Abstracts

Introduction

The Roter Interaction Analysis System (RIAS) is a computer-based methodology that permits to characterize the communication resulting from the interaction between health professionals and patients.¹1. RIASWORKS: Evidence-based communication for education, research & practice [cited 2011 mar 15]. Available at: http://www.riasworks.com.
http://www.riasworks.com... The RIAS was initially based on the work of Robert Bales (1950) which, in the 1970s, was transposed to the investigation of the communication in medical consultations. In RIAS, communication units are identified (phrases, parts of phrases or single words) to which codes are associated, divided into two broad categories:

1. Affective and social, that is, codes related to the expression of concerns, approval/disapproval, agreement, criticism, empathy, etc.;

2. Instrumental, which includes codes related to the provision or verification of clinical and therapeutic information, among others, in the form of questions, paraphrases and affirmations.¹1. RIASWORKS: Evidence-based communication for education, research & practice [cited 2011 mar 15]. Available at: http://www.riasworks.com.
   http://www.riasworks.com... ^,22. Roter DL, Larson S. The relationship between residents' and attending physicians' communication during primary care visits: an illustrative use of the Roter Interaction Analysis System. Health Commun 2001; 13:33-48.

The RIAS coding system is applied to the dialog between a patient and a healthcare provider, recorded in an audio or vi-deo support. The RIAS categories are adapted to all stages of the medical consultation, from initial greetings, collection of objective and subjective information, as well as the phase of the patient, guidance and education, including other consultation components, for example, response to emotions and activation of the partnership with the patient.²2. Roter DL, Larson S. The relationship between residents' and attending physicians' communication during primary care visits: an illustrative use of the Roter Interaction Analysis System. Health Commun 2001; 13:33-48.^,33. Sheldon LK, Ellington L, Barrett R, Dudley WN, Clayton MF, Rinaldi K.. Nurse responsiveness to cancer patient expressions of emotion. Patient Educ Couns 2009;76:63-70.

The RIAS method has been used in the United States and Europe in various healthcare and medical contexts, in observational and experimental studies, as well as in the pedagogic and educational contexts. Based on this methodology, it has been possible to characterize the communication in medical areas, such as primary care, gynecology, oncology, surgery, pediatrics and dentistry, as well as evaluating the results of educational interventions on physicians and patients.²2. Roter DL, Larson S. The relationship between residents' and attending physicians' communication during primary care visits: an illustrative use of the Roter Interaction Analysis System. Health Commun 2001; 13:33-48. However, the research published on communication in primary healthcare is still limited, particularly in Portuguese, although communication research may contribute to relational improvements in general and family medicine during consultation.⁴4. Brandão J. Relação e comunicação médico-doente. Rev Port Clin Geral 2008;24:503-4. The publication and prompt use of tools validated for the diagnosis and evaluation of professional-patient communication in the consultation environment has not yet significantly contributed to the propagation and popularization of innovative methods that contribute to improve the relationship and care provided by health professionals.⁵5. Santos I, Ribeiro L. Indicadores de desempenho na consulta. Rev Port Clin Geral 2009;25:228-36.

Objective

To systematically review publications and original works about communication studies involving health professionals and patients, with observational or experimental applications of the RIAS methodology, thereby illustrating the relevance of this tool and the underlying research area for the improvement of healthcare.

Methods

The review was conducted between October 2010 and February 2011 with the key-expression Roter Interaction Analysis System and/or RIAS, in the bibliographic resources described in Table 1. The first search was conducted without time limits and the summary of this search enabled the obtainment, among other data, of the main professional areas in which the RIAS studies were conducted. All of the original communication work using the RIAS and involving any health professionals in conventional medicine healthcare (e.g. physicians from different specialties, nurses, physiotherapists, etc.) were selected. The search was then limited to publications within the last 5 years (2006-2011), except for rare situations resulting from some professional areas, where studies involving the participation of at least 20 health of the most recent study classified as relevant. This procedure permitted the identification of the most relevant articles at the time of the study within each specialty or professional area.

The search began on the official RIAS webpage (www.riasworks.com)¹1. RIASWORKS: Evidence-based communication for education, research & practice [cited 2011 mar 15]. Available at: http://www.riasworks.com.
http://www.riasworks.com... , as this contains a systematized record of publications and information sources relating to works using this methodology. Next, databases and bibliographic sources were selected based on their relevance, in accordance with the area under study (health comunication) and the number of titles published annually (periodicals and e-books) (Table 1). The Database of Abstracts of Reviews of Effectiveness (DARE) was also consulted to confirm the existence of any RIAS related reviews, to avoid repetition as well as possible impairment of this work relevance. The literature search was updated in July 2013.

The literature selection criteria for this study were:

1. Having the RIAS methodology as the methodological basis;

2. Being an original work (observational or experimental);

3. Not being repeated record;

4. Having been published within the last 5 years (the time period was applied individually for each group of health professionals); and

5. Participation of at least 20 health professionals.

The search also included conference abstracts to expand the number of sources, giving a broader scope of the RIAS areas of research, while overcaming issues related with the last selection criteria. These criteria were defined in order to satisfy the objective of the present review. For example, the selection criteria included the number of health professionals to be at least 20 in order to select works with minimum methodological robustness. The articles selected for review were organized according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)⁶6. Prisma: Transparent reporting of systematic reviews and meta-analysis [cited 2011 feb 27]. Available at: http://www.prisma-statement.org/.
http://www.prisma-statement.org/... method, which describes the items to be considered in systematic reviews and meta-analyses. Within this scope, the exclusion criteria were:

1. Studies written in a language other than Portuguese or English due to issues of an operational nature involving the translation of articles;

2. Articles or works which, although experimental in nature, were aimed at the investigation of very specific situations, such as studies on the specific impact of a determined socio-demographic characteristic (sex, age or ethnicity) in the relationship between health professional and patient; or

3. Studies to validate scales, operational methodologies or statistics, as they are outside of the current review context, whose general objective is to illustrate the areas and issues where the RIAS has demonstrated greater application and interest to study professional-patient communication.

The selected articles were carefully analyzed in relation to their content in the period from March 2011 to February 2012.

Results

From a total of 1.262 articles, 34 articles were selected and distributed within the following health professionals: family medicine and general practitioners (14), pediatricians (5), nurses (4), geneticists (3), carers of patients with AIDS (2), oncologists (2), surgeons (2), anesthetists (1) and family planning specialists (1).

The number of studies excluded is described in Figure 1 and the number of articles selected by bibliographic resources is presented in Table 1. No review was found in relation to the RIAS in the DARE. None of the studies selected were conducted in countries where Portuguese is the official language. A summary table of the articles selected for the systematic review can be found in Table 2.

FIGURE 1
Results obtained after search of the bibliographic resources, with indication of the reason, the number of articles excluded, and the number of studies selected for the review.

The distribution of the studies selected by year of publication was as follows: 1997 (1), 1999 (1), 2002 (1), 2005 (1), 2006 (7), 2007 (3), 2008 (7), 2009 (7), 2010 (4), and 2011 (1). Four studies were dated before 2006, taking into account that the participation of at least 20 health professionals was not found in the areas of surgery (1997 and 1999),³⁶36. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;19:553-9.^,3737. Levinson W, Chaumeton N. Communication between surgeons and patients in routine office visits. Surgery 1999;125:127-34. anesthesia (2005),³⁸38. Kindler CH, Szirt L, Sommer D, Hausler R, Langewitz W. A quantitative analysis of anaesthetist-patient communication during the pre-operative visit. Anaesthesia 2005;60:53-9. and family planning (2002).³⁹39. Abdel-Tawab N, Roter D. The releVance of client-centered communication to family planning settings in developing countries: lessons from the Egyptian experience. Soc Sci Med 2002;54:1357-68.

Two of the references selected corresponded to abstracts from conferences. For illustration purposes only, all articles were published in periodicals with an average impact factor (IF) per year and per specialty as follows: surgery (5.801), pediatrics (5.151), geneticists (2.866), patients with AIDS (2.654), anesthesia (2.512), primary care (2.447), nurses (1.961), family planning (1.931) and oncology (1.778).

Discussion

Given the results of this review, the identification of RIAS studies was found amongst various groups of health professionals (Table 2) as well as confirmed the absence of works in Portuguese, both in the collection of field data or written publications.

The studies exemplify the investigation of verbal, synchronous and one-on-one (or dyadic) communication between professionals and patients, through the application of the RIAS methodology which, in some cases, was also associated with nonverbal behavior recording techniques. Taking into account the different professional areas studied, the total number of health professionals were superior to 2500 and the average IF of 3.11 of the selected articles, it is possible to consider the results obtained from this bibliographic review of sufficient interest for elucidating, albeit briefly, the contribution of the RIAS methodology for the processes analysis in interindividual communication in healthcare.

The selection criteria used in this review did not enable other professional areas or specialties studied by the RIAS to be selected, such as intensive care, mental and palliative care, dentistry, medical emergencies, prenatal diagnosis, hospitalization, medicine in adolescence, ophthalmology and radiotherapy. Even so, the boundaries imposed by the search criteria enable interesting data to be obtained, such as studies with a sample size of health professionals enough for aprooaching statistical representation. In the specific case of the RIAS, although a computer software, currently used on a global scale,¹1. RIASWORKS: Evidence-based communication for education, research & practice [cited 2011 mar 15]. Available at: http://www.riasworks.com.
http://www.riasworks.com... its application does not seem to be extensive, i.e. sufficient to represent the entire professional group under analysis. In fact, the possibility of coding and analyzing a large volume of data in a short time is one of the main advantages of the RIAS when compared with other methodologies for studying communication. This suggests, in the majority of cases, that results to be reproducible or extendable beyond small samples, which was impossible to prove in this review. In addition, there is a limited use of this method by health organizations and institutions in other areas of healthcare, beyond medical practice.

The RIAS has been useful for helping to establish causal links between verbal components of professionals' communication and the patients' health outcomes. Examples of these causal models are the relationships between some RIAS codes and satisfaction, adherence to treatment, level of control and patient knowledge about their pathologies.³3. Sheldon LK, Ellington L, Barrett R, Dudley WN, Clayton MF, Rinaldi K.. Nurse responsiveness to cancer patient expressions of emotion. Patient Educ Couns 2009;76:63-70.^,2626. Gilbert DA, Hayes E. Communication and outcomes of visits between older patients and nurse practitioners. Nurs Res 2009;58:283-93.^,3232. Kumar R, Korthuis PT, Saha S, et al. Decision-making role preferences among patients with HIV: associations with patient and provider characteristics and communication behaviors. J Gen Intern Med 2010;25:517-23.^,3434. Daugherty C, Kass NE, Roter DET et al. A study of physician investigator (PI) disclosure of alternatives of care and prognostic information to adVanced cancer patients (ACP) enrolling in phase I trials.ASCO Meeting Abstracts 2009 (Abst. 6508).^,3535. Siminoff LA, Graham GC, Gordon NH. Cancer communication patterns and the influence of patient characteristics: Disparities in informationgiving and affective behaviors. Patient Educ Couns 2006;62:355-60. As could be expected, the instrumental codes showed to be most important in the evaluation of technical aspects of the consultation,⁷7. Greer RC, Cooper LA, Crews DC, Powe NR, Boulware Le. Quality of patientphysician discussions about CKD in primary Care: a cross-sectional study. Am J Kidney Dis 2011;57:583-91.^,2929. Roter DL, Erby L, Larson S, Ellingtion L. Oral literacy demand of prenatal genetic counseling dialogue: predictors of learning. Patient Educ Couns 2009;75:392-97.^,3030. Roter DL, Erby LH, Larson S, Ellington L. Assessing oral literacy demand in genetic counseling dialogue: preliminary test of a conceptual framework. Soc Sci Med 2007;65:1442-57. and the affective categories were shown to be most preponderant in the evaluation of patient satisfaction.⁸8. Beach MC, Roter DL, Wang NY, Duggan PS, Cooper LA. Are physician's attitudes of respect accurately perceived by patients and associated with more positive communication behaviors? Patient Educ Couns 2006;62:347-54.^,99. Haskard B, Williams L, DiMatteo R, Rosenthal R, White K, Goldstein G. Physician and patient communication training in primary care: effects on participation and satisfaction. Health Psychol 2008;27:513-22. To fully interpret these last categories of RIAS codes it is also important to evaluate the nonverbal components, such as intonation, words and type of voice used by speakers.¹⁰10. Bensing M, Verheul W, Van Dulmen S. Patient anxiety in the medical encounter: a study of verbal and nonverbal communication in general practice. Health Educ 2008;108:373-83.^,4141. Sondell K, Söderfeldt B, Palmqvist S. Underlying dimensions of verbal communication between dentists and patients in prosthetic dentistry. Patient Educ Couns 2003;50:157-65.

The literature describes various mathematical relationships between different RIAS coding units, using formulas that result in composite variables or even constructs that describe linguistic and behavioral structures of the communication, such as patient-centeredness.³⁹39. Abdel-Tawab N, Roter D. The releVance of client-centered communication to family planning settings in developing countries: lessons from the Egyptian experience. Soc Sci Med 2002;54:1357-68.^,4040. Roter D, Larson S. The Roter Interaction Analysis System (RIAS): utility and flexibility for analysis of medical interactions. Patient Educ Couns 2002;46:243-51. In this context, the consensus is wich the components that encourage the patient to speak, that is, frequent RIAS codes associated with open questioning, verbal facilitators and empathic declarations, or those related to the psychosocial dimensions of the patient, result in more patient-focused healthcare. On the other hand, communication with a predominance of closed questions, or a dialogue flow that tends to limit, control or guide patients, is understood as a type of communication that is less focused on the patient's needs, expectations and concerns.¹¹11. Mjaaland TA, Finset A. Communication skills training for general practitioners to promote patient coping: the GRIP approach. Patient Educ Couns 2009;76:84-90.^,2121. Johnson KB, Serwint JR, Fagan LA, Thompson RE, Wilson ME, Roter D. Computer-based documentation: effects on parent-provider communication during pediatric health maintenance encounters. Pediatrics 2008;122:590-8.

22. Hart N, Drotar D, Gori A, Lewin L. Enhancing parent-provider communication in ambulatory pediatric practice. Patient Educ Couns 2006;63:38-46.^-2323. Wissow L, GadomskiA, Roter D, Larson S, Lewis B, Brown J. Aspects of mental health communication skills training that predict parent and child outcomes in pediatric primary care. Patient Educ Couns 2011;82:226-32.^,2727. Langewitz W, Heydrich L, Nübling M, Szirt L, Weber H, Grossman P. Swiss Cancer League communication skills training programme for oncology nurses: an evaluation. J Adv Nurs 2010;66:2266-77.^,3939. Abdel-Tawab N, Roter D. The releVance of client-centered communication to family planning settings in developing countries: lessons from the Egyptian experience. Soc Sci Med 2002;54:1357-68. Whether the results of a healthcare professional intervention are defined as short-term (e.g. patient satisfaction and their intention to adhere to treatment), medium-term (e.g. adherence to treatment and reduction in patient anxiety) or long-term (e.g. patient quality of life, with recovery and good general health status), the relationship between the health professional's communication characteristics and the patient's state of health is, in fact, one of the most important outcomes to be evaluated.²⁶26. Gilbert DA, Hayes E. Communication and outcomes of visits between older patients and nurse practitioners. Nurs Res 2009;58:283-93.^,3131. Roter D, Ellington L, Erby LH, Larson S, Dudley W. The Genetic Counseling Video Project (GCVP): models of practice. Am J Med Genet C Semin Med Genet 2006;142C:209-20.^,4242. Ong LM, Visser MR, Lammes FB, de Haes JC. Doctor-patient communication and cancer patients' quality of life and satisfaction. Patient Educ Couns 2000;41:145-56. RIAS has found a positive association between patient-centered communication, improvement in health results and the reduction of conflicts with professionals.¹²12. Weingarten MA, Guttman N, Abramovitch H, Margalit RS, Roter D, Ziv A et al. An anatomy of conflicts in primary care encounters: a multi-method study. Fam Pract 2010;27:93-100.^,3636. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;19:553-9.^,4343. Rouf E, Chumley H, Dobbie A. Patient-centered interviewing and student performance in a comprehensive clinical skills examination: Is there an association? Patient Educ Couns 2009;75:11-5. Indeed, one of the most common uses of the RIAS has been to study the association between communication and patient satisfaction, where a cause-effect relationship has been confirmed.⁸8. Beach MC, Roter DL, Wang NY, Duggan PS, Cooper LA. Are physician's attitudes of respect accurately perceived by patients and associated with more positive communication behaviors? Patient Educ Couns 2006;62:347-54.^,1313. Street RL Jr, Gordon H, Haidet P. Physicians' communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor? Soc Sci Med 2007;65:586-98.^,3232. Kumar R, Korthuis PT, Saha S, et al. Decision-making role preferences among patients with HIV: associations with patient and provider characteristics and communication behaviors. J Gen Intern Med 2010;25:517-23.^,4242. Ong LM, Visser MR, Lammes FB, de Haes JC. Doctor-patient communication and cancer patients' quality of life and satisfaction. Patient Educ Couns 2000;41:145-56.

With regard to the aspects relating to verbal communication, there are RIAS studies that have identified the verbal dominance of the physician in relation to the patient, with a predominance of technical and biomedical dialogs.⁷7. Greer RC, Cooper LA, Crews DC, Powe NR, Boulware Le. Quality of patientphysician discussions about CKD in primary Care: a cross-sectional study. Am J Kidney Dis 2011;57:583-91.^,1010. Bensing M, Verheul W, Van Dulmen S. Patient anxiety in the medical encounter: a study of verbal and nonverbal communication in general practice. Health Educ 2008;108:373-83.^,2828. Kim YM, Heerey M, Kols A. Factors that enable nurse-patient communication in a family planning context: a positive deviance study. Int J Nurs Stud 2008;45:1411-21.^,3737. Levinson W, Chaumeton N. Communication between surgeons and patients in routine office visits. Surgery 1999;125:127-34. One study identified that communication for anesthetists was almost biomedical in nature,³⁸38. Kindler CH, Szirt L, Sommer D, Hausler R, Langewitz W. A quantitative analysis of anaesthetist-patient communication during the pre-operative visit. Anaesthesia 2005;60:53-9. while another demonstrated that this communication pattern is more evident in medical interns than specialists.²⁴24. Liu CC, Wissow LS. Residents who stay late at hospital and how they perform the follow day. Med Educ 2008;42:74-81. In relation to other health professionals, such as nurses or those responsible for family planning, the dominance of technical conversation was also verified,²⁷27. Langewitz W, Heydrich L, Nübling M, Szirt L, Weber H, Grossman P. Swiss Cancer League communication skills training programme for oncology nurses: an evaluation. J Adv Nurs 2010;66:2266-77.^,2828. Kim YM, Heerey M, Kols A. Factors that enable nurse-patient communication in a family planning context: a positive deviance study. Int J Nurs Stud 2008;45:1411-21.^,3939. Abdel-Tawab N, Roter D. The releVance of client-centered communication to family planning settings in developing countries: lessons from the Egyptian experience. Soc Sci Med 2002;54:1357-68. while for genetic counselors this seems to depend on the context of the consultation.³⁰30. Roter DL, Erby LH, Larson S, Ellington L. Assessing oral literacy demand in genetic counseling dialogue: preliminary test of a conceptual framework. Soc Sci Med 2007;65:1442-57.^,3131. Roter D, Ellington L, Erby LH, Larson S, Dudley W. The Genetic Counseling Video Project (GCVP): models of practice. Am J Med Genet C Semin Med Genet 2006;142C:209-20. The works described in summary in Table 2 reveal that in addition to characterizing communication RIAS investigators also studied other factors, such as:

• The perception of respect by the participants in the consultations;⁸8. Beach MC, Roter DL, Wang NY, Duggan PS, Cooper LA. Are physician's attitudes of respect accurately perceived by patients and associated with more positive communication behaviors? Patient Educ Couns 2006;62:347-54.^,1313. Street RL Jr, Gordon H, Haidet P. Physicians' communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor? Soc Sci Med 2007;65:586-98.

• The changes of the communication characteristics over time (longitudinal studies);¹⁴14. Bensing JM, Tromp F, Van Dulmen S, Van den Brink-Muinen A, Verheul W, Schellevis FG. Shifts in doctor-patient communication between 1986 and 2002: a study of videotaped general practice consultations with hypertension patients. BMC Fam Pract 2006;7:62.^,1515. Van den Brink-Muinen A, Van Dulmen S, de Haes H, Visser A, Schellevis F, Bensing J. Has patients' involvement in the decision-making process changed over time? Health Expect 2006;9:333-42.

• The impact of training actions on patients and phy sicians;⁹9. Haskard B, Williams L, DiMatteo R, Rosenthal R, White K, Goldstein G. Physician and patient communication training in primary care: effects on participation and satisfaction. Health Psychol 2008;27:513-22.^,1111. Mjaaland TA, Finset A. Communication skills training for general practitioners to promote patient coping: the GRIP approach. Patient Educ Couns 2009;76:84-90.^,2222. Hart N, Drotar D, Gori A, Lewin L. Enhancing parent-provider communication in ambulatory pediatric practice. Patient Educ Couns 2006;63:38-46.^,2323. Wissow L, GadomskiA, Roter D, Larson S, Lewis B, Brown J. Aspects of mental health communication skills training that predict parent and child outcomes in pediatric primary care. Patient Educ Couns 2011;82:226-32.^,2828. Kim YM, Heerey M, Kols A. Factors that enable nurse-patient communication in a family planning context: a positive deviance study. Int J Nurs Stud 2008;45:1411-21.^,3333. Beach CM, Wilson I, Saha S et al. Impact of a patient and provider intervention to improve the quality of communication about medication adherence among HIV Patients. Conference abstracts: 5th International Conference on HIV treatment adherence 2010 (Abst. 61339).

• The reaction of simulated patients;³3. Sheldon LK, Ellington L, Barrett R, Dudley WN, Clayton MF, Rinaldi K.. Nurse responsiveness to cancer patient expressions of emotion. Patient Educ Couns 2009;76:63-70.^,2727. Langewitz W, Heydrich L, Nübling M, Szirt L, Weber H, Grossman P. Swiss Cancer League communication skills training programme for oncology nurses: an evaluation. J Adv Nurs 2010;66:2266-77.^,2929. Roter DL, Erby L, Larson S, Ellingtion L. Oral literacy demand of prenatal genetic counseling dialogue: predictors of learning. Patient Educ Couns 2009;75:392-97.
  
  30. Roter DL, Erby LH, Larson S, Ellington L. Assessing oral literacy demand in genetic counseling dialogue: preliminary test of a conceptual framework. Soc Sci Med 2007;65:1442-57.^-3131. Roter D, Ellington L, Erby LH, Larson S, Dudley W. The Genetic Counseling Video Project (GCVP): models of practice. Am J Med Genet C Semin Med Genet 2006;142C:209-20.

• Burnout,¹⁶16. Zantinge E, Verhaak P, Bakker D, Van der Meer K, Bensing J. Does burnout among doctors affect their involvement in patients' mental health problems? A study of videotaped consultations. BMC Fam Pract 2009;10:60.^,1717. Ratanawongsa N, Roter D, Beach MC, Laird SL, Larson SM, Carson KA et al. Physician burnout and patient-physician communication during primary care encounters. J Gen Intern Med 2008;23:1581-8. overwork,¹⁸18. Zantinge EM, Verhaak PF, de Bakker DH, Kerssens JJ, Van der Meer K, Bensing JM. The workload of general practitioners does not affect their awareness of patients' psychological problems. Patient Educ Couns 2007;67:93-9. tiredness²⁴24. Liu CC, Wissow LS. Residents who stay late at hospital and how they perform the follow day. Med Educ 2008;42:74-81. or clinical malpractice;¹⁰10. Bensing M, Verheul W, Van Dulmen S. Patient anxiety in the medical encounter: a study of verbal and nonverbal communication in general practice. Health Educ 2008;108:373-83.

• The identification of conflicts¹²12. Weingarten MA, Guttman N, Abramovitch H, Margalit RS, Roter D, Ziv A et al. An anatomy of conflicts in primary care encounters: a multi-method study. Fam Pract 2010;27:93-100.^,3636. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;19:553-9.

• The primary results (e.g satisfaction and the intention to adhere to treatment by the patient), secondary results (e.g changes in the way the patient approaches their health problems)²⁶26. Gilbert DA, Hayes E. Communication and outcomes of visits between older patients and nurse practitioners. Nurs Res 2009;58:283-93. and treatment decisions;³²32. Kumar R, Korthuis PT, Saha S, et al. Decision-making role preferences among patients with HIV: associations with patient and provider characteristics and communication behaviors. J Gen Intern Med 2010;25:517-23.^,3535. Siminoff LA, Graham GC, Gordon NH. Cancer communication patterns and the influence of patient characteristics: Disparities in informationgiving and affective behaviors. Patient Educ Couns 2006;62:355-60.

• The use of technical terms⁷7. Greer RC, Cooper LA, Crews DC, Powe NR, Boulware Le. Quality of patientphysician discussions about CKD in primary Care: a cross-sectional study. Am J Kidney Dis 2011;57:583-91. and informed consent (in clinical trials);²⁵25. Greenley RN, Drotar D, Zyzanski SJ, Kodish E. Stability of parental understanding of random assignment in childhood leukemia trials: an empirical examination of informed consent. J Clin Oncol 2006;24:891-97.^,3434. Daugherty C, Kass NE, Roter DET et al. A study of physician investigator (PI) disclosure of alternatives of care and prognostic information to adVanced cancer patients (ACP) enrolling in phase I trials.ASCO Meeting Abstracts 2009 (Abst. 6508).^,4444. Miller VA, Drotar D, Burant C, Kodish E. Clinician-parent communication during informed consent for pediatric leukemia trials. J Pediatr Psychol 2005;30:219-29.

• The approach to matters of a psychosocial nature;¹⁹19. Mjaaland TA, Finset A. Frequency of GP communication addressing the patient's resources and coping strategies in medical interviews: a videobased observational study. BMC Fam Pract 2009;10:49.^,4545. Wissow LS, Larson S, Anderson J, Hadjiisky E. Pediatric residents' responses that discourage discussion of psychosocial problems in primary care. Pediatrics 2005;115:1569-78.

• Intercultural differences.²⁰20. Van den Brink-Muinen A, Maaroos HI, Tähepõld H. Communication style in primary health care in Europe. Health Educ 2008;108:384-96.

The involvement of various countries and continents²2. Roter DL, Larson S. The relationship between residents' and attending physicians' communication during primary care visits: an illustrative use of the Roter Interaction Analysis System. Health Commun 2001; 13:33-48.^,2020. Van den Brink-Muinen A, Maaroos HI, Tähepõld H. Communication style in primary health care in Europe. Health Educ 2008;108:384-96.^,1515. Van den Brink-Muinen A, Van Dulmen S, de Haes H, Visser A, Schellevis F, Bensing J. Has patients' involvement in the decision-making process changed over time? Health Expect 2006;9:333-42.^,3838. Kindler CH, Szirt L, Sommer D, Hausler R, Langewitz W. A quantitative analysis of anaesthetist-patient communication during the pre-operative visit. Anaesthesia 2005;60:53-9. in the studies selected confirm the relevance of this methodology, but potential generalization of the conclusions is limited, given the differences in professional practice and context, from the training of the professionals up to the sociocultural characteristics of the populations.

The studies selected for this review³3. Sheldon LK, Ellington L, Barrett R, Dudley WN, Clayton MF, Rinaldi K.. Nurse responsiveness to cancer patient expressions of emotion. Patient Educ Couns 2009;76:63-70.^,77. Greer RC, Cooper LA, Crews DC, Powe NR, Boulware Le. Quality of patientphysician discussions about CKD in primary Care: a cross-sectional study. Am J Kidney Dis 2011;57:583-91.

8. Beach MC, Roter DL, Wang NY, Duggan PS, Cooper LA. Are physician's attitudes of respect accurately perceived by patients and associated with more positive communication behaviors? Patient Educ Couns 2006;62:347-54.

9. Haskard B, Williams L, DiMatteo R, Rosenthal R, White K, Goldstein G. Physician and patient communication training in primary care: effects on participation and satisfaction. Health Psychol 2008;27:513-22.

10. Bensing M, Verheul W, Van Dulmen S. Patient anxiety in the medical encounter: a study of verbal and nonverbal communication in general practice. Health Educ 2008;108:373-83.

11. Mjaaland TA, Finset A. Communication skills training for general practitioners to promote patient coping: the GRIP approach. Patient Educ Couns 2009;76:84-90.

12. Weingarten MA, Guttman N, Abramovitch H, Margalit RS, Roter D, Ziv A et al. An anatomy of conflicts in primary care encounters: a multi-method study. Fam Pract 2010;27:93-100.

13. Street RL Jr, Gordon H, Haidet P. Physicians' communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor? Soc Sci Med 2007;65:586-98.

14. Bensing JM, Tromp F, Van Dulmen S, Van den Brink-Muinen A, Verheul W, Schellevis FG. Shifts in doctor-patient communication between 1986 and 2002: a study of videotaped general practice consultations with hypertension patients. BMC Fam Pract 2006;7:62.

15. Van den Brink-Muinen A, Van Dulmen S, de Haes H, Visser A, Schellevis F, Bensing J. Has patients' involvement in the decision-making process changed over time? Health Expect 2006;9:333-42.

16. Zantinge E, Verhaak P, Bakker D, Van der Meer K, Bensing J. Does burnout among doctors affect their involvement in patients' mental health problems? A study of videotaped consultations. BMC Fam Pract 2009;10:60.

17. Ratanawongsa N, Roter D, Beach MC, Laird SL, Larson SM, Carson KA et al. Physician burnout and patient-physician communication during primary care encounters. J Gen Intern Med 2008;23:1581-8.

18. Zantinge EM, Verhaak PF, de Bakker DH, Kerssens JJ, Van der Meer K, Bensing JM. The workload of general practitioners does not affect their awareness of patients' psychological problems. Patient Educ Couns 2007;67:93-9.

19. Mjaaland TA, Finset A. Frequency of GP communication addressing the patient's resources and coping strategies in medical interviews: a videobased observational study. BMC Fam Pract 2009;10:49.

20. Van den Brink-Muinen A, Maaroos HI, Tähepõld H. Communication style in primary health care in Europe. Health Educ 2008;108:384-96.

21. Johnson KB, Serwint JR, Fagan LA, Thompson RE, Wilson ME, Roter D. Computer-based documentation: effects on parent-provider communication during pediatric health maintenance encounters. Pediatrics 2008;122:590-8.

22. Hart N, Drotar D, Gori A, Lewin L. Enhancing parent-provider communication in ambulatory pediatric practice. Patient Educ Couns 2006;63:38-46.

23. Wissow L, GadomskiA, Roter D, Larson S, Lewis B, Brown J. Aspects of mental health communication skills training that predict parent and child outcomes in pediatric primary care. Patient Educ Couns 2011;82:226-32.

24. Liu CC, Wissow LS. Residents who stay late at hospital and how they perform the follow day. Med Educ 2008;42:74-81.

25. Greenley RN, Drotar D, Zyzanski SJ, Kodish E. Stability of parental understanding of random assignment in childhood leukemia trials: an empirical examination of informed consent. J Clin Oncol 2006;24:891-97.

26. Gilbert DA, Hayes E. Communication and outcomes of visits between older patients and nurse practitioners. Nurs Res 2009;58:283-93.

27. Langewitz W, Heydrich L, Nübling M, Szirt L, Weber H, Grossman P. Swiss Cancer League communication skills training programme for oncology nurses: an evaluation. J Adv Nurs 2010;66:2266-77.

28. Kim YM, Heerey M, Kols A. Factors that enable nurse-patient communication in a family planning context: a positive deviance study. Int J Nurs Stud 2008;45:1411-21.

29. Roter DL, Erby L, Larson S, Ellingtion L. Oral literacy demand of prenatal genetic counseling dialogue: predictors of learning. Patient Educ Couns 2009;75:392-97.

30. Roter DL, Erby LH, Larson S, Ellington L. Assessing oral literacy demand in genetic counseling dialogue: preliminary test of a conceptual framework. Soc Sci Med 2007;65:1442-57.

31. Roter D, Ellington L, Erby LH, Larson S, Dudley W. The Genetic Counseling Video Project (GCVP): models of practice. Am J Med Genet C Semin Med Genet 2006;142C:209-20.

32. Kumar R, Korthuis PT, Saha S, et al. Decision-making role preferences among patients with HIV: associations with patient and provider characteristics and communication behaviors. J Gen Intern Med 2010;25:517-23.

33. Beach CM, Wilson I, Saha S et al. Impact of a patient and provider intervention to improve the quality of communication about medication adherence among HIV Patients. Conference abstracts: 5th International Conference on HIV treatment adherence 2010 (Abst. 61339).

34. Daugherty C, Kass NE, Roter DET et al. A study of physician investigator (PI) disclosure of alternatives of care and prognostic information to adVanced cancer patients (ACP) enrolling in phase I trials.ASCO Meeting Abstracts 2009 (Abst. 6508).

35. Siminoff LA, Graham GC, Gordon NH. Cancer communication patterns and the influence of patient characteristics: Disparities in informationgiving and affective behaviors. Patient Educ Couns 2006;62:355-60.

36. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;19:553-9.

37. Levinson W, Chaumeton N. Communication between surgeons and patients in routine office visits. Surgery 1999;125:127-34.

38. Kindler CH, Szirt L, Sommer D, Hausler R, Langewitz W. A quantitative analysis of anaesthetist-patient communication during the pre-operative visit. Anaesthesia 2005;60:53-9.^-3939. Abdel-Tawab N, Roter D. The releVance of client-centered communication to family planning settings in developing countries: lessons from the Egyptian experience. Soc Sci Med 2002;54:1357-68. aimed only at illustrating the relevance of the RIAS as a method for studying the communication between different health professionals and patients, by exemplifying some of the various approaches to the complex phenomenon of human communication. The studies presented here have enabled the identification of shortcomings in verbal and nonverbal communication by the health professionals involved, such as the absence nonverbal communication, predominance of instrumental communication and dialogs focused on the health professional, lack of patient involvement in discussions and confirmation of their comprehension, and short stimulation of adherence to the prescribed instructions. The RIAS has contributed to accept that understanding the affective, instrumental and nonverbal components of communication permits health professionals to carry out more humanized and, above all, more effective care. The scientific investigation of these communication components, with the use of objective tools such as the RIAS methodology, is not always well accepted by professionals, as well as by other accountable parties, as an important opportunity to monitor and continuously improve the quality of care provided to patients. Nevertheless, the RIAS is one of the instruments delivering objective measurements of the use of communication competencies, which clearly contributes to promote the capacity for diagnosis, clinical efficiency and patient and physician satisfaction, as well as reducing error and emotional difficulties often association with illness and disease. In addition to being an individual responsibility, good communication in the clinical context should also be a responsibility of health organizations, promoting the identification, discussion and continuous training in these competencies. Studies in this area are, in the majority of cases, limited to investigations on a theoretical basis or in a controlled environment (experimental or semi-experimental studies) and not necessarily observational and ecological studies applied to the day-to-day reality of institutions.

In general, various limitations were identified this review, such as the low sample sizes,¹³13. Street RL Jr, Gordon H, Haidet P. Physicians' communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor? Soc Sci Med 2007;65:586-98.^,2525. Greenley RN, Drotar D, Zyzanski SJ, Kodish E. Stability of parental understanding of random assignment in childhood leukemia trials: an empirical examination of informed consent. J Clin Oncol 2006;24:891-97. participation of a limited number of medical sites,²¹21. Johnson KB, Serwint JR, Fagan LA, Thompson RE, Wilson ME, Roter D. Computer-based documentation: effects on parent-provider communication during pediatric health maintenance encounters. Pediatrics 2008;122:590-8.^,2222. Hart N, Drotar D, Gori A, Lewin L. Enhancing parent-provider communication in ambulatory pediatric practice. Patient Educ Couns 2006;63:38-46.^,2424. Liu CC, Wissow LS. Residents who stay late at hospital and how they perform the follow day. Med Educ 2008;42:74-81.^,3232. Kumar R, Korthuis PT, Saha S, et al. Decision-making role preferences among patients with HIV: associations with patient and provider characteristics and communication behaviors. J Gen Intern Med 2010;25:517-23.^,3434. Daugherty C, Kass NE, Roter DET et al. A study of physician investigator (PI) disclosure of alternatives of care and prognostic information to adVanced cancer patients (ACP) enrolling in phase I trials.ASCO Meeting Abstracts 2009 (Abst. 6508). few longitudinal studies (in the majority of cases, the data was collected at a single point in time, with eventual implications on results reproducibility),¹⁴14. Bensing JM, Tromp F, Van Dulmen S, Van den Brink-Muinen A, Verheul W, Schellevis FG. Shifts in doctor-patient communication between 1986 and 2002: a study of videotaped general practice consultations with hypertension patients. BMC Fam Pract 2006;7:62.^,1515. Van den Brink-Muinen A, Van Dulmen S, de Haes H, Visser A, Schellevis F, Bensing J. Has patients' involvement in the decision-making process changed over time? Health Expect 2006;9:333-42.^,2525. Greenley RN, Drotar D, Zyzanski SJ, Kodish E. Stability of parental understanding of random assignment in childhood leukemia trials: an empirical examination of informed consent. J Clin Oncol 2006;24:891-97. studies without the parallel use of other measures for concurrent validity (e.g. questionnaires on the evaluation of the cognitive or satisfaction level of the participants),¹³13. Street RL Jr, Gordon H, Haidet P. Physicians' communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor? Soc Sci Med 2007;65:586-98. etc. All of the above contribute to non generalizable conclusions, frequently constituting evaluations of an exploratory nature. The following were identified as potential bias: the possibility of physician empathic variations based on the socioeconomics class of the patient,¹³13. Street RL Jr, Gordon H, Haidet P. Physicians' communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor? Soc Sci Med 2007;65:586-98. the specific clinical context (public or private clinics, city hospitals, academic medical centers, etc.),³3. Sheldon LK, Ellington L, Barrett R, Dudley WN, Clayton MF, Rinaldi K.. Nurse responsiveness to cancer patient expressions of emotion. Patient Educ Couns 2009;76:63-70.^,77. Greer RC, Cooper LA, Crews DC, Powe NR, Boulware Le. Quality of patientphysician discussions about CKD in primary Care: a cross-sectional study. Am J Kidney Dis 2011;57:583-91.^,2121. Johnson KB, Serwint JR, Fagan LA, Thompson RE, Wilson ME, Roter D. Computer-based documentation: effects on parent-provider communication during pediatric health maintenance encounters. Pediatrics 2008;122:590-8.^,2525. Greenley RN, Drotar D, Zyzanski SJ, Kodish E. Stability of parental understanding of random assignment in childhood leukemia trials: an empirical examination of informed consent. J Clin Oncol 2006;24:891-97.^,3939. Abdel-Tawab N, Roter D. The releVance of client-centered communication to family planning settings in developing countries: lessons from the Egyptian experience. Soc Sci Med 2002;54:1357-68. the potential to respond in a socially desirable manner to studies complemented by the administration of questionnaires,²⁸28. Kim YM, Heerey M, Kols A. Factors that enable nurse-patient communication in a family planning context: a positive deviance study. Int J Nurs Stud 2008;45:1411-21. and the exact type of events intended to be compared (e.g. pre and postoperative consultations for orthopedic surgery with incapacitating potential vs. other types of surgery).³⁷37. Levinson W, Chaumeton N. Communication between surgeons and patients in routine office visits. Surgery 1999;125:127-34.

The conclusions of this review merely intend to constitute an indicator for conducting future studies on communication between patients and health professionals, resulting from the systematization of some of the limitations and potential bias found here. This review did not aim to explore advantages and disadvantages of RIAS in comparison with other methodologies.

Conclusion

The scientific investigation of communication in healthcare, with the application of specific methodologies such as the RIAS, and the forthcoming of specialists in this area would be desirable for the sustainable and harmonious development of health systems. The RIAS methodology has proven to be an important tool for the study of communication between health professionals and patients, contributing to the elaboration of communication effectiveness diagnostics and education guidelines. Therefore, the RIAS has contributed to developing more adequate, effective and humanized communication, thereby defending the final mission of healthcare systems, i.e. human well-being.

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