title: The Physician Recommendation Coding System (PhyReCS): A Reliable and Valid Method to Quantify the Strength of Physician Recommendations During Clinical Encounters.
abstract: Physicians' recommendations affect patients' treatment choices. However, most research relies on physicians' or patients' retrospective reports of recommendations, which offer a limited perspective and have limitations such as recall bias.
  
  
  
  To develop a reliable and valid method to measure the strength of physician recommendations using direct observation of clinical encounters.
  
  
  
  Clinical encounters (n = 257) were recorded as part of a larger study of prostate cancer decision making. We used an iterative process to create the 5-point Physician Recommendation Coding System (PhyReCS). To determine reliability, research assistants double-coded 50 transcripts. To establish content validity, we used 1-way analyses of variance to determine whether relative treatment recommendation scores differed as a function of which treatment patients received. To establish concurrent validity, we examined whether patients' perceived treatment recommendations matched our coded recommendations.
  
  
  
  The PhyReCS was highly reliable (Krippendorf's alpha = 0.89, 95% CI [0.86, 0.91]). The average relative treatment recommendation score for each treatment was higher for individuals who received that particular treatment. For example, the average relative surgery recommendation score was higher for individuals who received surgery versus radiation (mean difference = 0.98, SE = 0.18, P < 0.001) or active surveillance (mean difference = 1.10, SE = 0.14, P < 0.001). Patients' perceived recommendations matched coded recommendations 81% of the time.
  
  
  
  The PhyReCS is a reliable and valid way to capture the strength of physician recommendations. We believe that the PhyReCS would be helpful for other researchers who wish to study physician recommendations, an important part of patient decision making.
authors.affiliation: Fuqua School of Business, Duke University, Durham, NC (KAS, LDW, JKD, PAU).|School of Medicine, Duke University, Durham, NC (KAS, PAU).
authors.forename: Karen A
authors.initials: KA
authors.lastname: Scherr
authors.affiliation: Departments of Internal Medicine and Psychology, Center for Bioethics and Sciences in Medicine, University of Michigan Ann Arbor (AF).|The Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI (AF).
authors.forename: Angela
authors.initials: A
authors.lastname: Fagerlin
authors.affiliation: Fuqua School of Business, Duke University, Durham, NC (KAS, LDW, JKD, PAU).
authors.forename: Lillie D
authors.initials: LD
authors.lastname: Williamson
authors.affiliation: Fuqua School of Business, Duke University, Durham, NC (KAS, LDW, JKD, PAU).
authors.forename: J Kelly
authors.initials: JK
authors.lastname: Davis
authors.affiliation: Columbia Business School, Columbia University, New York, NY (IF).
authors.forename: Ilona
authors.initials: I
authors.lastname: Fridman
authors.affiliation: Duke University, Durham, NC (NA).
authors.forename: Natalie
authors.initials: N
authors.lastname: Atyeo
authors.affiliation: Fuqua School of Business, Duke University, Durham, NC (KAS, LDW, JKD, PAU).|School of Medicine, Duke University, Durham, NC (KAS, PAU).|Sanford School of Public Policy, Duke University, Durham, NC (PAU).
authors.forename: Peter A
authors.initials: PA
authors.lastname: Ubel
mesh_terms: D000368:Aged; D002755:Choice Behavior; D003142:Communication; D003657:Decision Making; D003661:Decision Support Techniques; D006801:Humans; D000067010:Literacy; D008297:Male; D008875:Middle Aged; D010358:Patient Participation / Q000379:methods*; D057240:Patient Preference; D011471:Prostatic Neoplasms / Q000628:therapy*; D036301:Qualitative Research; D015203:Reproducibility of Results
keywords: physician-patient communication; prostate cancer; qualitative methods; shared decision making