0
Review Article |

Relationship, Communication, and Efficiency in the Medical Encounter:  Creating a Clinical Model From a Literature Review FREE

Larry B. Mauksch, MEd; David C. Dugdale, MD; Sherry Dodson, MLS; Ronald Epstein, MD
[+] Author Affiliations

Author Affiliations: Departments of Family Medicine (Mr Mauksch) and Medicine (Dr Dugdale) and Health Sciences Libraries (Ms Dodson), University of Washington, Seattle; and Departments of Family Medicine, Psychiatry, and Oncology, University of Rochester School of Medicine and Dentistry (Dr Epstein) Rochester, New York.


Arch Intern Med. 2008;168(13):1387-1395. doi:10.1001/archinte.168.13.1387.
Text Size: A A A
Published online

Background  While there is consensus about the value of communication skills, many physicians complain that there is not enough time to use these skills. Little is known about how to combine effective relationship development and communication skills with time management to maximize efficiency. Our objective was to examine what physician-patient relationship and communication skills enhance efficiency.

Data Sources  We conducted searches of PubMed, EMBASE, and PsychINFO for the date range January 1973 to October 2006. We reviewed the reference lists of identified publications and the bibliographies of experts in physician-patient communication for additional publications.

Study Selection  From our initial group of citations (n = 1146), we included only studies written in English that reported original data on the use of communication or relationship skills and their effect on time use or visit length. Study inclusion was determined by independent review by 2 authors (L.B.M. and D.C.D.). This yielded 9 publications for our analysis.

Data Extraction  The 2 reviewers independently read and classified the 9 publications and cataloged them by type of study, results, and limitations. Differences were resolved by consensus.

Results  Three domains emerged that may enhance communication efficiency: rapport building, up-front agenda setting, and acknowledging social or emotional clues.

Conclusions  Building on these findings, we offer a model blending the quality-enhancing and time management features of selected communication and relationship skills. There is a need for additional research about communication skills that enhance quality and efficiency.

Figures in this Article

Providing high quality care in the time allotted for primary care encounters, irrespective of the visit length, is a major challenge. Most adult primary care patients have 2 or more chronic conditions.1,2 Estimates of the time required to provide appropriate preventive care (7.5 h/d)3 and chronic illness care (10.5 h/d)4 for a panel of 2500 primary care patients suggest that doing an adequate job is difficult. With the addition of the time needed to address acute problems,5 complete paperwork, and update medical records, it often seems impossible to perform all of these tasks adequately, and primary care practitioners often feel overwhelmed.6,7 Therefore, effective communication in primary care must include skills that enhance quality of care while helping patients and physicians use time wisely.

In 2001, an expert panel identified the following specific relationship and communication elements fundamental to all medical encounters8:

  • Build the relationship: the fundamental task

  • Open the discussion

  • Gather information

  • Understand the patient's perspective

  • Share information

  • Reach agreement on problems and plans

  • Provide closure

These elements emphasize caring and trust to create a relationship in which physicians and patients share ideas and decision making about the visit agenda, the nature and meaning of disease and illness, and treatment options. Visits that contain these elements are associated with enhanced patient satisfaction,9 greater adherence to medication regimens,10 improved self-management,11 better health outcomes,12 reduced medical costs,13 and decreased risk of malpractice claims.14 Although relationship and communication skills can be taught to physicians,1517 most primary care encounters appear to be missing 1 or more of these essential elements.1824 Insufficient time with patients is often cited by physicians as a major cause for poor relationship development and communication.6,7

In countries with strong primary care systems, determining how much time is needed to provide quality care is a subject of ongoing research yielding conflicting results.2527 Visit length is influenced by many factors including the number and complexity of problems elicited and addressed, the degree of psychosocial distress, and the sex and age of the patient and the physicians.2830 Some data from primary care settings in the United States suggest that visits shorter than 15 minutes are associated with lower quality.26 In Great Britain, where visit lengths are shorter than in the United States, researchers have argued that visits should be lengthened to enhance quality of care.31,32 Many studies suggest that better communication takes more time.13,3335 However, more time does not guarantee better communication, as evidenced by patient perception of time use36 and poor communication found in 30- to 60-minute health maintenance visits.37

Research in the United States and in 6 European countries reveal differences in mean visit length ranging from 7.5 minutes in Germany38 to 18 minutes in the United States.39 In each country, physician styles can be sorted along continua from biomedical to psychosocial and from a physician-centered style to a patient-centered style. Visits with more psychosocial content, on average associated with better outcomes,8,40 are shorter in some countries than biomedical visits in other countries.41,42 One large study in the United States found no significant difference in visit length across the biomedical to psychosocial continuum.43 Some studies comparing patient-centered and physician-centered styles have shown no difference in visit length.44,45 Physician communication styles seem to remain constant irrespective of visit length.4143,46 While these studies suggest time use, and therefore quality, can vary considerably, they do not provide insight into how physicians manage time in visits that contain recommended communication and relationship elements.

When learning communication skills, physicians and trainees commonly ask, “How can I communicate well without lengthening the visit?” Although primary care physicians have long expressed frustration about time limitations,47,48 there is little consensus about how to blend time management skills with essential relationship and communication elements throughout the medical interview. While trainees are able to learn effective communication skills, these skills are often abandoned once they start working in busy clinical settings. These relationship and communication skills might be sustained if medical educators attended to learners' needs for time management skills. Furthermore, efficiency—making the best use of available time—is important for visits of any duration.

We searched PubMed, EMBASE, and PsychINFO for the period from January 1973 to October 2006 for descriptive or experimental research written in English that identified quality-enhancing relationship and communication skills that were associated with efficiency during face-to-face encounters between patients and physicians (the live PubMed search is availale at: http://tinyurl.com/3xswfv). We developed 3 inclusion criteria to characterize “efficiency.” The identified skill must have: (1) improved quality without increasing visit length, (2) improved quality and decreased visit length, or (3) helped manage time without compromising quality. We then searched for additional reports by the authors of these selected citations or by experts in the field of physician-patient communication. The original searches yielded a total of 1146 citations that we screened (L.B.M. and D.C.D.) to find articles that met our criteria. The 2 reviewers independently read and classified the publications by type of study, research question, outcomes, and limitations. We resolved differences by consensus.

The available research linking quality-enhancing relationship and communication skills with efficiency is sparse. Only 9 citations met inclusion criteria (Table 1); most others were not original research. We found only 1 experimental study on collaborative agenda setting53 that was conducted by one of the authors (L.B.M.). Its sample size was small, limited to a homogeneous group of physicians in an educational setting, and did not include any direct observation of physician skill use or link the intervention to health outcomes. The remaining studies used observational designs, and most were limited by small sample sizes using a narrowly defined population and did not examine patient and physician satisfaction or health outcomes.

Table Graphic Jump LocationTable 1. Studies Linking Communication Quality and Efficiency

The 9 articles revealed 3 domains that may be associated with communication and relationship quality and efficiency: rapport building may enhance quality of care without taking more time, while up-front agenda setting and acknowledgment of patients' social and emotional clues may both enhance quality of care and improve time management.

A MODEL OF RELATIONSHIP, COMMUNICATION, AND EFFICIENCY

To create a comprehensive model, we integrated these findings with components that are recognized as essential communication components8 plus 1 new component—topic tracking—to enhance efficiency throughout the visit. We cite the literature and explain the relevance of each component in the model. We did not study current, significant influences on communication and efficiency outside of face-to-face interactions between a physician and a patient (eg, previsit agenda forms, e-mail, electronic health records, interactions with other health care providers, or group visits).

In response to a call from the literature,54,55 we classified skills by the timing of their application during a visit: (1) skills with ongoing influence and (2) skills used sequentially. Four skill sets provide ongoing influence: relationship development and maintenance, mindful practice, topic tracking, and acknowledgment of patient clues. Three skill sets occur in a sequence: up-front, collaborative agenda setting, understanding the patient perspective, and reaching mutual agreement on a plan. The application of the skills at the beginning of the interview creates space for the use of important skills in subsequent interview phases and reduces the chance of using these latter skills in redundant or inefficient ways.54Figure 1 and Figure 2 list communication skills and their quality and efficiency benefits. In the following subsections, we (1) describe each skill; (2) give an example of skill use; (3) name pitfalls of not using each skill; and (4) explain how using each skill avoids pitfalls.

Place holder to copy figure label and caption
Figure 1.

Relationship, communication, and efficiency: skills.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Relationship, communication, and efficiency: quality and efficiency benefits.

Graphic Jump Location
SKILLS WITH ONGOING INFLUENCE
Rapport Building and Relationship Maintenance

Skill Description. A strong physician-patient relationship is essential for effective clinical encounters.8 Rapport building such as a warm greeting, eye contact, a brief nonmedical interaction, or checking on an important life event can occur in less than a minute.49,50

Example. “Nice to see you. “How is your garden this year?” or “How is it to have your son leave home?”

Pitfalls. Patients who feel a poor connection with their physician may have insufficient trust. Conversely, too much small talk may displace time for examining complicated problems.

Avoiding Pitfalls. As relationships develop, physicians can begin each interaction with a brief “check in” to reestablish the relationship. The following skills help maintain a trusting relationship.

Mindful Practice

Skill Description. Mindful practice is characterized by attentive observation of the patient and of the physician's own thought processes to guard against cognitive shortcuts and physician dominance of the agenda.56 The mindful physician is present and critically curious57 to avoid premature closure.

Example. A physician is concerned that a patient's blood glucose level remains high despite prior interventions. He or she begins to lecture the patient and notices that the patient withdraws. The physician senses a weakening partnership with the patient. The physician realizes that he or she does not know how the patient views diabetes and decides to explore the patient's views.

Pitfalls. The physician who is not present may waste time focusing on issues that are not important to the patient and may miss clues about important thoughts and feelings.

Avoiding Pitfalls. Monitoring one's own preoccupations can enhance the physician's ability to engage the patient in useful problem solving.58,59

Topic Tracking

Skill Description. Maintaining focus on a mutually agreed on topic is an essential ingredient60 in effective psychotherapeutic61 and behavior change interactions.62 In medical visits with multiple topics, discussions are often stopped and restarted as the patient and physician juggle priorities.63 The probability that no clear decision is made on a topic before the close of the visit is inversely proportional to the number of topics in the visit.64 The following 3 communication microskills are critical to topic tracking: summarization (sharing one's impression of what has been discussed); process transparency65 (describing the interaction); and goal alignment (confirming agreement on the discussion focus).

Example. “Ms Freeman, we decided to talk about your diabetes and it sounds like juggling exercise and diet is hard (summarization). I see that you also want to talk about your back pain (process transparency). I want to make sure that we accomplish something concrete today. Should we stay with your diabetes or shift our focus to back pain and delay dealing with your diabetes?” (goal alignment).

Pitfalls. Physicians who are not aware of “course changes” allow the interview to become disorganized, not completing a topic or rushing through another issue. Physicians, too, may introduce a new topic without an agreement at the beginning of the encounter.

Avoiding Pitfalls. The physician must monitor the discussion as if observing it from the outside. It may or may not be appropriate to adjust the agenda when new issues emerge. If physicians share their reasoning for time use adjustments, patients may be more engaged.66

Acknowledging Social or Emotional Clues With Empathy

Skill Description. Clues surface in any phase of the interview and signify thoughts or feelings contributing to patient behavior or illness. Empathic acknowledgment of clues may move the patient to reveal beliefs about illness and treatment preferences that can facilitate creating an effective plan. Providing empathy is intentional67,68 and teachable.69,70 It may promote patient self-efficacy without extending visit length.71,72 Empathy can be used to focus discussions or to invite further exploration. Acknowledging clues may shorten visits perhaps because there is a decreased need for patients to restate their concerns.24

Examples. (1) Clue acknowledgment to focus a discussion—“It is frustrating when your asthma prevents you from getting to work,” followed by, “Let's see how we can improve your symptoms and your ability to keep your job.” Empathic acknowledgment decreases risk of the patient feeling discounted and improves the quality of care.7274 (2) Clue acknowledgment to invite further exploration—“Even though the test results were normal, you still seem concerned this may be cancer. Can you tell me more?”

Pitfalls. Missing clues may hinder understanding the patient's core concern.75,76

Avoiding Pitfalls. When used judiciously, verbal and nonverbal expression of empathy can be very brief (1-10 seconds) while still conveying an appreciation of the patient's suffering.

SKILLS USED SEQUENTIALLY
Up-front, Collaborative Agenda Setting

Skill Description. Primary care physicians are generally presented with 3 to 6 concerns per visit18,63,77 and frequently more. It is not possible to address all concerns in detail in every visit. After initially checking in with the patient, the physician and patient can collaboratively create an agenda for the visit.53 Up-front, collaborative agenda setting is more thorough and efficient than the more common approach of addressing each issue as it surfaces.21,22,78 When physicians know the number, urgency, and importance of all the patient's concerns, they will be more likely to address them, and they are also able to make rapid judgments about their time needs.79 Up-front agenda setting allows the physician and the patient to prioritize and explore the most important concerns45 and decrease the probability of “Oh, by the way” issues surfacing at the end of the visit.21,51,52 The physician explains that creating a list of concerns will help determine how to make the best use of time. Diagnostic questioning is postponed. The physician uses repeated prompts to help the patient name additional concerns. Next, the physician confirms which problem is most important to the patient.80 If necessary, the physician negotiates with the patient to protect time for urgent medical problems and postpone some issues for subsequent visits.

Example. “Let's figure out how to make the best use of our time.” “What concerns would you like to address today?” Or in follow-up visits, “We planned to discuss your diabetes but I want to check if something else is a concern to you today?” Then, “something81 else?” and “Do you need any prescriptions refilled or paperwork filled out?” If the patient elaborates on a concern before listing other concerns, the physician might say, “Your headaches sound painful but before we go further, was there something else you hoped to address today?” And eventually, “Am I correct that your headaches are most important? How about if we begin with your headaches and save some time to check on the diabetes?”

Pitfalls. It is tempting to explore the first topic raised in the visit.22 Conversely, a physician who rigidly pursues agenda setting may compromise patient satisfaction82 by forgetting to make a connection or missing patient clues about emotionally laden issues.

Avoiding Pitfalls. When the patient's emotional clues reveal the patient's need to tell a story, the physician should listen. If not interrupted, the great majority of patients will talk less than 2 minutes.83 To contain patients who spend excessive time talking, use the skills described in the subsections on “Topic Tracking” and “Acknowledging Clues.” Spending more time on a complex issue may be a better use of time than skipping from one problem to another without first considering patient motivation and problem complexity.84 Follow-up visits may provide further opportunities to explore other issues in depth.

Exploring the Patient's Perspective

Skill Description. Once the agenda is defined, 2 forms of information gathering are woven together: diagnostic investigations and understanding the patient perspective. Explore the patient's perspective when (1) promoting self-management85; (2) examining health behavior change62; (3) the patient gives clues about underlying thoughts and feelings75,86; (4) family87 or cultural88 factors influence patient beliefs and behavior; (5) psychosocial problems diminish patient function89; and (6) symptoms are medically unexplained.90,91 These explorations can be done without increasing visit length92 and may reduce patient anxiety, identify knowledge gaps, and improve adherence and outcomes.93 Indeed, curious57 listening may be central to the “healing”94 experience.

Examples.“What do you know about diabetes?” “I know that food plays an important role in your life. Tell me about it.” “What would your physicians in Russia have done for this problem?”

Pitfalls. The exploration of the patient's perspective may be impeded by not allocating time during agenda setting. Ignoring the patient's beliefs may lead the physician to create a plan with little chance of success.95

Avoiding Pitfalls. Thirty seconds to 5 minutes86 is usually enough time to understand patient beliefs and behavior and assess motivation for self-management. Understanding the patient's perspective may reduce wasted time delivering rote, off-target educational monologues. Several interview models have been developed to explore patient,96 family,87 and cultural97 perspectives.

Cocreating a Plan

Skill Description. Complicated problems may benefit from more time devoted to shared and informed decision making.18 When patients are involved in plan creation, they are more satisfied and have better outcomes and their physicians are less likely to generate unnecessary tests or referrals.12,13,40 Physician documentation of agreement with patients on problems needing follow-up is associated with increased problem resolution by the next visit.98,99 Patients are more likely to adhere to plans if patients perceive that the plan accommodates their financial and social resources.100 Clinicians should also tailor recommendations to patients' readiness to change.101 The planning phase concludes with explicit agreement on the goals of care, next steps, and the roles of the patient, family members, and clinicians in implementing the plan.

Example. “I think we agree that something needs to be done about your rising blood glucose levels. In reviewing the options, you would like to first try diet change and increase your exercise. These choices are not easy to implement and maintain. Lets create a plan to support you in this effort. Does this make sense?”

Pitfalls. Forgetting to set an agenda, not using topic tracking skills or not pursuing an understanding of the patient’s perspective increases the risk of offering a plan misaligned with patient preferences102 and increasing resistance to self-management.103

Avoiding Pitfalls. Physicians must save time for cocreating a plan and explain why addressing fewer problems in greater depth may do a better job.102

CONTRASTING EFFICIENT AND INEFFICIENT INTERACTIONS

Table 2 gives a model in which the poles of the vertical axis are high-quality, efficient communication (top) and low-quality, inefficient communication (bottom). The poles of the horizontal axis are “feeling pressed for time” (left side) and “feeling there is enough time” (right side). We emphasize perception instead of naming absolute visit lengths because physician perception influences how time is used.102 Several factors may affect perception beyond appointment length such as whether one is behind schedule, one's understanding of patient needs, and one's sense of competence.79,104 The communication behaviors in the 2 high-quality, efficient quadrants include shared decision making about interview content, illness models,93 and treatment plans. The organizational structure and process of the visit is transparent. These behaviors are not present in low-quality, inefficient interactions.

Table Graphic Jump LocationTable 2. Contrasting Efficient and Inefficient Interactions

While evidence from several countries suggests that high-quality communication can occur between patients and physicians during interviews of variable lengths, our knowledge about how this is accomplished is limited. Rapport building, up-front collaborative agenda setting, and acknowledging social and emotional concerns may help improve quality of care and efficiency. We blended these skills into a comprehensive model to help physicians make the best use of time throughout the visit. Our review did not analyze important quality-enhancing encounters with other health care team members. The use of these skills in face-to-face encounters creates trust and understanding that may increase the willingness of patients to work with an expanded health care team105 in person or via telephone or e-mail. Future studies of physician-patient communication require effective training designs106 and should combine qualitative and quantitative methods to examine the relationships between physician behaviors, time use, patient and physician satisfaction, resource use, and health outcomes.107,108

Correspondence: Larry B. Mauksch, MEd, Department of Family Medicine, University of Washington, 4245 Roosevelt Way NE, Box 354775, Seattle, WA 98105 (mauksch@u.washington.edu).

Accepted for Publication: January 13, 2008.

Author Contributions:Study concept and design: Mauksch, Dugdale, and Epstein. Acquisition of data: Mauksch, Dugdale, Dodson, and Epstein. Analysis and interpretation of data: Mauksch, Dugdale, and Epstein. Drafting of the manuscript: Mauksch, Dugdale, and Epstein. Critical revision of the manuscript for important intellectual content: Mauksch, Dugdale, Dodson, and Epstein. Obtained funding: Mauksch. Administrative, technical, and material support: Mauksch, Dugdale, and Dodson. Study supervision: Mauksch, Dugdale, and Epstein.

Financial Disclosure: Mr Mauksch receives honoraria and consultation fees from health care organizations for teaching communication skills to health care providers. Dr Epstein gave a Web lecture in 2007 on physician-patient communication sponsored by Merck Pharmaceuticals.

Funding/Support: Portions of this work were supported by grant R01 HS13172_01 from the Agency for Health Research and Quality and by the Arthur Vining Davis Foundations Paired Observation and Video Editing education model (Mr Mauksch).

Previous Presentations: During the process of developing these ideas, portions of this work were presented to medical education audiences including medical educators, medical students, residents, and practicing physicians. An example of some of these presentations include the following: Annual Update in Family Practice and Primary Care, September 2006, University of Washington, Seattle; University of Washington Family Medicine Residency, October 2006-2008, Seattle; Faculty Training, Paired Observation and Video Editing Project, March 2007, University of Washington, Seattle; and Annual Scientific Assembly, Washington Academy of Family Physicians, May 2007, Pasco.

Additional Contributions: Daniel Cherkin, PhD, Stuart Farber, MD, Eric Larson, MD, MPH, and Valerie Ross, MS, provided thoughtful comments on the model and this manuscript, and Claire Mauksch provided editing assistance.

Additional Information: MeSH terms and search strategy are available from the corresponding author on request.

Fortin  MBravo  GHudon  CVanasse  ALapointe  L Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005;3 (3) 223- 228
PubMed
Starfield  B Threads and yarns: weaving the tapestry of comorbidity. Ann Fam Med 2006;4 (2) 101- 103
PubMed
Yarnall  KSPollak  KIOstbye  TKrause  KMMichener  JL Primary care: is there enough time for prevention? Am J Public Health 2003;93 (4) 635- 641
PubMed
Østbye  TYarnall  KSKrause  KMPollak  KIGradison  MMichener  JL Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005;3 (3) 209- 214
PubMed
Flocke  SAFrank  SHWenger  DA Addressing multiple problems in the family practice office visit. J Fam Pract 2001;50 (3) 211- 216
PubMed
Mechanic  D How should hamsters run? some observations about sufficient patient time in primary care. BMJ 2001;323 (7307) 266- 268
PubMed
Linzer  MKonrad  TRDouglas  J  et al.  Managed care, time pressure, and physician job satisfaction: results from the physician worklife study. J Gen Intern Med 2000;15 (7) 441- 450
PubMed
Makoul  G Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med 2001;76 (4) 390- 393
PubMed
Williams  SWeinman  JDale  J Doctor-patient communication and patient satisfaction: a review. Fam Pract 1998;15 (5) 480- 492
PubMed
Stewart  MBrown  JBBoon  HGalajda  JMeredith  LSangster  M Evidence on patient-doctor communication. Cancer Prev Control 1999;3 (1) 25- 30
PubMed
Glasgow  REDavis  CLFunnell  MMBeck  A Implementing practical interventions to support chronic illness self-management. Jt Comm J Qual Saf 2003;29 (11) 563- 574
PubMed
Stewart  MBrown  JBDonner  A  et al.  The impact of patient-centered care on outcomes. J Fam Pract 2000;49 (9) 796- 804
PubMed
Epstein  RMFranks  PShields  CG  et al.  Patient-centered communication and diagnostic testing. Ann Fam Med 2005;3 (5) 415- 421
PubMed
Levinson  WRoter  DLMullooly  JPDull  VTFrankel  RM Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;277 (7) 553- 559
PubMed
Smith  RCLyles  JSMettler  J  et al.  The effectiveness of intensive training for residents in interviewing: a randomized, controlled study. Ann Intern Med 1998;128 (2) 118- 126
PubMed
Roter  DLHall  JAKern  DEBarker  LRCole  KARoca  RP Improving physicians' interviewing skills and reducing patients' emotional distress: a randomized clinical trial. Arch Intern Med 1995;155 (17) 1877- 1884
PubMed
Yedidia  MJGillespie  CCKachur  E  et al.  Effect of communications training on medical student performance. JAMA 2003;290 (9) 1157- 1165
PubMed
Braddock  CH  IIIEdwards  KAHasenberg  NMLaidley  TLLevinson  W Informed decision making in outpatient practice: time to get back to basics. JAMA 1999;282 (24) 2313- 2320
PubMed
Kravitz  RLCallahan  EJPaterniti  DAntonius  DDunham  MLewis  CE Prevalence and sources of patients' unmet expectations for care. Ann Intern Med 1996;125 (9) 730- 737
PubMed
Kroenke  KJackson  JLChamberlin  J Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome. Am J Med 1997;103 (5) 339- 347
PubMed
Marvel  MKEpste in  RMFlowers  KBeckman  HB Soliciting the patient's agenda: have we improved? JAMA 1999;281 (3) 283- 287
PubMed
Beckman  HBFrankel  RM The effect of physician behavior on the collection of data. Ann Intern Med 1984;101 (5) 692- 696
PubMed
Barry  CABradley  CPBritten  NStevenson  FABarber  N Patients' unvoiced agendas in general practice consultations: qualitative study. BMJ 2000;320 (7244) 1246- 1250
PubMed
Levinson  WGorawara-Bhat  RLamb  J A study of patient clues and physician responses in primary care and surgical settings. JAMA 2000;284 (8) 1021- 1027
PubMed
Freeman  GKHorder  JPHowie  JG  et al.  Evolving general practice consultation in Britain: issues of length and context. BMJ 2002;324 (7342) 880- 882
PubMed
Dugdale  DCEpstein  RPantilat  SZ Time and the patient-physician relationship. J Gen Intern Med 1999;14 ((suppl 1)) S34- S40
PubMed
Wilson  AChilds  S The relationship between consultation length, process and outcomes in general practice: a systematic review. Br J Gen Pract 2002;52 (485) 1012- 1020
PubMed
Britt  HValenti  LMiller  G Time for care: length of general practice consultations in Australia. Aust Fam Physician 2002;31 (9) 876- 880
PubMed
Britt  HCValenti  LMiller  GC Determinants of consultation length in Australian general practice. Med J Aust 2005;183 (2) 68- 71
PubMed
Blumenthal  DCausino  NChang  YC  et al.  The duration of ambulatory visits to physicians. J Fam Pract 1999;48 (4) 264- 271
PubMed
Howie  JGHeaney  DJMaxwell  MWalker  JJFreeman  GKRai  H Quality at general practice consultations: cross sectional survey. BMJ 1999;319 (7212) 738- 743
PubMed
Martin  CMBanwell  CLBroom  DHNisa  M Consultation length and chronic illness care in general practice: a qualitative study. Med J Aust 1999;171 (2) 77- 81
PubMed
Zyzanski  SJStange  KCLanga  DFlocke  SA Trade-offs in high-volume primary care practice. J Fam Pract 1998;46 (5) 397- 402
PubMed
Flocke  SAMiller  WLCrabtree  BF Relationships between physician practice style, patient satisfaction, and attributes of primary care. J Fam Pract 2002;51 (10) 835- 840
PubMed
Goedhuys  JRethans  JJ On the relationship between the efficiency and the quality of the consultation: a validity study. Fam Pract 2001;18 (6) 592- 596
PubMed
Cape  J Consultation length, patient-estimated consultation length, and satisfaction with the consultation. Br J Gen Pract 2002;52 (485) 1004- 1006
PubMed
Scheitel  SMBoland  BJWollan  PCSilverstein  MD Patient-physician agreement about medical diagnoses and cardiovascular risk factors in the ambulatory general medical examination. Mayo Clin Proc 1996;71 (12) 1131- 1137
PubMed
Deveugele  MDerese  Avan den Brink-Muinen  ABensing  JDe Maeseneer  J Consultation length in general practice: cross sectional study in six European countries. BMJ 2002;325 (7362) 472
PubMed
Mechanic  DMcAlpine  DDRosenthal  M Are patients' office visits with physicians getting shorter? N Engl J Med 2001;344 (3) 198- 204
PubMed
Stewart  MA Effective physician-patient communication and health outcomes: a review. CMAJ 1995;152 (9) 1423- 1433
PubMed
van den Brink-Muinen  AVerhaak  PFBensing  JM  et al.  Communication in general practice: differences between European countries. Fam Pract 2003;20 (4) 478- 485
PubMed
Bensing  JMRoter  DLHulsman  RL Communication patterns of primary care physicians in the United States and the Netherlands. J Gen Intern Med 2003;18 (5) 335- 342
PubMed
Roter  DLStewart  MPutnam  SMLipkin  M  JrStiles  WInui  TS Communication patterns of primary care physicians. JAMA 1997;277 (4) 350- 356
PubMed
Belle Brown  J Time and the consultation. Jones  RBritten  NCulpepper  L  et al. Oxford Textbook of Primary Medical Care. Oxford, England Oxford University Press2003;190- 194
Henbest  RJFehrsen  GS Patient-centredness: is it applicable outside the West? its measurement and effect on outcomes. Fam Pract 1992;9 (3) 311- 317
PubMed
Ridsdale  LMorgan  MMorris  R Doctors' interviewing technique and its response to different booking time. Fam Pract 1992;9 (1) 57- 60
PubMed
Wilson  AD Consultation length: general practitioners' attitudes and practices. Br Med J (Clin Res Ed) 1985;290 (6478) 1322- 1324
PubMed
Mechanic  D The organization of medical practice and practice orientations among physicians in prepaid and nonprepaid primary care settings. Med Care 1975;13 (3) 189- 204
PubMed
Gross  DAZyzanski  SJBorawski  EACebul  RDStange  KC Patient satisfaction with time spent with their physician. J Fam Pract 1998;47 (2) 133- 137
PubMed
Eide  HGraugaard  PHolgersen  KFinset  A Physician communication in different phases of a consultation at an oncology outpatient clinic related to patient satisfaction. Patient Educ Couns 2003;51 (3) 259- 266
PubMed
White  JLevinson  WRoter  D “Oh, by the way. . . ”: the closing moments of the medical visit. J Gen Intern Med 1994;9 (1) 24- 28
PubMed
White  JCRosson  CChristensen  JHart  RLevinson  W Wrapping things up: a qualitative analysis of the closing moments of the medical visit. Patient Educ Couns 1997;30 (2) 155- 165
PubMed
Mauksch  LBHillenburg  LRobins  L The established focus protocol: training for collaborative agenda setting and time management in the medical interview. Fam Syst Health 2001;19 (2) 147- 157
Cegala  DJLenzmeier Broz  S Physician communication skills training: a review of theoretical backgrounds, objectives and skills. Med Educ 2002;36 (11) 1004- 1016
PubMed
Inui  TSCarter  WB Problems and prospects for health services research on provider-patient communication. Med Care 1985;23 (5) 521- 538
PubMed
Epstein  RM Mindful practice. JAMA 1999;282 (9) 833- 839
PubMed
Cecchin  G Hypothesizing, circularity and neutrality revisited: an invitation to curiosity. Fam Process 1987;26 (4) 405- 413
PubMed
Borrell-Carrió  FEpstein  RM Preventing errors in clinical practice: a call for self-awareness. Ann Fam Med 2004;2 (4) 310- 316
PubMed
Novack  DHSuchman  ALClark  WEpstein  RMNajberg  EKaplan  CWorking Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient, Calibrating the physician: personal awareness and effective patient care. JAMA 1997;278 (6) 502- 509
PubMed
Gendlin  E Focusing.  New York, NY Bantam1981;
Hegel  MTDietrich  AJSeville  JLJordan  CB Training residents in problem-solving treatment of depression: a pilot feasibility and impact study. Fam Med 2004;36 (3) 204- 208
PubMed
Rollnick  SMason  PButler  C Health Behavior Change.  Edinburgh, Scotland Churchill Livingstone1999;
Tai-Seale  MMcGuire  TZhang  W Time allocation in primary care visits. Health Serv Res 2007;42 (5) 1871- 1894
PubMed
Tai-Seale  MBramson  RBao  X Decision or no decision: how do patient-physician interactions end and what matters? J Gen Intern Med 2007;22 (3) 297- 302
PubMed
Brody  H Transparency: informed consent in primary care. Hastings Cent Rep 1989;19 (5) 5- 9
PubMed
Safran  DGTaira  DARogers  WHKosinski  MWare  JETarlov  AR Linking primary care performance to outcomes of care. J Fam Pract 1998;47 (3) 213- 220
PubMed
Larson  EBYao  X Clinical empathy as emotional labor in the patient-physician relationship. JAMA 2005;293 (9) 1100- 1106
PubMed
Suchman  ALMarkakis  KBeckman  HBFrankel  R A model of empathic communication in the medical interview. JAMA 1997;277 (8) 678- 682
PubMed
Coulehan  JLPlatt  FWEgener  B  et al.  “Let me see if I have this right . . . ”: words that help build empathy. Ann Intern Med 2001;135 (3) 221- 227
PubMed
Mercer  SWReynolds  WJ Empathy and quality of care. Br J Gen Pract 2002;52 ((suppl)) S9- S12
PubMed
Mercer  SWReilly  DWatt  GC The importance of empathy in the enablement of patients attending the Glasgow Homoeopathic Hospital. Br J Gen Pract 2002;52 (484) 901- 905
PubMed
Mercer  SWWatt  GCReilly  D Empathy is important for enablement. BMJ 2001;322 (7290) 865
PubMed
Mahoney  MJ Brief moments and enduring effects: reflections on time and timing in psychotherapy. Matthews  WJEdgette  JHCurrent Thinking and Research in Brief Therapy Solutions, Strategies, Narratives. Vol 1. New York, NY Brunner/Mazel1997;25- 38
Bylund  CLMakoul  G Examining empathy in medical encounters: an observational study using the empathic communication coding system. Health Commun 2005;18 (2) 123- 140
PubMed
Lang  FFloyd  MRBeine  KL Clues to patients' explanations and concerns about their illnesses. a call for active listening. Arch Fam Med 2000;9 (3) 222- 227
PubMed
Dyche  L Interpersonal skill in medicine: the essential partner of verbal communication. J Gen Intern Med 2007;22 (7) 1035- 1039
PubMed
Beasley  JWHankey  THErickson  R  et al.  How many problems do family physicians manage at each encounter? a WReN study. Ann Fam Med 2004;2 (5) 405- 410
PubMed
Dyche  LSwiderski  D The effect of physician solicitation approaches on ability to identify patient concerns. J Gen Intern Med 2005;20 (3) 267- 270
PubMed
Christensen  REFetters  MDGreen  LA Opening the black box: cognitive strategies in family practice. Ann Fam Med 2005;3 (2) 144- 150
PubMed
Baker  LHO'Connell  DPlatt  FW “What else?” setting the agenda for the clinical interview. Ann Intern Med 2005;143 (10) 766- 770
PubMed
Heritage  JRobinson  JDElliott  MNBeckett  MWilkes  M Reducing patients' unmet concerns in primary care: the difference one word can make. J Gen Intern Med 2007;22 (10) 1429- 1433
PubMed
Haas  LJGlazer  KHouchins  JTerry  S Improving the effectiveness of the medical visit: a brief visit-structuring workshop changes patients' perceptions of primary care visits. Patient Educ Couns 2006;62 (3) 374- 378
PubMed
Langewitz  WDenz  MKeller  AKiss  ARuttimann  SWossmer  B Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002;325 (7366) 682- 683
PubMed
Schor  ELLerner  DJMalspeis  S Physicians' assessment of functional health status and well-being: the patient's perspective. Arch Intern Med 1995;155 (3) 309- 314
PubMed
Von Korff  MGruman  JSchaefer  JCurry  SJWagner  EH Collaborative management of chronic illness. Ann Intern Med 1997;127 (12) 1097- 1102
PubMed
Lang  FFloyd  MRBeine  KLBuck  P Sequenced questioning to elicit the patient's perspective on illness: effects on information disclosure, patient satisfaction, and time expenditure. Fam Med 2002;34 (5) 325- 330
PubMed
Campbell  TLMcDaniel  SHCole-Kelly  KHepworth  JLorenz  A Family interviewing: a review of the literature in primary care. Fam Med 2002;34 (5) 312- 318
PubMed
Rust  GKondwani  KMartinez  R  et al.  A crash-course in cultural competence. Ethn Dis 2006;16 (2) ((suppl 3)) S3-29- S3-36
PubMed
Klinkman  MS Competing demands in psychosocial care: a model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry 1997;19 (2) 98- 111
PubMed
Kroenke  KMangelsdorff  AD Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med 1989;86 (3) 262- 266
PubMed
Katon  WJWalker  EA Medically unexplained symptoms in primary care. J Clin Psychiatry 1998;59 ((suppl 20)) 15- 21
PubMed
Girón  MManjón-Arce  PPuerto-Barber  JSánchez-García  EGómez-Beneyto  M Clinical interview skills and identification of emotional disorders in primary care. Am J Psychiatry 1998;155 (4) 530- 535
PubMed
Bass  MJBuck  CTurner  LDickie  GPratt  GRobinson  HC The physician's actions and the outcome of illness in family practice. J Fam Pract 1986;23 (1) 43- 47
PubMed
Egnew  TR The meaning of healing: transcending suffering. Ann Fam Med 2005;3 (3) 255- 262
PubMed
Williams  GCFrankel  RCampbell  TLDeci  EL Research on relationship-centered care and healthcare outcomes from the Rochester Biopsychosocial Program: a self-determination theory integration. Fam Syst Health 2000;18 (1) 79- 90
Stewart  MBrown  JWeston  WMcWhinney  IMc Willian  CFreeman  T Patient-Centered Medicine: Transforming The Clinical Method.  Thousand Oaks, CA Sage1995;
Mauksch  LRoesler  T Expanding the context of the patient's explanatory model using circular questioning. Fam Syst Med 1990;8 (1) 3- 13
Starfield  BWray  CHess  KGross  RBirk  PSD'Lugoff  BC The influence of patient-practitioner agreement on outcome of care. Am J Public Health 1981;71 (2) 127- 131
PubMed
Starfield  BSteinwachs  DMorris  IBause  GSiebert  SWestin  C Patient-doctor agreement about problems needing follow-up visit. JAMA 1979;242 (4) 344- 346
PubMed
Lynch  JWKaplan  GASalonen  JT Why do poor people behave poorly? variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse. Soc Sci Med 1997;44 (6) 809- 819
PubMed
Knight  KMMcGowan  LDickens  CBundy  C A systematic review of motivational interviewing in physical health care settings. Br J Health Psychol 2006;11 (pt 2) 319- 332
PubMed
Braddock  CH  IIISnyder  L The doctor will see you shortly: the ethical significance of time for the patient-physician relationship. J Gen Intern Med 2005;20 (11) 1057- 1062
PubMed
Ryan  RMDeci  EL Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol 2000;55 (1) 68- 78
PubMed
Miller  WL Routine, ceremony, or drama: an exploratory field study of the primary care clinical encounter. J Fam Pract 1992;34 (3) 289- 296
PubMed
Safran  DGMiller  WBeckman  H Organizational dimensions of relationship-centered care: theory, evidence, and practice. J Gen Intern Med 2006;21 ((suppl 1)) S9- S15
PubMed
Rao  JKAnderson  LAInui  TSFrankel  RM Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care 2007;45 (4) 340- 349
PubMed
Epstein  RMFranks  PFiscella  K  et al.  Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues. Soc Sci Med 2005;61 (7) 1516- 1528
PubMed
Miller  WLCrabtree  BFDuffy  MBEpstein  RMStange  KC Research guidelines for assessing the impact of healing relationships in clinical medicine. Altern Ther Health Med 2003;9 (3) ((suppl)) A80- A95
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

Relationship, communication, and efficiency: skills.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Relationship, communication, and efficiency: quality and efficiency benefits.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Studies Linking Communication Quality and Efficiency
Table Graphic Jump LocationTable 2. Contrasting Efficient and Inefficient Interactions

References

Fortin  MBravo  GHudon  CVanasse  ALapointe  L Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005;3 (3) 223- 228
PubMed
Starfield  B Threads and yarns: weaving the tapestry of comorbidity. Ann Fam Med 2006;4 (2) 101- 103
PubMed
Yarnall  KSPollak  KIOstbye  TKrause  KMMichener  JL Primary care: is there enough time for prevention? Am J Public Health 2003;93 (4) 635- 641
PubMed
Østbye  TYarnall  KSKrause  KMPollak  KIGradison  MMichener  JL Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005;3 (3) 209- 214
PubMed
Flocke  SAFrank  SHWenger  DA Addressing multiple problems in the family practice office visit. J Fam Pract 2001;50 (3) 211- 216
PubMed
Mechanic  D How should hamsters run? some observations about sufficient patient time in primary care. BMJ 2001;323 (7307) 266- 268
PubMed
Linzer  MKonrad  TRDouglas  J  et al.  Managed care, time pressure, and physician job satisfaction: results from the physician worklife study. J Gen Intern Med 2000;15 (7) 441- 450
PubMed
Makoul  G Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med 2001;76 (4) 390- 393
PubMed
Williams  SWeinman  JDale  J Doctor-patient communication and patient satisfaction: a review. Fam Pract 1998;15 (5) 480- 492
PubMed
Stewart  MBrown  JBBoon  HGalajda  JMeredith  LSangster  M Evidence on patient-doctor communication. Cancer Prev Control 1999;3 (1) 25- 30
PubMed
Glasgow  REDavis  CLFunnell  MMBeck  A Implementing practical interventions to support chronic illness self-management. Jt Comm J Qual Saf 2003;29 (11) 563- 574
PubMed
Stewart  MBrown  JBDonner  A  et al.  The impact of patient-centered care on outcomes. J Fam Pract 2000;49 (9) 796- 804
PubMed
Epstein  RMFranks  PShields  CG  et al.  Patient-centered communication and diagnostic testing. Ann Fam Med 2005;3 (5) 415- 421
PubMed
Levinson  WRoter  DLMullooly  JPDull  VTFrankel  RM Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;277 (7) 553- 559
PubMed
Smith  RCLyles  JSMettler  J  et al.  The effectiveness of intensive training for residents in interviewing: a randomized, controlled study. Ann Intern Med 1998;128 (2) 118- 126
PubMed
Roter  DLHall  JAKern  DEBarker  LRCole  KARoca  RP Improving physicians' interviewing skills and reducing patients' emotional distress: a randomized clinical trial. Arch Intern Med 1995;155 (17) 1877- 1884
PubMed
Yedidia  MJGillespie  CCKachur  E  et al.  Effect of communications training on medical student performance. JAMA 2003;290 (9) 1157- 1165
PubMed
Braddock  CH  IIIEdwards  KAHasenberg  NMLaidley  TLLevinson  W Informed decision making in outpatient practice: time to get back to basics. JAMA 1999;282 (24) 2313- 2320
PubMed
Kravitz  RLCallahan  EJPaterniti  DAntonius  DDunham  MLewis  CE Prevalence and sources of patients' unmet expectations for care. Ann Intern Med 1996;125 (9) 730- 737
PubMed
Kroenke  KJackson  JLChamberlin  J Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome. Am J Med 1997;103 (5) 339- 347
PubMed
Marvel  MKEpste in  RMFlowers  KBeckman  HB Soliciting the patient's agenda: have we improved? JAMA 1999;281 (3) 283- 287
PubMed
Beckman  HBFrankel  RM The effect of physician behavior on the collection of data. Ann Intern Med 1984;101 (5) 692- 696
PubMed
Barry  CABradley  CPBritten  NStevenson  FABarber  N Patients' unvoiced agendas in general practice consultations: qualitative study. BMJ 2000;320 (7244) 1246- 1250
PubMed
Levinson  WGorawara-Bhat  RLamb  J A study of patient clues and physician responses in primary care and surgical settings. JAMA 2000;284 (8) 1021- 1027
PubMed
Freeman  GKHorder  JPHowie  JG  et al.  Evolving general practice consultation in Britain: issues of length and context. BMJ 2002;324 (7342) 880- 882
PubMed
Dugdale  DCEpstein  RPantilat  SZ Time and the patient-physician relationship. J Gen Intern Med 1999;14 ((suppl 1)) S34- S40
PubMed
Wilson  AChilds  S The relationship between consultation length, process and outcomes in general practice: a systematic review. Br J Gen Pract 2002;52 (485) 1012- 1020
PubMed
Britt  HValenti  LMiller  G Time for care: length of general practice consultations in Australia. Aust Fam Physician 2002;31 (9) 876- 880
PubMed
Britt  HCValenti  LMiller  GC Determinants of consultation length in Australian general practice. Med J Aust 2005;183 (2) 68- 71
PubMed
Blumenthal  DCausino  NChang  YC  et al.  The duration of ambulatory visits to physicians. J Fam Pract 1999;48 (4) 264- 271
PubMed
Howie  JGHeaney  DJMaxwell  MWalker  JJFreeman  GKRai  H Quality at general practice consultations: cross sectional survey. BMJ 1999;319 (7212) 738- 743
PubMed
Martin  CMBanwell  CLBroom  DHNisa  M Consultation length and chronic illness care in general practice: a qualitative study. Med J Aust 1999;171 (2) 77- 81
PubMed
Zyzanski  SJStange  KCLanga  DFlocke  SA Trade-offs in high-volume primary care practice. J Fam Pract 1998;46 (5) 397- 402
PubMed
Flocke  SAMiller  WLCrabtree  BF Relationships between physician practice style, patient satisfaction, and attributes of primary care. J Fam Pract 2002;51 (10) 835- 840
PubMed
Goedhuys  JRethans  JJ On the relationship between the efficiency and the quality of the consultation: a validity study. Fam Pract 2001;18 (6) 592- 596
PubMed
Cape  J Consultation length, patient-estimated consultation length, and satisfaction with the consultation. Br J Gen Pract 2002;52 (485) 1004- 1006
PubMed
Scheitel  SMBoland  BJWollan  PCSilverstein  MD Patient-physician agreement about medical diagnoses and cardiovascular risk factors in the ambulatory general medical examination. Mayo Clin Proc 1996;71 (12) 1131- 1137
PubMed
Deveugele  MDerese  Avan den Brink-Muinen  ABensing  JDe Maeseneer  J Consultation length in general practice: cross sectional study in six European countries. BMJ 2002;325 (7362) 472
PubMed
Mechanic  DMcAlpine  DDRosenthal  M Are patients' office visits with physicians getting shorter? N Engl J Med 2001;344 (3) 198- 204
PubMed
Stewart  MA Effective physician-patient communication and health outcomes: a review. CMAJ 1995;152 (9) 1423- 1433
PubMed
van den Brink-Muinen  AVerhaak  PFBensing  JM  et al.  Communication in general practice: differences between European countries. Fam Pract 2003;20 (4) 478- 485
PubMed
Bensing  JMRoter  DLHulsman  RL Communication patterns of primary care physicians in the United States and the Netherlands. J Gen Intern Med 2003;18 (5) 335- 342
PubMed
Roter  DLStewart  MPutnam  SMLipkin  M  JrStiles  WInui  TS Communication patterns of primary care physicians. JAMA 1997;277 (4) 350- 356
PubMed
Belle Brown  J Time and the consultation. Jones  RBritten  NCulpepper  L  et al. Oxford Textbook of Primary Medical Care. Oxford, England Oxford University Press2003;190- 194
Henbest  RJFehrsen  GS Patient-centredness: is it applicable outside the West? its measurement and effect on outcomes. Fam Pract 1992;9 (3) 311- 317
PubMed
Ridsdale  LMorgan  MMorris  R Doctors' interviewing technique and its response to different booking time. Fam Pract 1992;9 (1) 57- 60
PubMed
Wilson  AD Consultation length: general practitioners' attitudes and practices. Br Med J (Clin Res Ed) 1985;290 (6478) 1322- 1324
PubMed
Mechanic  D The organization of medical practice and practice orientations among physicians in prepaid and nonprepaid primary care settings. Med Care 1975;13 (3) 189- 204
PubMed
Gross  DAZyzanski  SJBorawski  EACebul  RDStange  KC Patient satisfaction with time spent with their physician. J Fam Pract 1998;47 (2) 133- 137
PubMed
Eide  HGraugaard  PHolgersen  KFinset  A Physician communication in different phases of a consultation at an oncology outpatient clinic related to patient satisfaction. Patient Educ Couns 2003;51 (3) 259- 266
PubMed
White  JLevinson  WRoter  D “Oh, by the way. . . ”: the closing moments of the medical visit. J Gen Intern Med 1994;9 (1) 24- 28
PubMed
White  JCRosson  CChristensen  JHart  RLevinson  W Wrapping things up: a qualitative analysis of the closing moments of the medical visit. Patient Educ Couns 1997;30 (2) 155- 165
PubMed
Mauksch  LBHillenburg  LRobins  L The established focus protocol: training for collaborative agenda setting and time management in the medical interview. Fam Syst Health 2001;19 (2) 147- 157
Cegala  DJLenzmeier Broz  S Physician communication skills training: a review of theoretical backgrounds, objectives and skills. Med Educ 2002;36 (11) 1004- 1016
PubMed
Inui  TSCarter  WB Problems and prospects for health services research on provider-patient communication. Med Care 1985;23 (5) 521- 538
PubMed
Epstein  RM Mindful practice. JAMA 1999;282 (9) 833- 839
PubMed
Cecchin  G Hypothesizing, circularity and neutrality revisited: an invitation to curiosity. Fam Process 1987;26 (4) 405- 413
PubMed
Borrell-Carrió  FEpstein  RM Preventing errors in clinical practice: a call for self-awareness. Ann Fam Med 2004;2 (4) 310- 316
PubMed
Novack  DHSuchman  ALClark  WEpstein  RMNajberg  EKaplan  CWorking Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient, Calibrating the physician: personal awareness and effective patient care. JAMA 1997;278 (6) 502- 509
PubMed
Gendlin  E Focusing.  New York, NY Bantam1981;
Hegel  MTDietrich  AJSeville  JLJordan  CB Training residents in problem-solving treatment of depression: a pilot feasibility and impact study. Fam Med 2004;36 (3) 204- 208
PubMed
Rollnick  SMason  PButler  C Health Behavior Change.  Edinburgh, Scotland Churchill Livingstone1999;
Tai-Seale  MMcGuire  TZhang  W Time allocation in primary care visits. Health Serv Res 2007;42 (5) 1871- 1894
PubMed
Tai-Seale  MBramson  RBao  X Decision or no decision: how do patient-physician interactions end and what matters? J Gen Intern Med 2007;22 (3) 297- 302
PubMed
Brody  H Transparency: informed consent in primary care. Hastings Cent Rep 1989;19 (5) 5- 9
PubMed
Safran  DGTaira  DARogers  WHKosinski  MWare  JETarlov  AR Linking primary care performance to outcomes of care. J Fam Pract 1998;47 (3) 213- 220
PubMed
Larson  EBYao  X Clinical empathy as emotional labor in the patient-physician relationship. JAMA 2005;293 (9) 1100- 1106
PubMed
Suchman  ALMarkakis  KBeckman  HBFrankel  R A model of empathic communication in the medical interview. JAMA 1997;277 (8) 678- 682
PubMed
Coulehan  JLPlatt  FWEgener  B  et al.  “Let me see if I have this right . . . ”: words that help build empathy. Ann Intern Med 2001;135 (3) 221- 227
PubMed
Mercer  SWReynolds  WJ Empathy and quality of care. Br J Gen Pract 2002;52 ((suppl)) S9- S12
PubMed
Mercer  SWReilly  DWatt  GC The importance of empathy in the enablement of patients attending the Glasgow Homoeopathic Hospital. Br J Gen Pract 2002;52 (484) 901- 905
PubMed
Mercer  SWWatt  GCReilly  D Empathy is important for enablement. BMJ 2001;322 (7290) 865
PubMed
Mahoney  MJ Brief moments and enduring effects: reflections on time and timing in psychotherapy. Matthews  WJEdgette  JHCurrent Thinking and Research in Brief Therapy Solutions, Strategies, Narratives. Vol 1. New York, NY Brunner/Mazel1997;25- 38
Bylund  CLMakoul  G Examining empathy in medical encounters: an observational study using the empathic communication coding system. Health Commun 2005;18 (2) 123- 140
PubMed
Lang  FFloyd  MRBeine  KL Clues to patients' explanations and concerns about their illnesses. a call for active listening. Arch Fam Med 2000;9 (3) 222- 227
PubMed
Dyche  L Interpersonal skill in medicine: the essential partner of verbal communication. J Gen Intern Med 2007;22 (7) 1035- 1039
PubMed
Beasley  JWHankey  THErickson  R  et al.  How many problems do family physicians manage at each encounter? a WReN study. Ann Fam Med 2004;2 (5) 405- 410
PubMed
Dyche  LSwiderski  D The effect of physician solicitation approaches on ability to identify patient concerns. J Gen Intern Med 2005;20 (3) 267- 270
PubMed
Christensen  REFetters  MDGreen  LA Opening the black box: cognitive strategies in family practice. Ann Fam Med 2005;3 (2) 144- 150
PubMed
Baker  LHO'Connell  DPlatt  FW “What else?” setting the agenda for the clinical interview. Ann Intern Med 2005;143 (10) 766- 770
PubMed
Heritage  JRobinson  JDElliott  MNBeckett  MWilkes  M Reducing patients' unmet concerns in primary care: the difference one word can make. J Gen Intern Med 2007;22 (10) 1429- 1433
PubMed
Haas  LJGlazer  KHouchins  JTerry  S Improving the effectiveness of the medical visit: a brief visit-structuring workshop changes patients' perceptions of primary care visits. Patient Educ Couns 2006;62 (3) 374- 378
PubMed
Langewitz  WDenz  MKeller  AKiss  ARuttimann  SWossmer  B Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002;325 (7366) 682- 683
PubMed
Schor  ELLerner  DJMalspeis  S Physicians' assessment of functional health status and well-being: the patient's perspective. Arch Intern Med 1995;155 (3) 309- 314
PubMed
Von Korff  MGruman  JSchaefer  JCurry  SJWagner  EH Collaborative management of chronic illness. Ann Intern Med 1997;127 (12) 1097- 1102
PubMed
Lang  FFloyd  MRBeine  KLBuck  P Sequenced questioning to elicit the patient's perspective on illness: effects on information disclosure, patient satisfaction, and time expenditure. Fam Med 2002;34 (5) 325- 330
PubMed
Campbell  TLMcDaniel  SHCole-Kelly  KHepworth  JLorenz  A Family interviewing: a review of the literature in primary care. Fam Med 2002;34 (5) 312- 318
PubMed
Rust  GKondwani  KMartinez  R  et al.  A crash-course in cultural competence. Ethn Dis 2006;16 (2) ((suppl 3)) S3-29- S3-36
PubMed
Klinkman  MS Competing demands in psychosocial care: a model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry 1997;19 (2) 98- 111
PubMed
Kroenke  KMangelsdorff  AD Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med 1989;86 (3) 262- 266
PubMed
Katon  WJWalker  EA Medically unexplained symptoms in primary care. J Clin Psychiatry 1998;59 ((suppl 20)) 15- 21
PubMed
Girón  MManjón-Arce  PPuerto-Barber  JSánchez-García  EGómez-Beneyto  M Clinical interview skills and identification of emotional disorders in primary care. Am J Psychiatry 1998;155 (4) 530- 535
PubMed
Bass  MJBuck  CTurner  LDickie  GPratt  GRobinson  HC The physician's actions and the outcome of illness in family practice. J Fam Pract 1986;23 (1) 43- 47
PubMed
Egnew  TR The meaning of healing: transcending suffering. Ann Fam Med 2005;3 (3) 255- 262
PubMed
Williams  GCFrankel  RCampbell  TLDeci  EL Research on relationship-centered care and healthcare outcomes from the Rochester Biopsychosocial Program: a self-determination theory integration. Fam Syst Health 2000;18 (1) 79- 90
Stewart  MBrown  JWeston  WMcWhinney  IMc Willian  CFreeman  T Patient-Centered Medicine: Transforming The Clinical Method.  Thousand Oaks, CA Sage1995;
Mauksch  LRoesler  T Expanding the context of the patient's explanatory model using circular questioning. Fam Syst Med 1990;8 (1) 3- 13
Starfield  BWray  CHess  KGross  RBirk  PSD'Lugoff  BC The influence of patient-practitioner agreement on outcome of care. Am J Public Health 1981;71 (2) 127- 131
PubMed
Starfield  BSteinwachs  DMorris  IBause  GSiebert  SWestin  C Patient-doctor agreement about problems needing follow-up visit. JAMA 1979;242 (4) 344- 346
PubMed
Lynch  JWKaplan  GASalonen  JT Why do poor people behave poorly? variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse. Soc Sci Med 1997;44 (6) 809- 819
PubMed
Knight  KMMcGowan  LDickens  CBundy  C A systematic review of motivational interviewing in physical health care settings. Br J Health Psychol 2006;11 (pt 2) 319- 332
PubMed
Braddock  CH  IIISnyder  L The doctor will see you shortly: the ethical significance of time for the patient-physician relationship. J Gen Intern Med 2005;20 (11) 1057- 1062
PubMed
Ryan  RMDeci  EL Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol 2000;55 (1) 68- 78
PubMed
Miller  WL Routine, ceremony, or drama: an exploratory field study of the primary care clinical encounter. J Fam Pract 1992;34 (3) 289- 296
PubMed
Safran  DGMiller  WBeckman  H Organizational dimensions of relationship-centered care: theory, evidence, and practice. J Gen Intern Med 2006;21 ((suppl 1)) S9- S15
PubMed
Rao  JKAnderson  LAInui  TSFrankel  RM Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care 2007;45 (4) 340- 349
PubMed
Epstein  RMFranks  PFiscella  K  et al.  Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues. Soc Sci Med 2005;61 (7) 1516- 1528
PubMed
Miller  WLCrabtree  BFDuffy  MBEpstein  RMStange  KC Research guidelines for assessing the impact of healing relationships in clinical medicine. Altern Ther Health Med 2003;9 (3) ((suppl)) A80- A95
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 66

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Topics
PubMed Articles
JAMAevidence.com