Engaging communication experts in a Delphi process to identify patient behaviors that could enhance communication in medical encounters

Jaya K Rao,Richard M Frankel,Bhuvana Sukumar,Terry Stein,Danielle A Beauchesne,Lynda A Anderson

doi:10.1186/1472-6963-10-97

Abstract

BackgroundThe communication literature currently focuses primarily on improving physicians' verbal and non-verbal behaviors during the medical interview. The Four Habits Model is a teaching and research framework for physician communication that is based on evidence linking specific communication behaviors with processes and outcomes of care. The Model conceptualizes basic communication tasks as "Habits" and describes the sequence of physician communication behaviors during the clinical encounter associated with improved outcomes. Using the Four Habits Model as a starting point, we asked communication experts to identify the verbal communication behaviors of patients that are important in outpatient encounters.MethodsWe conducted a 4-round Delphi process with 17 international experts in communication research, medical education, and health care delivery. All rounds were conducted via the internet. In round 1, experts reviewed a list of proposed patient verbal communication behaviors within the Four Habits Model framework. The proposed patient verbal communication behaviors were identified based on a review of the communication literature. The experts could: approve the proposed list; add new behaviors; or modify behaviors. In rounds 2, 3, and 4, they rated each behavior for its fit (agree or disagree) with a particular habit. After each round, we calculated the percent agreement for each behavior and provided these data in the next round. Behaviors receiving more than 70% of experts' votes (either agree or disagree) were considered as achieving consensus.ResultsOf the 14 originally-proposed patient verbal communication behaviors, the experts modified all but 2, and they added 20 behaviors to the Model in round 1. In round 2, they were presented with 59 behaviors and 14 options to remove specific behaviors for rating. After 3 rounds of rating, the experts retained 22 behaviors. This set included behaviors such as asking questions, expressing preferences, and summarizing information.ConclusionThe process identified communication tasks and verbal communication behaviors for patients similar to those outlined for physicians in the Four Habits Model. This represents an important step in building a single model that can be applied to teaching patients and physicians the communication skills associated with improved satisfaction and positive outcomes of care.

Highlights

The communication literature currently focuses primarily on improving physicians' verbal and nonverbal behaviors during the medical interview
The experts were asked, "Which patient verbal communication behaviors should be added to the Four Habits Model so that it reflects the interactive nature of communication between physicians and patients?" We describe our approach and findings and discuss the implications of our results
23 experts responded to our initial invitation and agreed to participate; this group was balanced with respect to gender (11 females, 12 males) and included 5 individuals from countries outside of United States (US)

Summary

Introduction

The communication literature currently focuses primarily on improving physicians' verbal and nonverbal behaviors during the medical interview. Prior investigations have demonstrated substantial progress in improving specific communicative behaviors of physicians and patients, they have tended to focus exclusively on either the physician or patient, and do not examine how the physician's and patient's communication behaviors relate to each other during the interaction These limitations were noted by Inui and colleagues in 1985 [4], and to a certain extent, may result from the lack of an overarching framework that describes the sequence of physician and patient communication behaviors as they might occur during the course of a clinical visit. The Four Habits Model addresses these concerns by focusing on how temporal and sequential elements of the encounter relate to each another and to outcomes (Table 1) [5,6,7,8,9] This framework identifies the basic communication tasks of the clinical encounter and conceptualizes how these tasks or "habits" relate to one another during the visit. Each habit includes a group of physician communication behaviors and skills that are associated with effective clinical practice and positive health outcomes [7,8]

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