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Biomedical subjects

Debra Roter

Publications and source records attributed to Debra Roter.

At least 19 recordsLinked to original sources
PubMed2006

Genetic counseling communication with an African American BRCA1 kindred.

We studied communication in genetic counseling sessions conducted with an African American, Breast Cancer 1, Early Onset (BRCA1) kindred in the USA. The Roter Interaction Analysis System (RIAS) was used to code and compare two sessions of 46 participants (26 females and 20 males) before and after they underwent genetic testing. Three certified genetic counselors and one medical geneticist conducted the sessions. When compared to pre-test communication, most of the providers' post-test communication was devoted to the provision of biomedical information (including screening recommendations) with fewer questions and psychosocial statements. Clients contributed a similar proportion to the total session dialogue in pre- and post-test sessions (40%). A larger proportion of their post-test session was devoted to indicating receptiveness to provider information than in the pre-test session. We found when providers were informing clients that they were BRCA1 mutation carriers, they provided more biomedical and psychosocial information and asked more psychosocial questions than when talking with non-carriers. This study provides the first description of genetic counseling communication for pre- and post-test BRCA1 sessions with African American individuals.

Black or African American↗
PubMed2006

Impact of breast cancer screening intervention on Korean-American women in Maryland.

BACKGROUND: Adherence to mammography guidelines among Korean-American women (KAW) is lower than that of Caucasian-Americans, and disparities in breast cancer screening related to lack of English proficiency is under-researched. This study examined the impact of a breast cancer intervention on intentions to use mammography among KAW. METHODS: Face-to-face pre-intervention surveys were conducted in control (n=95) and intervention groups (n=105), and were followed by implementation of a breast cancer education program. At 6 months, both groups were re-interviewed by phone (92 control and 94 intervention participants). Generalized estimating equation (GEE) analysis was used to assess the intervention effect before and after the breast cancer educational program. RESULTS: The intervention effect was statistically significant. Women in the intervention reported 2.96 times greater posttest intentions to have mammogram than those in the control group (95% CI, 1.13-7.66). Prior intentions, age, and positive attitudes toward mammography were associated with follow-up intentions to have a mammogram. CONCLUSION: This culturally and linguistically tailored educational intervention was effective in increasing breast cancer awareness in a non-English speaking population.

Adult↗
PubMed2006

Exploring genetic counseling communication patterns: the role of teaching and counseling approaches.

The educational and counseling models are often touted as the two primary professional approaches to genetic counseling practice. Yet, research has not been conducted to examine how these approaches are used in practice. In the present study, we conducted quantitative communication analyses of BRCA1 genetic counseling sessions. We measured communication variables that represent content (e.g., a biomedical focus) and process (e.g., passive listening) to explore whether genetic counselor approaches are consistent with prevailing professional models. The Roter Interaction Analysis System (RIAS) was used to code 167 pre-test genetic counseling sessions of members of a large kindred with an identified BRCA1 mutation. Three experienced genetic counselors conducted the sessions. Creating composite categories from the RIAS codes, we found the sessions to be largely educational in nature with the counselors and clients devoting the majority of their dialogue to providing biomedical information (62 and 40%, respectively). We used cluster analytic techniques, entering the composite communication variables and identified four patterns of session communication: Client-focused psychosocial, biomedical question and answer, counselor-driven psychosocial, and client-focused biomedical. Moreover, we found that the counselors had unique styles in which they combined the use of education and counseling approaches. We discuss the importance of understanding the variation in counselor communication to advance the field and expand prevailing assumptions.

Adult↗
PubMed2006

Electronic medical record use and physician-patient communication: an observational study of Israeli primary care encounters.

OBJECTIVES: Within the context of medical care there is no greater reflection of the information revolution than the electronic medical record (EMR). Current estimates suggest that EMR use by Israeli physicians is now so high as to represent an almost fully immersed environment. This study examines the relationships between the extent of electronic medical record use and physician-patient communication within the context of Israeli primary care. METHODS: Based on videotapes of 3 Israeli primary care physicians and 30 of their patients, the extent of computer use was measured as number of seconds gazing at the computer screen and 3 levels of active keyboarding. Communication dynamics were analyzed through the application of a new Hebrew translation and adaptation of the Roter Interaction Analysis System (RIAS). RESULTS: Physicians spent close to one-quarter of visit time gazing at the computer screen, and in some cases as much as 42%; heavy keyboarding throughout the visit was evident in 24% of studied visits. Screen gaze and levels of keyboarding were both positively correlated with length of visit (r = .51, p < .001 and F(2,27) = 2.83, p < .08, respectively); however, keyboarding was inversely related to the amount of visit dialogue contributed by the physician (F(2,27) = 4.22, p < .02) or the patient (F(2,27) = 3.85, p < .05). Specific effects of screen gaze were inhibition of physician engagement in psychosocial question asking (r = -.39, p < .02) and emotional responsiveness (r = -.30, p < .10), while keyboarding increased biomedical exchange, including more questions about therapeutic regimen (F(2,27) = 4.78, p < .02) and more patient education and counseling (F(2,27) = 10.38, p < .001), as well as increased patient disclosure of medical information to the physician (F(2,27) =3.40, p < .05). A summary score reflecting overall patient-centered communication during the visit was negatively correlated with both screen gaze and keyboarding (r = -.33, p < .08 and F(2,27) = 3.19, p < .06, respectively). DISCUSSION: The computer has become a 'party' in the visit that demanded a significant portion of visit time. Gazing at the monitor was inversely related to physician engagement in psychosocial questioning and emotional responsiveness and to patient limited socio-emotional and psychosocial exchange during the visit. Keyboarding activity was inversely related to both physician and patient contribution to the medical dialogue. Patients may regard physicians' engrossment in the tasks of computing as disinterested or disengaged. Increase in visit length associated with EMR use may be attributed to keyboarding and computer gazing. CONCLUSIONS: This study suggests that the way in which physicians use computers in the examination room can negatively affect patient-centered practice by diminishing dialogue, particularly in the psychosocial and emotional realm. Screen gaze appears particularly disruptive to psychosocial inquiry and emotional responsiveness, suggesting that visual attentiveness to the monitor rather than eye contact with the patient may inhibit sensitive or full patient disclosure. PRACTICAL IMPLICATIONS: We believe that training can help physicians optimize interpersonal and educationally effective use of the EMR. This training can assist physicians in overcoming the interpersonal distancing, both verbally and non-verbally, with which computer use is associated. Collaborative reading of the EMR can contribute to improved quality of care, enhance the decision-making process, and empower patients to participate in their own care.

Adult↗
PubMed2005

How much do surgeons like their patients?

OBJECTIVES: Physicians experience feelings of caring and sometimes frustration toward patients during routine visits. To date, no studies have explored surgeons' feelings toward patients. Our objectives were: (1) to examine how much surgeons like their patients and (2) to assess the relationship of surgeons' liking to patient and surgeon characteristics and to patient satisfaction. METHODS: Participants included 66 surgeons (orthopaedic and general surgeons) in community practice in Colorado and Oregon, and 701 of their patients. Exit questionnaires asked surgeons how much they liked the patient on a 1-5 scale ranging from "not at all" to "very much". Patients scored satisfaction with the visit on a 1-5 scale. Logistic regression was conducted with surgeon liking and patient satisfaction as dependent variables. RESULTS: Surgeons' ratings of liking ranged across all five categories. Patient characteristics including age over 65 years, higher education and income, and better health were associated with higher liking scores. Surgeon characteristics hours worked per week, practice setting and surgeons' self-rating of their own health were associated with liking. Patient satisfaction were associated with "liking". CONCLUSION AND PRACTICE IMPLICATIONS: These findings shed light on a rarely addressed issue-surgeons' feelings toward their patients. We found that surgeons do not like their patients equally. Their feelings are associated with surgeon and patient characteristics, and with patient satisfaction. Our findings have important implications for surgeons seeking to improve care striving to enhance or maintain their own career satisfaction.

Adult↗
PubMed2005

Communication analysis of BRCA1 genetic counseling.

In this study, we apply an existing medical communication coding system to BRCA1 genetic counseling sessions, describe the session dynamics, and explore variation in session communication. The sample was comprised of 167 members of an identified BRCA1 kindred whose pretest counseling session was audiotaped and coded using Roter's Interaction Analysis System (RIAS). Three certified genetic counselors followed a research protocol that dictated areas to be covered in the counseling session. We found that it was feasible to code long, protocol driven BRCA1 sessions in a quantitative manner without the use of transcripts and capture the dialogue of all session participants. These findings support the use of RIAS in genetic counseling research. Our results indicate that these BRCA1 sessions were predominantly educational in nature with minimal dialogue devoted to psychosocial issues. We found that participant gender, presence of a client companion, and counselor identity influence session communication.

Communication↗
PubMed2005

How do obstetric providers discuss referrals for prenatal genetic counseling?

To investigate referrals of pregnant women to genetic counseling, we analysed transcripts from audiotaped first prenatal visits of 104 patients (72 actual patient visits and 32 simulated patient visits) with 32 providers (obstetricians and nurse-midwives). All patients had at least one indication for referral. Only 10% of visits with actual patients included a genetic counseling referral. When genetic counseling was discussed, it was only briefly described, primarily as an information session. This study shows that the majority of pregnant women with an indication for referral for genetic counseling are not referred. In addition, obstetric providers' inadequate descriptions of prenatal genetic counseling may result in women being poorly prepared for genetic counseling sessions.

Adult↗
PubMed2005

Autonomy-related behaviors of patient companions and their effect on decision-making activity in geriatric primary care visits.

The objective of this study, undertaken in the USA, was to investigate the consequences of autonomy-related companion behaviors on patient decision-making activity during geriatric primary care visits. Videotapes were analyzed to characterize patient and companion decision-making activity and related companion behaviors. These behaviors were coded throughout the visit using an autonomy-based framework that included both autonomy enhancing (i.e. facilitating patient understanding, patient involvement, and doctor understanding) and detracting behaviors, (i.e. controlling the patient and building alliances with the physician). Patients (N = 93) in this cross-sectional sample range in age from 65 to 95 years and are mostly white (n = 73, 79%) and female (n = 67, 72%). Companions are spouses (n = 42, 46%), adult children (n = 33, 36%), or other relatives and friends (n = 15, 16%) of patients. Companions are active participants in medical visits and engage in more autonomy enhancing than detracting behaviors. Companions of sicker (compared with less sick) patients were more likely to facilitate patient understanding, p < .05; doctor understanding, p < .01; and patient involvement, p = .06, in care. Patients whose companions facilitated their involvement in the medical visit by asking the patient questions, prompting the patient to talk, and asking for the patient's opinion were more than four times as likely to be active in decision-making as patients whose companions did not assist in this manner (unadjusted OR 3.5, CI 1.4-8.7, p < .01; adjusted OR 4.5, CI 1.6-12.4, p < .01). Companions can play an important role in the visits of geriatric patients by facilitating communication throughout the visit as well as patient activity in decision-making.

Aged↗
PubMed2004

Improving client-provider communication: evaluation of a training program for women, infants and children (WIC) professionals in New York state.

Results are presented from evaluation of an intensive 1 day training program to improve the growth monitoring counseling skills of Special Supplemental Nutrition Program for Women, Infants and Children (WIC) providers. The training was framed by the patient-centered approach, and focused on a seven-step technique that emphasized eliciting client perspective on the child's health and negotiating follow-up strategies. Changes in skill were assessed during audiotaped mock counseling sessions with simulated clients. Observed intervention effects were moderate but encouraging for future training programs. After the training, more providers elicited client perspective, and provider level of engagement in negotiating with the client increased. At post-test providers asked more open-ended questions than at pre-test, and provider-to-client talk ratio decreased. Increases in provider total and competence-related satisfaction paralleled improvements in counseling proficiency. Study results suggest that counseling skills of non-physician health providers can change after a 1 day focused training: providers were more client-centered in their discussions. Limitations and implications of the study are discussed.

Attitude of Health Personnel↗
PubMed2004

What do physicians tell patients about themselves? A qualitative analysis of physician self-disclosure.

OBJECTIVE: Physician self-disclosure (PSD) has been alternatively described as a boundary violation or a means to foster trust and rapport with patients. We analyzed a series of physician self-disclosure statements to inform the current controversy. DESIGN: Qualitative analysis of all PSD statements identified using the Roter Interaction Analysis System (RIAS) during 1,265 audiotaped office visits. SETTING AND PARTICIPANTS: One hundred twenty-four physicians and 1,265 of their patients. MAIN RESULTS: Some form of PSD occurred in 195/1,265 (15.4%) of routine office visits. In some visits, disclosure occurred more than once; thus, there were 242 PSD statements available for analysis. PSD statements fell into the following categories: reassurance (n = 71), counseling (n = 60), rapport building (n = 55), casual (n = 31), intimate (n = 14), and extended narratives (n = 11). Reassurance disclosures indicated the physician had the same experience as the patient ("I've used quite a bit of that medicine myself"). Counseling disclosures seemed intended to guide action ("I just got my flu shot"). Rapport-building disclosures were either humorous anecdotes or statements of empathy ("I know I'd be nervous, too"). Casual disclosures were short statements that had little obvious connection to the patient's condition ("I wish I could sleep sitting up"). Intimate disclosures refer to private revelations ("I cried a lot with my divorce, too") and extended narratives were extremely long and had no relation to the patient's condition. CONCLUSIONS: Physician self-disclosure encompasses complex and varied communication behaviors. Self-disclosing statements that are self-preoccupied or intimate are rare. When debating whether physicians ought to reveal their personal experiences to patients, it is important for researchers to be more specific about the types of statements physicians should or should not make.

Counseling↗
PubMed2004

Is physician self-disclosure related to patient evaluation of office visits?

CONTEXT: Physician self-disclosure has been viewed either positively or negatively, but little is known about how patients respond to physician self-disclosure. OBJECTIVE: To explore the possible relationship of physician self-disclosure to patient satisfaction. DESIGN: Routine office visits were audiotaped and coded for physician self-disclosure using the Roter Interaction Analysis System (RIAS). Physician self-disclosure was defined as a statement describing the physician's personal experience that has medical and/or emotional relevance for the patient. We stratified our analysis by physician specialty and compared patient satisfaction following visits in which physician self-disclosure did or did not occur. PARTICIPANTS: Patients (N= 1,265) who visited 59 primary care physicians and 65 surgeons. MAIN OUTCOME MEASURE: Patient satisfaction following the visit. RESULTS: Physician self-disclosure occurred in 17% (102/589) of primary care visits and 14% (93/676) of surgical visits. Following visits in which a primary care physician self-disclosed, fewer patients reported feelings of warmth/friendliness (37% vs 52%; P =.008) and reassurance/comfort (42% vs 55%; P =.027), and fewer reported being very satisfied with the visit (74% vs 83%; P =.031). Following visits in which a surgeon self-disclosed, more patients reported feelings of warmth/friendliness (60% vs 45%; P =.009) and reassurance/comfort (59% vs 47%; P=.044), and more reported being very satisfied with the visit (88% vs 75%; P =.007). After adjustment for patient characteristics, length of the visit, and other physician communication behaviors, primary care patients remained less satisfied (adjusted odds ratio [AOR], 0.45; 95% confidence interval [CI], 0.24 to 0.81) and surgical patients more satisfied (AOR, 2.22; 95% CI, 1.12 to 4.50) after visits in which the physician self-disclosed. CONCLUSIONS: Physician self-disclosure is significantly associated with higher patient satisfaction ratings for surgical visits and lower patient satisfaction ratings for primary care visits. Further study is needed to explore these intriguing findings and to define the circumstances under which physician self-disclosure is either well or poorly received.

Female↗
PubMed2004

Teaching communication skills: an AACE survey of oncology training programs.

BACKGROUND: The extent of communication skills training (CST) in American oncology fellowship programs is unknown. METHODS: A survey was sent to program directors of medical oncology, radiation oncology, gynecologic oncology, and surgical oncology training programs regarding (1) the presence and method(s) of CST in their programs, (2) their attitude about mandatory CST, and (3) their attitude about a mandatory assessment of communication skills competence as a prerequisite for specialty certification. RESULTS: Only a third of programs contained some form of CST. Surgical oncology programs were particularly lacking. Lack of faculty time was cited as the major barrier to implementing CST. A majority of program directors support mandatory CST but not a core competence requirement for certification. CONCLUSIONS: There is a current deficiency in CST in American oncology fellowship training. Given the importance of communication skills in the provision of high-quality cancer care, initiatives to address this deficiency are a priority.

CD-ROM↗
PubMed2004

Patient race/ethnicity and quality of patient-physician communication during medical visits.

OBJECTIVES: We examined the association between patient race/ethnicity and patient-physician communication during medical visits. METHODS: We used audiotape and questionnaire data collected in 1998 and 2002 to determine whether the quality of medical-visit communication differs among African American versus White patients. We analyzed data from 458 African American and White patients who visited 61 physicians in the Baltimore, Md-Washington, DC-Northern Virginia metropolitan area. Outcome measures that assessed the communication process, patient-centeredness, and emotional tone (affect) of the medical visit were derived from audiotapes coded by independent raters. RESULTS: Physicians were 23% more verbally dominant and engaged in 33% less patient-centered communication with African American patients than with White patients. Furthermore, both African American patients and their physicians exhibited lower levels of positive affect than White patients and their physicians did. CONCLUSIONS: Patient-physician communication during medical visits differs among African American versus White patients. Interventions that increase physicians' patient-centeredness and awareness of affective cues with African Americans patients and that activate African American patients to participate in their health care are important strategies for addressing racial/ethnic disparities in health care.

Affect↗
PubMed2003

Longitudinal care improves disclosure of psychosocial information.

BACKGROUND: While longitudinal primary care is thought to promote patient rapport and trust, it is not known if longitudinality helps overcome barriers to communication that may occur when the patient and physician are of different ethnicities and/or sexes. OBJECTIVE: To examine if longitudinal pediatric care ameliorates disparities in parent disclosure of psychosocial information associated with ethnic and gender discordance between parent and physician. DESIGN: Longitudinal, observational study of parent-physician interaction at early visits and over the course of 1 year. PARTICIPANTS: Parents (90% African American and 10% white mothers or female guardians) and their infant's assigned primary care physician (white first- and second-year pediatric residents). MAIN OUTCOME MEASURE: Parents' psychosocial information giving measured by the Roter Interaction Analysis System. RESULTS: Sex- and race-related barriers to disclosure of psychosocial information were evident early in the parent-physician relationship. At early visits, African American mothers made 26% fewer psychosocial statements than white mothers; this discrepancy was not affected by physician sex. At early visits, white mothers made twice as many psychosocial statements when seeing white female compared with white male physicians. CONCLUSIONS: Patient-centeredness is an important factor promoting psychosocial information giving for African American and white mothers, regardless of physician sex. Longitudinal relationships facilitate mothers' disclosure to physicians of a different ethnicity or sex, but only if physicians remain patient-centered.

Adolescent↗
PubMed2002

Mechanisms behind the failure of residents' longitudinal primary care to promote disclosure and discussion of psychosocial issues.

CONTEXT: Longitudinality (care by a single physician over time) and continuity (receipt of most care from a single physician) are believed to enhance patient-physician relationships and facilitate disclosure of emotional distress, but some studies suggest this potential goes unrealized. OBJECTIVES: To determine whether care in a pediatric residents' continuity clinic promotes, over time, increased discussion, disclosure, and detection of parents' social and emotional distress and to understand physicians' communication behaviors underlying changes with time. DESIGN: Longitudinal, observational study of parent-physician interaction over the course of 1 year. PARTICIPANTS: One hundred ninety parents (90% African American) and their infants' primary care physicians (31 [4 Asians and 27 whites] first- and second-year pediatric residents). MAIN OUTCOME MEASURES: Frequency with which parents and physicians raised topics related to parental mood and family or social functioning; proportion of distressed parents discussing mood or functioning; and physicians' detection of parent distress. RESULTS: Physician initiation of psychosocial topics fell in the course of longitudinal relationships (odds of initiation in visits > or =6 vs odds of initiation in visits 1-5 = 0.46 [95% confidence limits, 0.31%, 0.67%]); parent initiation did not change over time nor was it increased by greater levels of continuity. Length of relationship was not associated with increased physician detection of parental distress or with increased rates of disclosure by distressed parents. Physicians' positively framed leading questions, and their avoidant responses to prior parental disclosures were significantly associated with decreased odds of problem disclosure. In contrast, visits in which parents or physicians raised psychosocial topics were characterized, on average, by 40% higher levels of physicians' "patient-centeredness" (increases of about 100 utterances per visit [95% confidence limits, 65.7%, 133.9%]). CONCLUSIONS: Longitudinal relationships between residents and patients may not be sufficient to promote the discussion, disclosure, and detection of psychosocial issues. Training in communication skills may help residents achieve the potential and goals of longitudinal care.

Adult↗
PubMed2002

The relevance of client-centered communication to family planning settings in developing countries: lessons from the Egyptian experience.

Concern for client's rights in the provision of reproductive health services in the developing world has prompted intense efforts by international experts to promote client-centered models of communication as a replacement for more provider-centered approaches. Nonetheless, the usefulness or feasibility of cross-cultural transplantation of client-centered models of communication has not been examined. The present study examines the feasibility, acceptability, and effectiveness of client-centered models of communication in 31 family planning clinics in Egypt. Consultations between 34 physicians and 112 clients requesting family planning methods were audio-taped and analyzed for physician communication style. Client satisfaction was measured through exit interviews. Method continuation was determined through home interviews at 3 and 7 months from the index visit. Based on audio-tape analysis, two-thirds of physician consultations were characterized as physician-centered and one-third as client-centered. Client-centered consultations were only one minute longer than physician-centered consultations. A client-centered consultation was associated with a three-fold increase in the likelihood of client satisfaction and method continuation at 7 months. A high proportion of solidarity statements (positive talk) by the physician was predictive of client satisfaction whereas a high proportion of disagreement statements and directive instructions by the physician were predictive of method discontinuation. The study findings suggest that in Egypt, as in more developed countries, client-centered models of communication are likely to produce better client outcomes than provider-centered models, with no substantial changes in the structure of services.

Adult↗
PubMed2002

Patient adherence to HIV medication regimens: a review of published and abstract reports.

A literature search was conducted to collect published articles reporting correlates of HIV medication adherence or interventions designed to increase HIV medication adherence. Proceedings from seven HIV/AIDS-related conferences were searched for relevant abstracts. We found 18 descriptive studies in published articles and 57 in conference proceedings producing over 200 separate variables falling into four broad areas: (1) factors related to treatment regimen; (2) social and psychological factors; (3) institutional resources; and (4) personal attributes. More complex regimens were related to decreased adherence, but were often successfully mitigated by regimen aids. Social and psychological factors reflecting emotional adjustment to HIV/AIDS and provider support were related to adherence. Access to institutional resources was associated with better adherence. Personal attributes showed a mixed relationship; gender was not consistently related to adherence, but younger age, minority status, and a history of substance abuse were often related to non-adherence. The intervention search yielded 16 interventions employing a wide range of behavioral, cognitive and affective strategies. Evidence of effectiveness was weak. We conclude the abstracts are a useful source of information as part of a systematic review, particularly when available published literature is limited, if results and study characteristics are reported in an adequate and standard manner.

Adult↗