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A Randomized Clinical Trial

Debra L. Roter, DrPH; Judith A. Hall, PhD; David E. Kern, MD, MPH; L. Randol Barker, MD, ScM; Karan A. Cole, ScD; Robert P. Roca, MD

Arch Intern Med. 1995;155(17):1877-1884.

Abstract
Background
Despite high prevalence, emotional distress among primary care patients often goes unrecognized during routine medical encounters.

Objective
To explore the effect of communication-skills training on the process and outcome of care associated with patients' emotional distress.

Methods
A randomized, controlled field trial was conducted with 69 primary care physicians and 648 of their patients. Physicians were randomized to a no-training control group or one of two communication-skills training courses designed to help physicians address patients' emotional distress. The two training courses addressed communication through problem-defining skills or emotion-handling skills. All office visits of study physicians were audiotaped until five emotionally distressed and five nondistressed patients were enrolled based on patient response to the General Health Questionnaire. Physicians were also audiotaped interviewing a simulated patient to evaluate clinical proficiency. Telephone monitoring of distressed patients for utilization of medical services and General Health Questionnaire scores was conducted 2 weeks, 3 months, and 6 months after their audiotaped office visits.

Results
Audiotape analysis of actual and simulated patients showed that trained physicians used significantly more problem-defining and emotion-handling skills than did untrained physicians, without increasing the length of the visit. Trained physicians also reported more psychosocial problems, engaged in more strategies for managing emotional problems with actual patients, and scored higher in clinical proficiency with simulated patients. Patients of trained physicians reported reduction in emotional distress for as long as 6 months.

Conclusions
Important changes in physicians' communication skills were evident after an 8-hour program. The training improved the process and outcome of care without lengthening the visits.

(Arch Intern Med. 1995;155:1877-1884)

Author Affiliations
From the Department of Health Policy and Management, School of Hygiene and Public Health (Dr Roter), and the Division of General Internal Medicine, The Johns Hopkins Bayview Medical Center, School of Medicine (Drs Kern, Barker, Cole, and Roca), The Johns Hopkins University, Baltimore, Md; and the Department of Psychology, Northeastern University, Boston, Mass (Dr Hall).

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