Sectional Studies; D003463:Cues; D006801:Humans; D016015:Logistic Models; D008875:Middle Aged; D009633:Nonverbal Communication; D016017:Odds Ratio; D010817:Physician-Patient Relations; D016012:Poisson Distribution; D012044:Regression Analysis; D014705:Verbal Behavior; D014741:Video Recording