Comunicação entre profissionais de saúde e pacientes: revisão dos
                  estudos que utilizaram o método RIAS (<i>Roter Interaction Analysis
                     System</i>)

Pires, Carla M.; Cavaco, Afonso M.

doi:10.1590/1806-9282.60.02.014

Tabla de contenido Anterior Actual Siguiente

Tabla de contenido

REVIEW ARTICLES • Rev. Assoc. Med. Bras. 60 (2) • 2014 • https://doi.org/10.1590/1806-9282.60.02.014 linkcopiar

Comunicação entre profissionais de saúde e pacientes: revisão dos estudos que utilizaram o método RIAS (Roter Interaction Analysis System)

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo

Objetivo: rever, de forma sistemática os estudos que investigaram a comunicação entre pacientes e profissionais de saúde através da aplicação da metodologia RIAS.

Métodos: foram utilizados como expressão-chave Roter Interaction Analysis System e os recursos bibliográficos de: Academic Search Complete, Current Contents, ISI Proceedings, PubMed, Elsevier, SpringerLink, Web of Science, RCAAP, Solo e o site oficial do RIAS. Período de seleção: 2006 a 2011. Os estudos foram selecionados por análise dicotômica multicritério e organizados segundo os critérios PRISMA.

Resultados: identificação de 1.262 artigos (455 não repetidos). Foram selecionados para análise 34 artigos, distribuídos pelas seguintes profissões de saúde: médicos de medicina geral e familiar (14), pediatras (5), enfermeiros (4), geneticistas (3), prestadores de cuidados a pacientes com Aids (2), oncologistas (2), cirurgiões (2), anestesistas (1) e especialistas de planejamento familiar (1). O RIAS é escassamente utilizado e divulgado no âmbito dos cuidados de saúde nos países de língua portuguesa.

Discussão: os principais temas estudados incluíram a influência do cansaço, ansiedade e esgotamento profissional na comunicação e o impacto das ações específicas de formação no exercício profissional. A revisão permitiu identificar as principais forças e fraquezas na comunicação verbal, em díade e síncrona na prestação de cuidados de saúde.

Conclusão: a investigação científica da comunicação entre profissionais de saúde e pacientes por meio do RIAS tem produzido resultados concretos. É esperada uma melhoria dos resultados em saúde decorrente da aplicação do RIAS.

RIAS; Roter Interaction Analysis System ; comunicação; profissionais de saúde

Resource	Results	Selected
Elsevier	29	1
PubMed	120	3
Solo	145	6
RIASWORKS Website	161	16
Highwire Press	75	5
SCIRUS	355	3
ISI Proceedings	0	0
SpringerLink	30	0
RCAAP	4	0
DOAJ	2	0
Web of Science	119	0
SciELO	0	0
Academic Search Complete	30	0
Willey Online	30	0
Current Contents	108	0
Annual Reviews	12	0
OAIster	42	0
TOTAL	1.262	34

Citation	Objective	Venue	Nº P	Nº HP	Results, discussion and conclusions*	Other observations
	Family medicine
Greer RC et al. (2010)⁷	Evaluate the quality of communication about chronic kidney disease in primary care	USA (Baltimore, MD)	236	40	• The physicians frequently used technical terms (28%, n= 17).	• 15 primary care practices.
						• Hypertensive patients. Studies with the enrollment of more participants might be desirable(conclusions are not generalizable).
					• The comprehension of technical terms by patients rarely was confirmed by physicians (2%, n= 1).
					• The discussion on chronic renal disease was not frequent in encounters.
					• Ideally, these types of discussions must be encouraged.
					• The optimization of the communication between patients and physicians on these issues might promote better health outcomes.
Beach MC et al. (2006)⁸	Evaluate the attitudes of respect between physicians and patients	USA (Baltimore and Washington, DC)	215	30	• The physicians' perception of respect by patients was variable, and was preferentially associated with patients' familiarity.	• Physicians rated their level of respect by patients (after each encounter).Questionnaire (patients).
Haskard B et al. (2008)⁹	Investigate the impact of a training intervention on communication	USA	2196 (Total treated patients)	156	• This training aimed to improve physicians' communication, and stimulate the participation of the patients.	• Randomized experiment.
						• Controlled trial.
						• Groups: 1) physicians received training; 2) patients received training, and 3) both received training.
					• Patients' and physicians' satisfaction might be improved with this type of training.
Bensing M et al. (2008) ¹⁰	To characterize the verbal and non-verbal communication, and possibly patients' anxiety	Holland	2095 (1388)	142	• The patients' concerns were not directly expressed in more than a half of the consultations, nor even by patients with a higher level of anxiety.	• Patient direct gaze (percentage). Questionnaire (administered before consultation). Patients' subjective health, state anxiety, and reason for encounter was evaluated.
Bensing M et al. (2008) ¹⁰		Holland	2095 (1388)	142	• General practitioners might encourage patients to express their concerns: verbally, or non-verbally (e.g. showing more affect).
Mjaaland TA et al. (2009) ¹¹	Analyze the effects of a communication skills training for general practitioners	Norway	266	25	• The communication patterns between general practitioners and patients changed in some situations.	• Communication skill training: 40h
Mjaaland TA et al. (2009) ¹¹		Norway	266	25		• Examples of skills: 1) obtain indicators of the disease, such as subjective symptoms of the patient; 2) give an explanation to the patient about their health problems; 3) identify solutions and resources, and 4) promote appropriate behaviors.
Weingarten MA et al. (2010) ¹²	Investigate the nature of conflicts between doctors and patients (primary care encounters)	Israel	291	28 / 56	• 40% of consultations with cases of conflicts (21.2% related to the packages of health services/ rationing).	• Videotape of 291 consultations (28 general practitioners). 7 focus groups with 56 general practitioners (to collect provider opinion about conflicts).
					• Conflictual encounters were characterized by shorter opening and closing phases.
					• The physician showed a certain duality in the management of problems, because of the health system demands
					• The physicians' training might be relevant in view of an adequate managing conflict situations.
Street JR et al. (2007) ¹³	Study of the communication style of physicians, and their perception about patients	USA (Houston, Texas)	207	29	• The doctors' communication was more appropriated in relation to the patients with a communication more positive.	• 10 clinics (public or private).
						• Possible limitations: small sample size, non-evaluation of patients' health condition, the reason for the encounter, or the specialty of physicians.
					• Physicians might communicate better with patients of certain ethnic groups (possibility of bias).
Bensing JM et al. (2006) ¹⁴	Assessing the variations on communication patterns between general practitioners and patients	Holland	102/108 (1986 /2002)	27/108 (1986 /2002)	• No differences were found between both patients' groups regarding sex and age.	• Longitudinal study.
						• Analysis of video tapes (general practice consultations with hypertensive patients).
					• In relation to the most recent data: the general practitioners gave more medical information and expressed less concern about patients' health conditions; patients were less active (e.g. made less questions, and also demonstrated less concerns).
Van Den Brink-Muinen A et al. (2006) ¹⁵	Identify communication changes between patients and general practioners over time (about medical treatment issues)	Holland	442/2784 (1987/ 2001)	16/142 (1987/ 2001)	• In 2001: general practitioners provided more information and requested the patient involvement in the decision-making process more often, on the other hand this providers checked less patients' understanding. Excepting older patients the involvement of patients in medical decision-making was higher in 2001.	• Questionnaire (pre and post visit). Descriptive and multivariate Analysis.
Zantinge M et al. (2009) ¹⁶	Analyze if doctors' burnout affect their communication on patients' mental health problems, and the duration of consultations	Holland	1890 (consultations)	126	• In the case of general practitioners suffering from bunout neither their attention on patients' psychological problems nor their diagnosis were affected.It was found that general practitioners with more possibility of exhaustion sometimes create more opportunities to discuss the mental health problems of patients. General practitioners suffering from burnout might benefit from training (or coaching).	• Nationally representative sample of general practioners.
Zantinge M et al. (2009) ¹⁶		Holland	1890 (consultations)	126		• Subscales of burnout: 1) emotional exhaustion, 2) depersonalization, or 3) personal accomplishment.
Ratanawongsa N et al. (2008) ¹⁷	Describe the patient-physician communication in the case of physicians' burnout	USA (Baltimore, MD)	235	40	• The signs of physicians' professional exhaustion did not affect significantly:1) their attention with the patient, 2) verbal dominance, 3) the consultation length, and 4) the levels of satisfaction or confidence of the patients.	• 15 clinics.
						• Hypertensive patients were enrolled in view of improving their adherence.
					• The patients of doctors with more serious problems gave twice negative rapport-building statements.
Zantinge EM et al. (2007) ¹⁸	Evaluate how the workload of general practitioners affect their attention on patients' psychological problems	Netherlands	2095 (consultations)	142	• Physicians' professional exhaustion was not significantly associated with:1) patient-centeredness, 2) verbal dominance, 3) the length of consultation, and 4) patients' satisfaction.The patients of doctors with more serious problems gave more negative rapport-building statements.	• 2095 videotaped consultations.
						• The videotapes were from a National survey (2000-2002).
						• Eye contact was quantified (%).
Mjaaland TA et al. (2009) ¹⁹	Investigate the use of questions and comments during the consultations	Nor way (Bœrum)	145	24	• In addition to RIAS, 4 new coding categories were created to classify the interactions of communication.	• Pilot Study.
						• Additional categories: 1) resources (e.g. general practitioner comment something positive), 2) coping (e.g. comments/questions on the managment of dificult health situations), 3) attribution (e.g. question/ comments discussing patients' opinion about their own situation), and 4) Solution-focused techniques (e.g. use of scales to classify a problem).
					• 2% of the utterances were classified as resource or coping oriented (6 general practitioners were responsible for 59% of these utterances).
					• The general practitioners might be more trained to cognitively manage their interactions with patients.
Van Den Brink-Muinen A et al. (2008)²⁰	Investigate patterns of communication in primary health care (diverse European countries)	Estonia, Poland and Romania	1376	92	• It were found difference between the patterns of communication of general practitioners. Intercultural differences should be taking into account during the providers' eduction (e.g. communication skills trainning).	• Videotaped consultations (doctor-patient).
	Pediatrics
Johnson KB et al. (2008) ²¹	Evaluate the parent-provider communication before and after the introduction of a computer-based documentation tool in consultations	USA	243 (consultations)	149/94	• Computer-based vs. control consultations: duration slightly higher (32 vs. 27 min); more open-ended questions (28% vs. 21 %); > use of partnership strategies; > use of positive and social talk; more patient-centered interactions; < use of orienting and transition phrases.	• Pediatrics residents. The audio recordings were coded. One control group: 149 consultations were not computer-based (control group), and 94 consultations were computer-based.
					• The quantity of dialogs (conversation) was similar in both groups.
					• The introduction of the computerized system had a positive impact on the communication between family and providers.
Hart N et al. (2006) ²²	Evaluating parent-provider communication after a training	USA	92 (consultations)	28	• 28 residents. The consultations (92) were audio-taped.	• 3 consultations: 1 before and 2 after the residents' training.
					• Parents were significantly more satisfied (p < 0.05), and providers use more interpersonal communication after the training intervention.
					• Residents' training on communication skills may contribute to increas parents' satisfaction of parents.
Wissow L et al. (2011) ²³	Determining indicators to predict parent and child outcomes after a mental health training	USA (Baltimore, MD, Washington, DC and New York)	403	50	• Providers who received training on mental care were more patient-centerd, and presented more appropriate characteristics of communication.The consultations more family-centered were predictive of an improvement on children and adolescents mental symptoms.	• Children and adolescents with emotional and behavioral problems (5 to 16 years). 50 providers: trained in pediatrics (68%), or family practice (30%).
Wissow L et al. (2011) ²³		USA (Baltimore, MD, Washington, DC and New York)	403	50		• 15 primary care offices.
Liu CC et al. (2008) ²⁴	How working until late might in influence residents' communication/ performance in the consultations of the following day	USA	243 (primary care visits)	52	• Residents who stay working until late were more verbally dominant, and less patient centered.	• Teaching hospital.
Liu CC et al. (2008) ²⁴		USA	243 (primary care visits)	52	• Implications: it is required a better management of profissional performance in case of fatigue.	• Teaching hospital.
Greenley RN et al. (2006) ²⁵	Analyze the stability of parents' understanding of the random assignment in childhood leukemia trials	USA	84	Not applicable (only patients' interviews)	• 49% of parents failed to understand the random assignment. Favorable factors related to parents' understanding: majority ethnicity, high socioeconomic status, provider-patient communication, and the presence of nurses during the consultation.	• Pediatric Hospitals.
						• Limitations: only urban areas and academic centers, small sample size, informational materials not evaluated, and the parents' understanding only was checked at two points (48 h and 6 months later).
					• Implications: Further studies are advisable (in different geographical locations and clinical contexts).
	Nursing
Sheldon LK et al. (2009) ³	Analyze nurse responsiveness to cancer patient expressions of emotion	USA	Simulated patients	74	• The simulated patients' expressions of sadness elicited a superior affective responses (e.g. concern, approval, empathy and concordance) than anger. The simulated patients' expressions of neutrality and anger elicited a superior instrumental behaviors in professionals (e.g. orient, check, opinion about the therapy) than sadness. Age, work stress, and professional experience were variables significantly correlated.	• 8 sites (e.g. oncology services).
						• The simulated expressions were: 1) anger, 2) sadness, and 3) neutrality.
					• This methodology was considered convenient to training communication skills by the majority of nurses.
Gilbert DA et al. (2009) ²⁶	Investigate patient-nurse communication, and variations in outcomes	USA (New England)	155	31	• Better outcomes were obtained in the case of: older patients with less previous medical and social assistance, nurses with previous longer professional experience, the encounters with higher biomedical and psychosocial information, or predominance of positive dialogs (e.g. expressing reassurance or optimism).	• Studies in view of improving communication on lifestyle are needed.
Langewitz W et al. (2010) ²⁷	Studying the impact of a training on the communication between the nurses and simulated oncologic patients	Switzerland	Simulated patients	70	• There was a statiscally significant increase regarding the statements: appropriate empathic (1.6% vs. 3.2%), reassuring (2.3% vs. 3.4%), questions concerning psychosocial information (2.8% vs. 4.0%).	• The training was advertized by email. The patient centeredness was assessed based on the type and duration of dialogs (between health professionals and simulated patients).
					• On the other hand biomedical utterances: 17.8% vs. 13.3% (nurses) and 8.1% vs. 6.7% (patients) decreased.	• Video record ofinterviews (pre- and post-intervention).
						• Only 61 video recordings were analyzed.
Kim YM et al. (2008) ²⁸	Identifying factors that contribute to increase the effectiveness communication between nurses and patients	Indonesia (Java)	768	64	• More effective communication in 32 patients (4.2% of 768) and 7 providers (10.9 % of 64). Example of additional measures: better management of patients flow and media campaigns.	• 64 clinics (randomized).
						• Qualitative interviews with collection of individual and profissional data (e.g. number of years of professional experience).
						• Potential sources of bias: social correct responses, or mood states (from patients or providers).
						• Limitations: only 1 consultation, translation of the audio recording of the consultation to English (for application of RIAS) with possible compromise of texts integrity, and a reduced number of evaluations.
	Geneticists
Roter DL et al. (2009) ²⁹	Observe how the complexity of genetic counseling sessions are related with the learning of genetic-related information by low literate participants	USA	Simulated patients	96	• 312 participants observed videos of genetic consultations.The genetic informations learned by participants were assessed.Highly technical terms/ dialogs represent an obstacle for individuals of lower literacy. However these obstacules were smaller, in the case of the sessions with more dialogs/ interactivity.	• 79 video sessions of prenatal counseling were observed by a total of 312 participants.
						• 9 simulated patients. The genetic counselors were recruited through the National Society of Genetic Counselors.
						• The number of words related to genetic terms were quantified.
					• It is advisable that the genetic counselor communicate in a suitable manner, especially with low literate patients.
Roter DL et al. (2007) ³⁰	Assessing the impact associated with the complexity of the genetic counseling sessions	USA	Simulated clients	152	• Sessions with a high porportion of technical terms were associated with short sessions, less interactive dialogs, and less satisfied simulated clients.	• Audio and video recording (152 sessions on pre-natal, and cancer counseling).
						• It was evalutated: 1) the use of technical terms, 2) the complexity of language (use of the Microsoft Word grammar), and 3) the structural characteristics of dialogs (RIAS).
					• The opinion of the simulated client on the information provided by the genetic counselor is inversely related with the use of technical terms.
Roter D et al. (2006) ³¹	Identify patterns of communication in genetic counseling sessions: teaching vs. counseling	USA	Simulated clients	152	• Identification of 4 communication patterns: 2 teaching patterns and 2 counseling patterns.	• Questionnaires: 1) simulated clients (to collect data on their opinion about the genetic counselor, and on their satisfaction with the verbal and non-verbal communication of the genetic counselor), and 2) genetic counselors (to collect demographic data, and their perception about interpersonal relationship with the client simulated and opinion about the realism of the session).
Roter D et al. (2006) ³¹		USA	Simulated clients	152	• The genetic counselor were more verbally dominant (i.e. using greater conversation times) in the teaching patterns.
	Aids care
Kumar R et al. (2010) ³²	Explore how the communication between patients with HIV and health providers might influence patients' decisions	USA (Baltimore, Detroit, New York and Portland)	434	45	• In relation to patients: 72% preferred to share decisions, 23% preferred that the provider take de decision alone, and 5% preferred to take their own decisions.	• Health professionals: doctors and nurses. Patients were questioned about their role in relation to the medical decions.
Kumar R et al. (2010) ³²		USA (Baltimore, Detroit, New York and Portland)	434	45	• Patients who prefer that the professional decide alone are less likely: to manifest symptoms of depression, to understand providers' explanations. Might be considered a more appropriate approach when the health professional involves patients in the decision making process.
Beach CM et al. (2010) ³³	Impact of a training administered to health professionals of HIV patients (on medication adherence).	USA	140	24	• The training produced a positive impact on communication about medication adherence.	• Providers from 3 care sites.
						• HIV patients.
						• Conference abstract.
					• Differences (before and after training): more dialogs on therapeutic regims (p= 0.003), more positive dialogs (p= 0.039), more emotional dialogs (p< 0.001), more questions on patients' opinion (p= 0.009), and discussions about adherence (p = 0.026).	• Conference abstract.
	Oncology
Daugherty C et al. (2009) ³⁴	Characterize the communication between oncologists and patients with advanced cancer in relation to the understanding of the informed consent (phase I clinical trials)	USA	131	25	• Other treatment options were discussed by physicians in 47% of the encounters.	• Confervâceo abstract.
					• The option of not performing any treatment was reported by the physician in 29% of encounters.
					• The terms "death" and "terminal" were used by the physician in 5.8% of the encounters.
					• The communication on alternative treatments, or prognosis was not considered adequate.
Siminoff LA et al. (2006) ³⁵	Patterns of communication in consultations (patients with breast cancer)	USA	405	58	• In this study physicians spend more time communicating with the patients more educated and young, as well as with the patients of higher income level.These discrepancies in communication might influence patients' health outcomes.	• 14 practices (two states).
					• The discussions on psychosocial issues such as how patients deal with their diagnosis, and patients' feelings were limited.
					• The way how providers communicated was different depending of the patients' sociocultural characteristics.
					• Specific training on how to deal with these differences might be useful to patients, and providers.
	Surgery
Levinson W et al. (1997) ³⁶*	Relate the communication with malpractice claims	USA (Oregon and Colorado)	10 clinics per doctor	124	• Two groups: primary care physicians, and surgeons.	• In view of avoiding claims the implementation of good communication practices is advisable.
					• Primary care physicians with no-claims registered: more statements of orientation, laughed more, requested more patients' opinion, confirmed more patients' understanding, and encouraged more the dialoge comparatively to the primary care physicians with complaints, as well as their consultations were more longer (18.3 vs. 15 minutes).
					• It were not found different communication characteristics between surgeons with claims, or no-claims.
Levinson W et al. (1999) ³⁷*	Characterize the communication between surgeons and patients in routine consultations	USA	676 (routine visits)	66 (29/37)	• 29 general surgeons and 37 orthopaedic surgeons. Social conversations, or the discussion of patients' problems was limited.	• Possible limitations: limited number of topics discussed in this type of consultations
Levinson W et al. (1999) ³⁷*		USA	676 (routine visits)	66 (29/37)	• Further investigations are recommended to understand the influence of surgeons' communication on patient behavior.
	Anesthesia
Kindler CH et al. (2005) ³⁸*	Quantitative Analysis of the communication between the anesthetist and the patient in preoperative consultation	Switzerland (Basel)	57	57	• Duration of visit: 16.1 min (average).	• The discussions on biomedical, and psychosocial issues were quantified (number of utterances).
					• The number of utterances per patient/anaesthesist, and the duration of the consultations were not influenced by gender. % of utterances/consultation: anaesthesists (53.5%) and patients (46.5%).
					• Anaesthetists: < 0.1% utterances related with psychosocial issues (dialogs mainly related with biomedical issues).
					• The use of open questions and emotional statements by these providers were positively related with the patients' involvment.
	Family planning
Abdel-Tawab N et al. (2002) ³⁹*	Investigate the importance of client-centered communication in consultations of family planning	Egypt	112 (clients)	34	• The communication was physician-centered in 2/3 of consultations.	• Home visits to confirm clients' contraceptive adherence (at 3 and 7 months).
					• Client-centered consultations were one minute longer than physician-centered consultations.
					• Client-centered consultations were associated with great satisfaction, and adherence.
					• The interruption of the contraceptive method was associated with more physicians' disagreement statements.
					• Similarly to what happen in developed countries, client-centered models are more advantageous than physician-centered models.

location_on

Associação Médica Brasileira R. São Carlos do Pinhal, 324, 01333-903 São Paulo SP - Brazil, Tel: +55 11 3178-6800, Fax: +55 11 3178-6816 - São Paulo - SP - Brazil
E-mail: ramb@amb.org.br

rss_feed Acompañe los números de esta revista en su lector de RSS

[1] P: Patients; HP: Health Professionals; Result, Disc and Conclusions: Some main results, discussion, and conclusions; Other observations: Place, possible study weakness or bias, and other relevant aspects; USA: United States of America.

[tfn01t02] ^*
Studies selected not according to the study period.