Doctor–Couple Communication During Assisted Reproductive Technology Visits

D. Leone; L. Borghi; S. Del Negro; C. Becattini; E. Chelo; M. Costa; L. De Lauretis; A.P. Ferraretti; G. Giuffrida; C. Livi; A. Luehwink; R. Palermo; A. Revelli; G. Tomasi; F. Tomei; C. Filippini; E. Vegni


Hum Reprod. 2018;33(5):877-886. 

In This Article

Materials and Methods


The study was conducted in eight Italian ART Centers in the north (Trento, Bologna, Genoa, Turin, Milan), center (Florence, two centers) and south (Catania) of Italy, through a convenience sample. Of these centers, three were part of public hospitals, three were private clinics and two were private clinics with a special arrangement with the public health system. All ART patients over 18 years old were eligible to participate in the study. Patients were excluded if they presented major psychiatric disorders in the clinician's opinion or were unable to understand Italian. All ART physicians who agreed to participate were recruited.

Data Collection

Patients were recruited during their visit to the ART centers. Before the consultation, patients were informed about the aim of the study by two researchers. Patients who agreed to participate signed an informed consent form and completed a sociodemographic form. During the visit, the researcher turned on the video camera in the visiting room (avoiding the clinical examination area) and left the room. At the end of the visit, patients were asked to confirm their consent for the data to be used for research. The physicians signed an informed consent form too and completed a sociodemographic form. The research project was approved by the Ethical Review Board of the University of Milan and by the Ethical Review Boards of the eight participating ART clinics


Sociodemographic characteristics. Patient age, level of education and relationship status were collected. Physician age and years of professional experience were also collected.

Clinical information. Data on the cause of infertility, duration of infertility, number of previous treatments, prognosis and therapeutic plan were collected from medical records. The prognosis was summarized in a clinical judgment upon the success expectations of the treatment, according to couple age, infertility etiology, infertility duration and the center-specific success rate in similar situations.

Doctor–patient communication during the visit. The videotaped consultations were coded using the RIAS (Roter and Larson, 2002). The RIAS is a well validated and widely used coding system for categorizing verbal exchanges during physician–patient interactions. Conceptually, communication categories can be broadly viewed as reflecting task-focused and socioemotional elements of medical exchange (Roter and Hall, 2006). Task-focused behaviors among physicians are defined as technically based skills used in problem solving that comprise the basis of the biomedical expertise acquired through professional medical education, while the socioemotional dimension includes exchanges with explicit affective content related to the building of social and emotional relationships. The unit of analysis for RIAS coding is called 'utterance' and is defined as a statement reflecting a complete thought or phrase, which may vary in length from a single word to a long sentence. The statements are assigned to mutually exhaustive and exclusive coding categories applied to all speakers. The system includes 37 common patient and clinician coding variables and a few unique patient and clinician codes. The categories were combined to create 10 composite macro-categories each for the clinician and patients. Task-focused exchange includes categories aimed at data gathering (biomedical and lifestyle/psychosocial questions) and patient education and counseling (biomedical and lifestyle/psychosocial information), while socioemotional exchange includes categories aimed at relationship building (emotional, positive, negative, social talk), facilitation and patient activation, and orientation during the communication flow (procedural talk). Examples of the application of the RIAS macro-categories are given in Table I.

The following additional communication elements were derived from the videotape analysis: (i) duration of the visit, measured in minutes; (ii) physician verbal dominance, which is the number of physician statements divided by the number of patient statements; and (iii) patient-centeredness index (PCI), which is a ratio of all codes relating to socioemotional and psychosocial elements of exchange divided by codes that further the biomedical agenda. A value >1 indicates a more socioemotionally centered encounter and a value <1 indicates a more bio-medically centered encounter (Paasche-Orlow and Roter, 2003).

Two trained coders (L.B. and S.D.N.) coded the consultations half each using RIAS software. A random sample of 12% of the visits, evenly distributed between the two coders, were double coded by a third trained RIAS coder (D.L.), revealing an inter-rater agreement of 0.8 across the composite categories (range: 0.73–0.86).

Data Analysis

Descriptive statistics were calculated for demographic and clinical characteristics and for communication contents (RIAS macro-categories). Continuous and categorical data were shown as mean (standard deviation) and frequency (proportion), respectively.

For continuous variables, comparisons between two groups were performed using unpaired t-test.

A one way ANOVA was used for comparison of continuous values between more than two groups.

Chi-squared test was used to evaluate differences between categorical variables.

The magnitudes of the effect were quantified using the standardized mean difference effect size for within-subject designs (Cohen's d z). If one of the two patients was found to dominate the verbal exchange, the observed distribution for each RIAS composite category was compared with the expected distribution using Chi-squared tests, in order to evaluate whether the same dominance was observed for all the RIAS composite categories.

All statistical tests were two-sided. P values of 0.05 or less were considered statistically significant and were conducted using the SAS version 9.4 (SAS Institute, Cary, NC) and SPSS version 22 for Windows.