Debra Roter, whom another researcher referred to as “the royalty” of researchers in communication, grew up in a working-class home in Flatbush, Brooklyn, in the 1960s. Her father was a butcher, and Yiddish was the lingua franca. Neither of her parents had graduated high school, though her mother later earned a GED. From these humble beginnings, Debra went on to create one of the definitive research tools for understanding how doctors and patients communicate.
Like most families of that era and locale, Debra’s was mostly focused on the daily business of keeping family and livelihood going. Everyone was either an immigrant or the child of an immigrant, and noses were kept solidly to the grindstone. Debra recalled that when she first played Scrabble as an adult, she lost all the time because unlike her “American” counterparts, she’d had zero experience with board games in childhood.
But news and politics were a different story. Everyone took a visceral—and vocal—interest in the goings-on of the world. Political discussions and left-leaning newspapers competed with brisket, herring, and kugel for space at the dinner table. Debra’s parents and three older brothers staked out opinions on everything; shyness in expressing such opinions was not a Roter trait.
One summer, after much begging and pleading, Debra and one of her brothers were sent to Camp Kinderland, the legendary summer retreat in the Berkshire Mountains founded by Yiddish labor activists in the early 1920s. Camp activities were saturated with social justice, progressive values, and lively horas. This being the 1960s, the counselors were usually busy coordinating protests at their colleges during the school semesters. Feminism was beginning to change the rules of the game.
Debra was steeped in these swirls of debate. Everybody, it seemed, was trying to say something. How it would all play out, nobody quite knew; but it was electrifying. In 1971, while Debra was attending college in California, the first edition of the feminist classic Our Bodies, Ourselves was published. This book had something to say that had not yet been heard before: women could be active participants in their medical care. This hardly seems like a radical statement today, but for all of the upheaval the 1960s brought to family, work, and society, the field of medicine was still firmly rooted in the hidebound 1950s.
The rigid medical hierarchy and the bedrock rules of doctor-patient interaction had hardly budged despite the foment in nearly every other aspect of society. The term “paternalism” wasn’t even needed because the idea of the doctor telling the patient what to do wasn’t seen as a problem. (“If our family doctor instructed my mother to crash my head through a plate-glass window,” one of my colleagues recalled of that time, “she would simply have rolled up her sleeves and hoisted me through.”) Telling the patient what to do was the very model of proper, effective, caring medicine. The idea that patients should speak up and assume an active role in their medical care, never mind try to be partners with their doctors in this care, was almost seditious. And, of course, nearly all the doctors were men. Even in 1970, fewer than 10 percent of doctors were women.1 It wasn’t until 1972, when the Title IX amendment to the Higher Education Act banned discrimination on the basis of gender, that women began entering medical school in significant numbers. (Currently, about one-third of doctors are women, though this percentage is destined to grow given that 47 percent of medical students are female.)2
Debra devoured Our Bodies, Ourselves and even today remains proud to have owned a 35-cent mimeographed copy of the original manuscript. The idea that language—how, when, and where we speak—could be a mechanism for women to assert power in a nearly all-male medical establishment was a heady thought. You didn’t need money, position, or prestige to access some of that power; you just needed to understand how language and communication worked.
Debra’s first job out of college was at the New York City Department of Health. Her task was to evaluate community health centers, to help define the needs of their patients. This involved talking with people in the community, understanding and prioritizing their concerns. One major issue was the low “show rate” to doctor appointments. At some inner-city clinics, fewer than half of appointments were kept. Debra thought perhaps that show rate could be improved if patients were more active in their care. Taking a page from Our Bodies, Ourselves, she encouraged patients to take a role in their care, even by doing something as elementary as planning a question to ask their doctor.
When Debra started her graduate studies in public health shortly thereafter, this idea became the central focus of her doctoral thesis. She hypothesized that if patients became more engaged in their medical care by asking questions, they would be more satisfied with the overall process and then keep their appointments more regularly.
So she set up a research project at an inner-city clinic in Baltimore near the Johns Hopkins campus, where she was working on her doctorate. The main thrust of the project was to have a health educator sit with patients for ten minutes before their appointments. The educator would ask about their medical conditions, which treatments they were getting, which medications they were on, and what they knew about side effects and prognoses. The educator would then encourage patients to come up with a few questions on these topics that they might ask their doctors. These questions were written down to be easier to remember during the visit. (For the control group, the educator simply reviewed the services that the clinic offered.)
Now, of course, Debra needed a way to figure out whether the patients actually asked the questions, so she audiotaped the medical visits. But then she was faced with transcribing three hundred audiotapes, word by word, onto paper in order to analyze what was being said during the visits. This was a laborious and daunting task. Plus, she was interested in more than just whether the patients asked questions. She was curious how doctors received the questions: With concern? Annoyance? Interest? Confusion? She realized she was interested not just in which words were being spoken, but rather in the whole gestalt of communication between the patient and doctor.
Debra wondered if there was a way to glean the crucial information from a conversation just by listening to the tape, rather than painstakingly transcribing every word that was spoken. There had to be a way to quantify what type of statement or question was being communicated and what sort of emotion was being expressed.
She realized she’d first have to figure out how to define a unit of speech. Would it be a word? A phrase? A sentence? Because she was interested in the meaning of what was being communicated, she decided the unit would be defined as a complete thought, whether that thought was a whole sentence, a small phrase, a single word, or even just an “mm-hmm” of agreement.
Then these units needed to be sorted out, or coded, into categories. First a unit would be coded as to who had spoken it, the doctor or the patient. Then it would be categorized by what purpose the speech was serving. For example, a good amount of speech in a doctor-patient visit is primarily about obtaining data, such as the doctor asking the patient about prior illnesses or the patient asking the doctor about lab test results. There’s also “procedural” speech, directing a patient to, for example, sit on the table or take a deep breath. There is patient education and counseling, in which the doctor explains a test or how a medication works.
These categories were easy to identify because they are straightforward and don’t vary much from visit to visit or person to person. Woven around these nuts and bolts of medicine, however, is an enormous amount of give-and-take that is less easy to define but is probably what patients are responding to when they say they have a fantastic doctor or a second-rate doctor. Or what doctors are talking about when they describe the most wonderful patient or the most difficult patient.
These elements of interpersonal connection can be hard to pinpoint and they can’t be measured as easily as, say, whether doctors remember to introduce themselves at the start of visits (you’d be amazed at how many doctors forget to do this!). Various terms hint at this: bedside manner, compassion, enthusiasm, graciousness, warmth. A pure rationalist could say that they aren’t really needed; if the patient is accurately diagnosed, treated, and cured, that’s success. And from a statistical standpoint, that’s true. A computer could surely accomplish any number of medical tasks, maybe even more accurately than a human.
But you can imagine—and maybe you have experienced—what medical visits without those components are like. Such visits leave much to be desired. When it comes to a medical visit that contains elements such as empathy, give-and-take, respect, and amiability—most of us know it when we see it, and surely know it when it’s absent.
Debra was intrigued by these other elements in the doctor-patient interaction. She suspected these weren’t just niceties that made the visit more pleasant but key elements in medical care. As a scientist, though, she needed a reliable way to measure these kinds of statements, something more than just “You know it when you see it.”
So she created another category called “activation and partnership.” These are statements from the doctor or patient that cue interest and connection, such as “Tell me more about that” or “So, what do you think?” or “Let me see if I’ve got this right. . . .” These types of statements clarify what’s being said and, most important, let the speaker know that the listener is interested. As I would later learn from researcher Janet Bavelas, this is the doctor acting as a conarrator with the patient, helping to draw out, enhance, and shape the patient’s story. These statements ultimately end up doing double duty: establishing key facts for good medical care and also working to build a relationship between the two people speaking.
Then there are statements that signal emotional responsiveness. For instance, when the doctor acknowledges the pain of the patient’s headache or the patient’s frustration at having waited so long for an appointment. Or, conversely, the doctor might downplay the nausea or fatigue caused by a medication. These are statements that indicate how the person is responding to the other person’s concerns and serve to legitimize—or minimize—what the other person is saying.
Within these broad categories, the units of speech had to be subcategorized as to whether they were questions, statements of opinion, statements of approval, or requests for clarification. There were also categories for statements of agreement, personal comments, and requests for questions. Questions could be open-ended or closed-ended. In the end there were several dozen distinct types of speech that took place in the conversation of a typical medical visit. Debra now had a detailed system for categorizing the myriad elements of doctor-patient communication.
On top of all these detailed categories of speech, Debra added one more thing to be recorded: the emotion being expressed. It was critical to know whether a statement was spoken matter-of-factly, irritably, sympathetically, angrily, or anxiously. The measurement of emotion was a crucial addition to the system. In the old-fashioned transcribing system, there would be no way to distinguish one doctor’s warm, friendly “How are you?” from another’s curt and perfunctory “How are you?”—even though these obviously set the stage for radically different communication. This additional category rated the emotional temperature of what was being said.
Collaborating with Judy Hall, a faculty member from her dissertation committee, Debra had now created a scientific way of measuring both the factual content and emotional components of conversations between doctors and patients.3 Rather than having to transcribe on paper every word that was spoken, Debra could listen to the tape and simply check off the appropriate categories for each unit of speech that occurred. In the end she would have a detailed analysis of each conversation. She could know, for example, how many empathetic statements a doctor made, or what percentage of the visit was spent gathering data, or how many questions a patient asked, and then correlate these numbers with medical outcomes such as blood pressure control or medication adherence. Because these were hard numbers and not simply impressions of what had occurred, statistics could be applied to rigorously evaluate the outcomes.
For Debra’s original study about patients asking questions of their doctors, this coding system enabled her to document that the ten minute session encouraging questions actually worked. It turned out that these patients asked twice as many direct questions as patients in the control group.4 On average, the patients asked two questions per visit, as opposed to one question for the patients in the control group. Doesn’t sound like much of a difference, but the patients who asked the extra question were 17 percent more likely to keep their follow-up appointments. That’s an effect that’s noticeable and meaningful.
Unexpectedly, however, the patients who asked more questions left the medical visit with more anxiety and anger. Overall, they were less satisfied with their experience. This ran counter to Debra’s hypothesis, that once patients were more active in their health care they would be more satisfied.
This outcome was puzzling but it did have a paradigm in the political upheavals of the day. When historically passive segments of society—women, African Americans, immigrants—began speaking up, the traditional order of things was challenged. The establishment wasn’t necessarily pleased to have the comfortable working order destabilized. Reactions and backlashes made things worse, and it often took years or even decades before society settled around new norms—if it ever did. Patients in the 1970s—especially patients from lower socioeconomic strata—were generally a docile group. Doctors told patients what to do and that was that. One can imagine that having patients question this would be a surprise to doctors at the very least, or perhaps an affront or even an insult. It could change the tenor of the interaction and leave both parties feeling uncomfortable.
Or it could simply be that doing anything different than usual inherently feels uncomfortable. The patients had been asked about their satisfaction directly after the visit, and may have felt out of sorts from the experience of stepping out of their comfort zone moments earlier. But the fact that their show rates six months later were higher suggests that they may have grown more comfortable with this type of interaction. Although the patients weren’t specifically polled again after six months, they may have indicated their increased satisfaction by voting with their feet and returning for the next appointment.
The bigger question for Debra Roter was how all of this affected medical care. Now that she had a tool to rapidly and reliably measure how doctors and patients communicated with one another, her career was ready to unfold. The tool became known as the Roter Interaction Analysis System (RIAS), and it has become the standard yardstick in communication studies.5 It’s been used in every aspect of medicine. Debra herself has published more than two hundred papers using the system to study communication in the fields of oncology, podiatry, pediatrics, obstetrics, psychiatry, and geriatrics. She has used the RIAS system to research medication adherence, sexually transmitted diseases, diabetes, domestic violence, genetic testing, HIV, hypertension, Alzheimer’s disease, asthma, malpractice, the prescribing of psychiatric medications, the teaching of communication to medical students, the use of humor, the effects of patient race and ethnicity, and the role of doctor gender. It’s been used in Japan, Israel, England, and China.
The term “medical visit” is often used in a way that suggests it is a very standard thing, that doctor-patient encounters are generally homogeneous. Debra and her colleagues suspected that there was more variety, and that the different types of encounters presaged different outcomes. They analyzed more than five hundred medical visits in ordinary clinics and private practices.6 These were ongoing-care visits (that is, not new visits) between 127 doctors and 537 patients. These visits are the bread and butter of general medical practices. Most patients in these visits have a couple of chronic conditions to check in on and an occasional new issue to discuss. Then there are clusters at either end of the severity spectrum—some patients with multiple, serious conditions, and some who are generally healthy, just coming for an annual checkup.
By examining the communication between patients and doctors, the researchers were able to divide these encounters into several types of visits. The first was the traditional medical visit, which they termed “narrowly biomedical.” As the name suggests, nearly everything in this type of visit was about medical issues. Neither the doctor nor the patient delved into psychological or social issues. Much of the doctor’s talk involved asking questions of the patient, usually of the closed-ended variety. (Have you ever had chest pain? Do your legs swell? Do you get dizzy?) About one-third of doctor-patient visits were of this “just-the-facts-ma’am” type.
Another one-third fell into the category of “expanded biomedical” visit. This visit was still predominantly medical in nature, with the doctor asking the lion’s share of questions, but the doctor and patient did venture into some of the psychological and social well-being of the patient.
The elements were far more balanced in what was called the “bio-psycho-social” category. Patient talk was equally divided between the medical and the psychosocial. Physician talk was still weighted toward the medical but much less so than in the other categories. One-fifth of visits fell into this category. (In a sprinkling of visits, the patient talk was nearly all psychosocial.)
Far fewer visits fell into what the researchers termed the “consumerist” category. Here the patient was more like a customer utilizing a service, in this case the doctor’s medical knowledge. The patient asked most of the questions and the doctor spent the visit dispensing information. Little of the psychosocial realm came up. These were about one-tenth of visits.
When asked their opinion about the visits they’d experienced, patients were distinctly unenamored of the narrowly biomedical visits. These had the lowest satisfaction ratings. Patients preferred the more balanced experience of the bio-psycho-social visit. These visits were more evenly balanced not just by topic but also by who did the speaking. Interestingly, doctors were not especially fans of the narrowly biomedical visits, either. They ultimately saw these visits as inefficient, making poor use of their time and yielding low-quality data.
One analysis in the study that intrigued me was of communication control, that is, who feels in control of the conversation. Not surprisingly, patients felt they had the least control of the conversation in the narrowly biomedical visits and had the most in the consumerist visit, where they asked the questions and the doctor served mainly as the consultant.
The term “consumerist” has always rubbed me the wrong way—the whiff of shopping-mall abyss is enough to make me cringe—but I know exactly what kind of visit this is. The patient arrives armed with questions and I am already on the defensive even before the patient has opened his mouth. When the patient unfolds the shopping list of questions with that crisp, disheartening snap, immediate pangs of dread besiege me.
When I’ve thought about why my hackles get automatically raised, I’ve usually chalked it up to the volume of requests that typically follow and the impossibility of addressing everything in a short visit. But Debra’s study made me wonder if I’m perhaps reacting unconsciously to the ceding of control. In more-typical visits, the patient brings up a few things and then—if I look honestly at myself—I take over the conversation. I rapidly prioritize the issues and then start asking the questions that eventually dictate our course of action. Of course I am engaging the patient in all of this conversation, but the truth is that I’m usually steering the course. When the patient begins by positioning herself as the asker of questions, as in the consumerist type of visit, the dynamic changes. Maybe that’s why I feel uncomfortable.
When I look back at what I just wrote, I notice that I said the patient comes “armed” with questions. Indeed, I sometimes feel like I’m under attack when the barrage of questions comes forth, along with the expectation that there will be ready answers for every one. Part of my defensiveness is surely that I know that I will disappoint for a good percentage of these questions. Medicine is much less precise than we’d like to think, and so when that sheet of questions unfolds, I know I’ll be equivocating—and disappointing—quite a bit. My patients will be annoyed, as will I.
Reexamining my reactions through the prism of this research is helpful. No one relishes losing control and we all respond to this—usually unconsciously and often negatively. Next time I notice a reflexive spine-stiffening when a patient unfolds a list of questions, I’ll try to remind myself that the center of control is going to shift a bit. If I can readjust myself in advance, maybe I won’t lose my balance so easily.
One of the (many) things Debra Roter is using her RIAS system for is to help train doctors to use communication more effectively. A standard method many medical schools use is the videotape review. Medical students or residents are videotaped interviewing patients and later review the tapes with a faculty member. At our medical school I participated in this for years, but I have to admit that I found it painfully laborious. I would sit with four students and we’d watch a few minutes of one tape, then discuss it. Then we’d watch a bit more and offer a few comments. But we could never watch the full visit because it would take too long, plus so much time was wasted rewinding and fast-forwarding. In the end, we’d glean only a little from the experience. The juice never felt worth the squeeze.
“With RIAS,” Debra explained, “you can look at the entire visit at once.” An intern could see that she had offered reassurance to the patient seventeen times but never once made a statement that offered empathy, even though the patient had raised ten issues of concern during the conversation. Furthermore, the intern could click on those seventeen “reassurance statements” and listen to what she’d actually said. She might find that she used the same phrase—”There’s nothing to worry about”—over and over, which probably began to sound like a platitude to the patient. She could click on the nine “patient concerns” and realize that the patient had only two real concerns but kept repeating them because the intern kept saying, “There’s nothing to worry about.”
A medical student could see, for example, that he was speaking for 80 percent of the time while the patient spoke only 20 percent of the time. He could be gently reminded to cede the floor more frequently.
Most doctors have never had their conversations with patients analyzed, and I bet many of us would be surprised to learn what we look like and sound like. The first time I saw myself on videotape I was shocked to see how much I talk with my hands. I was a veritable tarmac flag-waver. It’s a wonder I didn’t accidentally knock any patients off the exam table.
I also noticed that whenever I was asked a question for which I had to stop and think, my eyes would flit up toward the ceiling and hover there while I cogitated. This, I know, is common behavior, but it still annoyed me to see my gaze wander off. However, when I was really stumped, I would actually close my eyes completely. Seeing that on tape horrified me. Did my patients think I was zoning out completely? Did they think I was running low on caffeine or maybe debating what to make for dinner that evening? Either way, seeing these tapes made me more conscious of how I was responding to my patients.
Simply having this enhanced consciousness may be sufficient to increase the effectiveness of communication. If patients recognize, for example, that they aren’t asking their doctors enough questions, they may be able to focus the conversation to ensure that their most important concern is addressed. If doctors notice they’re dominating the conversation or ignoring issues beyond the strictly medical, they may find that a few small adjustments will increase their effectiveness, as well as the satisfaction all around. David Baron and Tracey Pratt are one such doctor-patient pair who made the effort to be more conscious of their interaction, and it propelled them onto an unexpected path.