Measuring patient and physician participation in exchanges on medications: Dialogue Ratio, Preponderance of Initiative, and Dialogical Roles

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Patient Education and Counseling 65 (2007) 329–341

Measuring patient and physician participation in exchanges

on medications: Dialogue Ratio, Preponderance

of Initiative, and Dialogical Roles

Claude Richard a,*, Marie-Therese Lussier b,1

a GEIRSO, chaıne des medicaments, Universite du Quebec a Montreal, Pavillon Hubert-Aquin, local A-1445,

C.P. 8888, succ. centre-ville, Montreal, Quebec H3C 3P8, Canadab Faculty of Medicine, Department of Family Medicine, Universite de Montreal, Canada

Received 3 February 2006; received in revised form 16 August 2006; accepted 26 August 2006

Abstract

Objective: To identify, describe and characterize the patient and physician participation in content production in medication-related

exchanges during primary care consultations.

Methods: Descriptive study of audio recordings of 422 medical encounters. MEDICODE, a validated instrument was used to analyze verbal

exchanges on medications. Two main indicators of participation were developed: Dialogue Ratio (DR), a 0–1 scale indicating extent of

monologue/dialogue; Preponderance of Initiative (PI), a�1 to +1 scale for patient/physician initiative. Participation analyses were conducted

by content theme and medication categories (New, Represcribed and Active).

Results: We identified 1492 discussions of medications. Categorical analyses identified four communication roles patients and physicians

adopted when participating in medication-related exchanges during consultations: (a) Listener, (b) Information Provider, (c) Participant, and

(d) Instigator. The mean observed DRs and PIs indicated that monologues and physician initiation dominated medication-related exchanges.

Conclusion: Four factors are suggested to explain the communicational behaviors observed: (1) patient knowledge about medications, (2)

physician expertise, (3) patient experience with the medication, and (4) the act of prescribing. Our data indicate a generally low level of

dialogue when discussing medications during primary care encounters since physicians’ monologues seem to be the rule rather than the

exception, pointing to a lack of mutuality in exchanges on medications.

Practice implications: The proposed concepts offer a unique vocabulary and conceptual framework to help physicians master the necessary

content and process skills required to discuss medications with patients.

# 2006 Elsevier Ireland Ltd. All rights reserved.

Keywords: Interpersonal communication; Doctor–patient communication; Doctor–patient relationship; Prescription; Discourse analysis; Content analysis;

Medication; Prescription discourse; Prescription dialogue

* Corresponding author. Tel.: +1 514 987 3000/0379;

fax: +1 514 987 6733.

E-mail addresses: [email protected] (C. Richard),

[email protected] (M.-T. Lussier).

URL: http://geirso.uqam.ca1 Present address: Equipe de recherche en soins de premiere ligne,

Hopital Cite de la Sante de Laval, 1755 Boul Rene Laennec, Laval, Quebec

H7M 3L9, Canada. Tel.: +1 450 668 1010x2742; fax: +1 450 975 5089.

0738-3991/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved

doi:10.1016/j.pec.2006.08.014

1. Introduction

Of all possible treatments discussed during encounters

between patients and physicians, medications are no doubt

one of the most frequent. Experts agree there are many

potential themes of discussion about medications [1] and

patients say they want to learn more about their medications

[2]. Yet various studies indicate that communication about

medications during medical interviews is limited in breadth

and depth [3–17]. In particular, Makoul et al. [11] indicate that

physicians were ‘‘neither giving nor eliciting much of the

.

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http://dx.doi.org/10.1016/j.pec.2006.08.014

C. Richard, M.-T. Lussier / Patient Education and Counseling 65 (2007) 329–341330

information that might help patients make optimal decisions

about their treatment’’ (p. 1253). Patients, for their part, are

described as ‘‘extremely passive, seldom offering an opinion

and rarely initiating discussion about any aspect of treatment’’

(p. 1252). More recently Braddock et al. [16] and Stevenson

et al. [6] report similar results. This is of concern since

physicians’ skills in partnership building and patients’ active

participation in medical encounters and, more specifically in

treatment discussions, have been associated with better

quality of care and health outcomes [17–21]. Up to now

however, patient and physician participation in conversation

exchanges has been examined mostly through an ‘‘interaction

perspective lens’’ emphasizing physician human interaction

skills such as avoiding interruptions, asking for patient

opinion, inviting patient questions and patient communicative

behaviors such as question asking [17,22,23], expression of

concerns [24,25], and assertiveness [26]. This type of

approach to participation describes the relational dimension

of exchanges. Although useful, it offers little insight into who,

of the patient and the physician, contributes content to

conversation exchanges on medications and the manner in

which they do so. In our view participation in a discussion

about medications that is conceptualized as ‘‘co-production of

content’’ may more effectively describe the process of

production and elaboration of content between patients and

their health care provider. ‘‘Co-production of content’’ by

both physicians and patients refers to their contribution to

content elaboration in exchanges about medications rather

than to the type of interaction occurring between them during

these exchanges. The asymmetry of medical knowledge in the

provider–patient dyad [27] however leads us to believe that

contributions to discussions of medications are not a uniform

phenomenon.

Moreover, most previous studies on communication about

medications have dealt only with conversations surrounding

New prescriptions. Physician–patient communication beha-

vior surrounding renewed prescriptions for medications that

are already being taken could not be documented to any great

extent in the literature [4,9,10]. Therefore, the objective of this

article is to describe the contributions to content patients and

physicians make to conversation exchanges about medica-

tions during primary care consultations. More specifically, we

explore how patient and physician participation to content

elaboration in medication-related discussions varies, in

relation to the medication-related themes discussed and the

category of the medication (e.g. medication ‘‘status’’): (1)

New prescription, (2) Represcribed medication during the

visit, and (3) Active medication that was discussed during the

visit but not specifically represcribed.

2. Methods

This is a descriptive study of medication-related exchanges

during consultations between patients and general practi-

tioners.

2.1. Participants

The study population included a sample of 422 interviews,

selected from a database of 1011 medical interviews recorded

on audiotape during the normal course of clinical activities as

part of a study on the detection of psychological distress by

general practitioners [28,29]. The sample has been described

at length in two previous articles published in this journal

[30,31].

At the time the recordings were made, neither patients nor

physicians knew that the interviews would be used in a study

on conversation exchanges about medications. All partici-

pating physicians and patients had given written consent for

the use of the tapes in other communication studies,

however. This study was approved by the Research and

Ethics Board of the Cite de la sante Hospital, Laval, Canada.

2.2. Instrument: MEDICODE, a coding grid for

discussions of medications

For this study, the MEDICODE grid was applied to each

of the 422 sample interviews. MEDICODE is a descriptive

tool dedicated to the quantitative content analysis of

discussions of medications during medical consultations.

The method does not require verbatim transcription. The

validity and reliability of the instrument have been

documented and found to be quite satisfactory [30].

2.2.1. Main coding categories

2.2.1.1. Status of the medication. A ‘‘New’’ prescription is

one that is prescribed for the first time during the encounter.

A ‘‘Represcribed’’ medication is one currently being taken

and a prescription for which is renewed during the visit. An

‘‘Active’’ medication is one the patient is currently taking,

but no renewal of the prescription is required during the

encounter. These three categories of status of medications

comprise 70% of all instances of discussions about

medications in our sample. In the initial coding, medications

previously used but no longer in use, potential medications

discussed and medications discussed but not recommended

were identified. These are not reported on in this article for

two reasons: (1) the number of observations within each

category was not sufficient to allow comparisons between

them and (2) we wanted to focus on issues and questions

about medications for which a prescription was written

during the encounter or that the patient was currently using.

2.2.1.2. Medication content themes of discussion. This

paper reports on 33 content themes grouped into 10

categories in accordance with the guidelines of the National

Council on Patient Information and Education [1], the

literature on adherence [32,33] and the more affective

aspects of medication use [34]. Content theme names

included in each of the 10 categories are self-explanatory

(see Table 1).

C. Richard, M.-T. Lussier / Patient Education and Counseling 65 (2007) 329–341 331

Table 1

Content theme categories and related specific themes

Content themes Specific themes

Designation Medication named

Form of medication

Class named

Possible

Main Effect

Expected effect on symptoms

Action of medication

Observed

Main Effect

Control of problem

Observed effects on symptoms

Possible

Adverse

Effect

Possible Adverse Effects of medication

Precautions against Possible Adverse Effects

of medication

Seriousness of Possible Adverse Effects

of medication

Probability of Possible Adverse Effects

of medication

Observed

Adverse

Effect

Observed Adverse Effects

Seriousness of Observed Adverse Effects of medication

Probability of Observed Adverse Effects of medication

Precautions against Observed Adverse Effects

of medication

Warnings Contraindications of medication

Drug interactions

Allergies/intolerance to medications

Instructions Instructions for medication (dosage instructions)

Physician recommends medication only as needed

Timeframe for expected effect

Duration of treatment

Adjustment of dosage/instructions

Opinion on strength of medication

Indication

to reconsult

Indication to reconsult

Adherence Adherence with medication

Commitment to take medication

Consequences of non-adherence

Solutions for non-adherence

Attitudes/

Emotions

Expression of attitude towards medication

Expression of objections regarding medication

Expression of doubt about effect of medication

Expression of concern regarding medication

Table 2

Quality of interlocutor participation and associated Dialogical Roles

Coding Complementary roles

Initiation Participation MD PT

Pt Monologue Listener: 0 Information

provider: 1

Pt Dialogue Participant: 2 Instigator: 3

MD Monologue Information provider: 1 Listener: 0

MD Dialogue Instigator: 3 Participant: 2

2.2.2. Coding procedure

For each medication identified in an encounter, the coder

opens a file and selects an appropriate descriptor from the

original list of themes and indicates for each theme who, of

the physician or the patient, initiates the discussion and who

contributes to the discussion. New information is added to

the same file until the end of the consultation thus capturing

all discussions of the same medication regardless of when

they occurred during the encounter. Coders at the end of the

tape assign the ‘‘status’’ of the medication because it often

only becomes clear at this time if a prescription is going to be

written.

2.2.3. Types of participation or dialogue measures

We have developed two new indicators intended to

capture both initiation and participation in conversation

exchanges on medications. Though initiation has been

evaluated in previous communication studies [6,9,11], we

did not find any studies that propose a coding strategy that

directly measures mutuality.

2.2.3.1. Dialogical Roles. For each medication identified

the coder determined whether the physician or the patient

initiated the discussion of a medication content theme and

whether the theme was developed by one or both individuals.

Thus coders could choose from four types of categories: (1)

individual production, patient alone; (2) individual produc-

tion, physician alone; (3) dialogue initiated by the patient or

(4) dialogue initiated by the physician. A scheme similar to

the one we used in this study has recently been proposed by

Makoul and Clayman [35], in their extensive review of

shared decision making in medical encounters as a proxy to

capture the degree of sharing in decisions with more sharing

occurring as the input of the other party increases (p. 307). It

is important to note that coders were instructed to select the

code for ‘‘dialogue’’ on a medication content theme as

opposed to ‘‘individual production’’ (physician or patient

alone), the minute they could identify a reply from the

interlocutor on the theme initiated by the other party. The

only replies that were excluded here were facilitative replies,

which did not contribute any content to the exchanges. See

Appendix A for examples of coding.

From these initial coder evaluations we then derived four

complementary physician and patient Dialogical Roles in

the exchanges on medications (see Table 2). When one

individual, either the physician or the patient, provides all of

the medication-related content on a given theme, that

individual becomes an ‘‘Information Provider’’. The other is

said to be a ‘‘Listener’’. When both interlocutors contribute

to the content on a theme, the person who initiated the

dialogue is said to be the ‘‘Instigator’’ and the other the

‘‘Participant’’. Thus the four roles are (a) Information

Provider, (b) Listener, (c) Instigator, and (d) Participant.

This coding strategy is such that each physician role has a

corresponding complementary patient role. Because parti-

cipation is valued in contemporary models of doctor–patient

communication [36–40], and has been shown to be

associated with better clinical outcomes [17–21], a

numerical value was attributed to each role, the lower

values (0 and 1) corresponding to monologues or absence of

sharing and the higher values (2 and 3) to dialogues in which

both patients and physicians participate.


From these four roles, two participation measures were

then computed for each category of content theme: the

Dialogue Ratio (DR) and the Preponderance of Initiative

(PI). Each is described below.

2.2.3.2. Dialogue Ratio (DR). The DR of the doctor–

patient dyad with regard to each medication content theme is

calculated by summing the values of the complementary

roles played by the two parties for each instance of

discussion of that theme and then by computing the average

value for that theme. This average value is then transposed

onto a 0–1 scale. The DR indicates whether the exchange is,

on the whole, more of a monologue (value from 0 to 0.5) or a

dialogue (value from 0.5 to 1).

2.2.3.3. Preponderance of Initiative (PI). PI is a rating that

captures the most predominant source that initiates the

exchange on individual medication content themes. The PI is

calculated by subtracting the value of the physician role

from the value of the patient role for all instances of

discussion of one given medication content theme and then

by computing the average value for that medication content

theme which can vary from �1 to +1. Physician PI is

arbitrarily indicated by a plus sign (+) and the patient PI by a

minus sign (�). For example, if the PI is equal to +1, then the

physicians had always taken the initiative in discussing the

medication content theme considered. A 0 value indicates

that both physician and patient took the initiative equally. A

value of �1 indicates that the patient always took the

initiative.

2.3. Statistical analyses

Statistical analyses were conducted using both the

Statistical Analysis System (SAS, Version 9.1) and the

Statistical Package for the Social Sciences (SPSS, Version

14). First, descriptive data on the characteristics of the

participants and the communication material – themes raised

and statuses of medication – were generated. The unit of

analysis chosen was the medication, not the encounter [31].

We then proceeded to compare the three medication statuses

on each content theme in terms both of the DR and PI by

analysis of variance (ANOVA). When we found a

statistically significant difference between the statuses on

a content theme, we used Tukey’s studentized range (HSD)

test to specify where the difference lied [41]. Finally to take

into account the correlations between repeated observations

on the same individual, we ran linear logistic regressions

using the generalized estimating equations or GEE which

adjusts standard errors thus controlling for these correlations

[42]. We obtained odd ratios comparing the probability of

obtaining a DR greater than 0 in the three different statuses

considered two by two (e.g. New prescriptions compared to

Active or to Represcribed medications or Active compared

to Represcribed medications). The alpha level was set at

0.05 for all analyses.

3. Results

3.1. Characteristics of participating physicians and

patients

In all, 40 physicians – 17 women (42.5%) and 23 men

(57.5%) – conducted the 422 interviews included in this

report. On average, each physician was thus involved in

10.6 interviews (range: 1–16). The mean age of the

physicians was 39.4 years (from 26 to 51 years), and they

had been in practice for 14.5 years on average (from 1 to 30

years).

Women made up 65.4% and men 34.6% of the patient

sample. The mean age of the patients was 52.4 years (S.D.,

17.9; range, 18–94 years). A third of the sample was 65 years

old or more. Nearly 50% of the sample had a technical or

college diploma or a higher degree. In 78% of cases, the

interviews were conducted during a visit made by

appointment versus dropping in, and the physicians knew

84% of the patients.

3.2. Medications

Of 1643 instances of medication-related exchanges

recorded, 13 could not be classified and 138 were either

medications used in the past but not taken at the moment nor

prescribed during the taped encounter (e.g. Pt: ‘‘I used

Tylenol when I sprained my ankle last month.’’ Dr: ‘‘OK.’’)

or medications mentioned but not recommended (e.g. Pt:

‘‘Do you think an anti-inflammatory could help? Dr: ‘‘No

because of your high blood pressure.’’). This left us with

1492 discussions of medications within the 422 encoun-

ters—a mean of 3.5 medications per interview (range: 1–21).

‘‘Active’’ medications account for the majority of the

drugs recorded by the coders (43.1%), while ‘‘Repre-

scribed’’ and ‘‘New’’ prescriptions account for 16.3% and

10.6% of the total, respectively. Together these three

clinically relevant medication statuses represent 70% of the

medications discussed.

3.3. Indicators of participation in content production

for each medication content theme and for each of the

three medication statuses

The frequency distribution of the four physician roles for

each of the ten categories of medication content themes by

the three medication statuses is presented in Table 3. Table 4

presents the detailed data on the average DR and PI

measures for each content theme category within each

medication status as well as the results of the analysis of

variance. To better visualize these behaviors (roles) and their

relationship to our two participation measures, we present

Figs. 1 and 2 in which the x-axis represents the DR

(0 = presence of monologue only, 0.5 = presence of ‘‘mono-

logue’’ and ‘‘dialogue’’ in equal amounts, 1 = presence of

dialogue only) and the y axis the PI (+1 = always physician


Table 3

Distribution of physician Dialogical Roles expressed as a proportion (%) of discussions by category of content themes and medication status

Content themes Statusa Physician’s role % of discussions

Listener Information provider Participant Instigator

Designation Active 31.7 34.5 1.9 32.0

Represcribed 13.2 47.6 2.7 36.5

New prescriptions 6.2 80.8 1.1 11.9

Possible Main Effect Active 15.9 79.3 2.4 2.5

Represcribed 4.3 89.2 4.3 2.2


Observed Main Effect Active 49.1 13.9 9.7 27.3

Represcribed 39.5 20.9 3.5 36.0


Possible Adverse Effect Active 9.1 80.3 6.0 4.5



Observed Adverse Effect Active 58.5 13.0 14.3 14.3

Represcribed 50.0 11.3 9.1 29.6


Warnings Active 8.7 34.8 21.8 34.8

Represcribed 0.0 20.0 20.0 60.0


Instructions Active 34.5 31.3 14.3 20.0

Represcribed 10.5 56.4 8.3 24.8


Indication of need to reconsult Active 0.0 91.4 1.7 6.9



Adherence Active 47.3 25.5 3.7 23.6

Represcribed 28.6 23.8 14.3 33.3


Attitudes/Emotions Active 66.4 27.9 2.2 3.6



Means all themes combined Active 32.1 43.2 7.8 16.9

Represcribed 23.6 46.0 7.7 22.7


a Active discussed, n = 643; Represcribed, n = 243; New prescriptions, n = 158.

initiated discussion of the theme, 0 = initiative shared

equally between physician and patient, �1 = always patient

initiated discussion of theme). We have individually located

along these two axes the ten content theme categories by the

three main medication statuses. We have also plotted the

average value (all themes combined) by the three medication

statuses. These graphs can be subdivided into four areas

that correspond to a dominance of one of the four physician

roles previously defined. In the shaded left-hand side of

the figures are discussions that are predominantly mono-

logues. Physician roles in these monologues are either

‘‘Information Provider’’ (upper left quadrant) or ‘‘Listener’’

(lower left quadrant). The right-hand side of the figures

represents discussions with a dominance of dialogues.

Here the physician can play the ‘‘Instigator’’ role (upper

right quadrant) or the ‘‘Participant’’ role (lower right

quadrant).

3.3.1. Roles, DRs and PIs for medication content theme

categories combined (means)

All medication-related exchanges were conducted pre-

dominantly in a monologic manner irrespective of the

medication statuses (Fig. 1). For New prescriptions

physicians predominantly adopted the role of ‘‘Information

Provider’’ (65.9%). They also adopted this role to a

significant extent when discussing Represcribed (46.0%)

and Active (43.2%) medications although, in these two

cases, we observed two differences from the roles observed

when discussing New prescriptions. First, the ‘‘Instigator’’

role was the more frequently adopted (16.9% and 22.7%,

respectively, for Active and Represcribed medications) and

was associated with a significant increase in the DR for these

two medication statuses (0.28 and 0.32) compared to New

prescriptions (0.11) (F(2,1012) = 24.5, p < 0.001). These

differences remained significant when we controlled for


Table 4

Dialogue Ratio and Preponderance of Initiative for each content theme by status of medication

Content themes Dialogue Ratio Preponderance of Initiative

Active Represcribed New ANOVA F Difference

between means

(95% CI)

Active Represcribed New ANOVA F Difference

between means

(95% CI)

Designation 0.33 0.39 0.12 15.76*** c 0.267*

(0.153; 0.381),

b 0.207*

(0.105; 0.309)

0.32 0.69 0.86 34.09*** b 0.540*

(0.354; 0.726),

a 0.375*

(0.230; 0.520)

Possible Main

Effect

0.04 0.06 0.04 0.19 NS 0.65 0.82 0.94 5.07** b 0.283*

(0.072; 0.494)

Observed Main

Effect

0.37 0.40 0.21 NS �0.20 0.08 5.10** a 0.291*

(0.037; 0.544)

Possible Adverse

Effect

0.10 0.10 0.17 0.51 NS 0.63 0.66 0.80 0.61 NS

Observed Adverse

Effect

0.27 0.37 1.29 NS �0.40 �0.20 0.99 NS

Warnings 0.59 0.80 0.30 2.84# NS 0.36 0.60 0.88 2.38 NS

Instructions 0.33 0.35 0.08 19.88*** c 0.267*

(0.151; 0.383),

b 0.254*

(0.152; 0.357)

�0.02 0.59 0.91 67.01*** b 0.934*

(0.729; 1.138),

a 0.621*

(0.428; 0.814),

c 0.312*

(0.081; 0.544)

Indications to

reconsult

0.08 0.06 0.12 0.56 NS 0.96 0.95 0.92 0.21 NS

Adherence 0.29 0.59 0.57 4.45** a 0.306*

(0.050; 0.561)

�0.02 0.31 1.00 4.55** b 1.023*

(0.168; 1.877)

Attitudes/Emotions 0.05 0.02 0.11 1.19 NS �0.47 �0.78 �0.53 2.61# NS

All themes 0.28 0.32 0.11 24.5*** c 0.209*

(0.134; 0.284),

b 0.173*

(0.108; 0.238)

0.12 0.51 0.85 77.55*** b 0.724*

(0.577; 0.872),

a 0.385*

(0.260; 0.510),

c 0.339*

(0.169; 0.508)

a: Estimate of difference between Active and Represcribed medications. b: Estimate of difference between Active and Newly prescribed medications. c:

Estimate of difference between Represcribed and Newly prescribed medications. *p < 0.05, **p < 0.01, ***p < 0.001, #p = 0.07, ##p = 0.06. NS: non-significant

difference between means.

repeated measures (see Table 5). Second there was a greater

use of the ‘‘Listener’’ role for Represcribed (23.6%) and

Active (32.1%) medications compared to New prescriptions

(10.5%) that accounted for the lowering of the PI. All three

medication statuses thus differed significantly from one

another with New prescriptions showing the highest

predominance of physician initiative (0.85) followed by

Represcribed (0.51) and Active (0.12) medications corre-

sponding to an almost equally shared initiative

(F(2,1012) = 77.55, p < 0.001). Of these differences, only

the one between the Represcribed and New prescriptions did

not remain significant when we controlled for repeated

measures ( p > 0.05).

3.3.2. Categories of medication content themes

Examination of Figs. 1 and 2 first reveals that most of the

10 medication content theme categories were discussed in a

predominantly ‘‘monologic’’ manner with DRs lower than

0.5. Within these, three distinct groups of content themes can

be distinguished however. Discussions of the first group of

themes (Designation, Instructions, Possible Main Effect,

Indication another Consultation is Needed and Possible

Adverse Effect) were usually monologues with the physician

playing the ‘‘Information Provider’’ role. For the second

group of themes (Attitudes/Emotions, Observed Main and

Observed Adverse Effects), discussions were also mono-

logues but the physician took the ‘‘Listener’’ role, as patients

were the ones to provide information. When physicians

discussed Warnings and Adherence, the third group of

themes, ‘‘dialogue’’ was predominant.

3.3.2.1. Content themes addressed as Information provi-

sion physician monologues. We found that 5 of the 10

medication content themes were situated in the left upper

quadrant. Of these, Possible Main Effect, Possible Adverse

Effect and Indication another Consultation is Needed are

themes characterized by physicians adopting predominantly

the ‘‘Information Provider’’ role. Thus the DR was very low

(varying from 0.04 to 0.17) and it did not vary according to

the status of the medication discussed ( p > 0.05) (Table 4).

The PI was high for these three content themes (0.63–0.96).

There were no significant differences in the PI except for


Fig. 1. Dialogue Ratio, Preponderance of Initiative and Roles. Fig. 2. Dialogue Ratio, Preponderance of Initiative and Roles.

New prescriptions compared to Active medications when

discussing Possible Main Effect (F(2,195) = 5.07,

p < 0.01). The shift towards the ‘‘Listener’’ role (15.9%)

for the Active medications accounted for the lower physician

PI for this theme. Repeated measures analyses for DRs and

PIs could not be computed for this content theme (see

Table 5).

Designation and Instructions themes both also fell in the

left upper quadrant (Fig. 1) indicating a general predomi-

nance of physician monologue and these themes followed a

pattern of variation between the three medication statuses

similar to the ‘‘all themes combined’’ pattern. When

discussing these themes, physicians adopted the ‘‘Instiga-

tor’’ role more frequently for Represcribed (Designation:

36.5%/Instructions: 24.8%) and Active medication (32%/

20%) compared to New prescriptions (11.9%/4.9%). The

relative importance of this ‘‘Instigator’’ role compared to the

‘‘Information Provider’’ role was responsible for the shift

towards more dialogue on the DR axis. Thus the DR for the

Represcribed (0.39/0.35) and Active medications (0.33/

0.33) statuses were both significantly higher than the New

prescriptions (0.12/0.08) (F(2,932) = 15.76, p < 0.001;

F(2,532) = 19.88, p < 0.001). After controlling for repeated

measures, these differences remained significant for the

Instructions content theme ( p < 0.01). However for the

Designation content theme only the difference between the

Represcribed and New prescriptions remained significant

( p < 0.05). The PI decreased steadily from New prescrip-

tions (0.86/0.91), Represcribed (0.69/0.59) to Active (0.32/

�0.02) medications. The difference between Active

medications on the one hand and Represcribed and New

prescriptions on the other was significant whether inde-

pendent measures (F(2,532) = 67.01, p < 0.001) or

repeated measures ( p < 0.001) were considered. Table 3

shows the relative increase of the physician ‘‘Listener’’ role

as we move from New prescriptions to Represcribed to

Active medications that explains the variation in the PI

noted above.

3.3.2.2. Content themes addressed as physician-initiated

dialogues. Warnings and Adherence were the only two

content themes for which the DR crossed the value of 0.5

indicating a change from a predominance of monologue to

one of dialogue. It was for the discussion of the Warnings


Table 5

Computed logistic regressions (repeated measures) of Dialogue Ratio and Preponderance of Initiative for each content theme by status of medication

Content themes Status of medication comparisons Odds-ratio of having Dialogue

Ratio > 0 (or not pure monologue)

(95% CI)

Odds-ratio of having Preponderance

of Initiative > 0 (or MD’s Preponderance

of Initiative) (95% CI)

Designation Represcribed vs. Active discussed 1.080 (0.909; 1.283) 1.420*** (1.251; 1.612)

New prescription vs. Active discussed 0.898# (0.799; 1.009) 1.456*** (1.344; 1.578)

New prescription vs. Represcribed 0.831* (0.712; 0.970) 1.026 (0.900; 1.169)

Observed Main Effect Represcribed vs. Active discussed 1.643*** (1.245; 2.170) 1.555** (1.138; 2.125)

Possible Adverse Effect Represcribed vs. Active discussed 1.231 (0.631; 2.399) 0.946 (0.474; 1.887)

New prescription vs. Active discussed 1.279 (0.899; 1.820) 1.150 (0.788; 1.678)

New prescription vs. Represcribed 1.039 (0.608; 1.755) 1.215 (0.710; 2.079)

Observed Adverse Effect Represcribed vs. Active discussed 0.854 (0.510; 1.429) nc

Instructions Represcribed vs. Active discussed 1.119 (0.872; 1.436) 1.667*** (1.441; 1.928)

New prescription vs. Active discussed 0.797*** (0.696; 0.912) 1.657*** (1.475; 1.860)

New prescription vs. Represcribed 0.712** (0.576; 0.881) 0.994 (0.877; 1.126)

Indications to reconsult Represcribed vs. Active discussed 1.037 (0.805; 1.335) 0.922 (0.731; 1.163)

New prescription vs. Active discussed 1.034 (0.877; 1.220) 1.025 (0.926; 1.135)

New prescription vs. Represcribed 0.997 (0.770; 1.292) 1.111 (0.898; 1.376)

Attitudes/Emotions Represcribed vs. Active discussed NS 1.013 (0.553; 1.857)

New prescription vs. Active discussed NS 0.953 (0.692; 1.311)

New prescription vs. Represcribed NS 0.940 (0.581; 1.523)

All themes Represcribed vs. Active discussed 1.280*** (1.098; 1.493) 1.646*** (1.475; 1.837)

New prescription vs. Active discussed 0.903* (0.814; 1.001) 1.699*** (1.565; 1.844)

New prescription vs. Represcribed 0.705*** (0.610; 0.815) 1.032 (0.936; 1.137)

GEE Model results (repeated measures on MDs considered). *p < 0.05, **p < 0.01, ***p < 0.001, #p = 0.07, ##p = 0.06. nc: non-computable.

theme, that physicians engaged the most predominantly in

the two roles that create dialogue: the Instigator (25–60%)

and Participant roles (10–22%). However, ANOVA did not

reveal any significant differences between the three

medication statuses ( p = 0.07). In terms of PI, whatever

the medication status, the values indicate that the discussion

of Warnings was predominantly physician initiated and we

found no significant differences between the three medica-

tion statuses ( p > 0.05). Repeated measures analyses for

DRs and PIs could not be computed for this content theme

(see Table 5).

When Adherence was discussed, we observed physi-

cians adopting the ‘‘Instigator’’ role (23–57%) just about

as often as for the Warnings theme but they adopted the

‘‘Participant’’ role somewhat less often (0–14%) shifting

the DR more to the left compared to the discussion of

Warnings. There was more dialogue in the case of

Represcribed (0.59) compared to Active medications

(0.29) (F(2,78) = 4.45, p < 0.01). The PI went to

physicians for New prescriptions (1.0) but it evolved

towards more of a shared initiative for the Represcribed

(0.31) and Active (�0.02) medications as the physician

became less of an ‘‘Instigator’’ and adopted the role of

‘‘Listener’’ more frequently. There were significant

differences for the PI between the Active medications

and the New Prescriptions statuses (F(2,78) = 4.55,

p < 0.01). Again, possibly due to the low number of

observations for this theme, repeated measures analyses

could not be computed for DR and PI.

3.3.2.3. Themes addressed as patient monologues. The

third group of medication content themes, Observed Main

Effect, Observed Adverse Effect and Attitudes and Emotions,

differed from the two previous in that they were patient

initiated more frequently, falling in the left lower quadrant of

Fig. 2.

In discussing Attitudes/Emotions, physicians predomi-

nantly adopted the roles of a ‘‘Listener’’ (66% or more) and

an ‘‘Information Provider’’ (10–30%) thus either responding

silently to patients (Table 3) or by informing them on this

subject without engaging them in conversation. The mean

DR was thus very weak (0.02–0.11), indicating an almost

absent level of dialogue, for physicians took on an

‘‘Instigator’’ or ‘‘Participant’’ role very rarely (less than

6%). No significant differences were found on this theme

between statuses whether independent measures or repeated

measures were used ( p > 0.05). Patients held the initiative

(PI varied from�0.47 to�0.78) for all three statuses. There

was a tendency for Represcribed medications compared

either to New prescriptions or Active medications to present

a higher patient initiative (F(2,293) = 2.61, p = 0.07)

explained by the fact that physicians adopted the ‘‘Listener’’

role most often (87.2%) when discussing Attitudes/Emo-

tions for Represcribed medications. However no significant

differences between the three medication statuses were

found whether independent or repeated measures were used

( p > 0.05).

Observed Effects (Main and Adverse) can be discussed

with reference only to Active and Represcribed medications.


For Observed Effect (Main and Adverse), physicians still

predominantly adopted the ‘‘Listener’’ role (40–50%) but

less often than in the discussion of Attitudes/Emotions and

more often an ‘‘Instigator’’ role (14–36%) explaining the

higher DR for both of these themes. The increase in DR was

thus related to the increase in the physician taking on the

‘‘Instigator’’ role more frequently than the patient. We found

no significant differences between the two medication

statuses ( p > 0.05) when significance tests using indepen-

dent measures were used but a significantly higher DR for

Represcribed compared to Active medications did appear

when repeated measures were used ( p < 0.001). The PI

again lied with the patients for these two themes, more so in

discussing the Observed Adverse Effect theme than the

Observed Main Effect theme. When comparing statuses for

these two themes, physicians adopted a ‘‘Listener’’ role

relatively more frequently 40–50% versus 50–60% when

discussing Adverse Effects than Main Effects. In terms of

medication status, we found a significant difference in PI

between Active and Represcribed medications for the

Observed Main Effect theme whatever the type of analysis

(see Tables 4 and 5).

4. Discussion and conclusion

4.1. Discussion

On the whole, the Dialogue Ratio is low, and remains

largely in the realm of physician monologue when

discussing issues of importance in medication taking. Our

results demonstrate that the roles physicians adopt while

discussing medications during primary care consultations

are complex; the roles vary depending on the medication

content theme under discussion and the status of the

medication.

4.1.1. Factors explaining the variation in the DR and PI

Kennedy [43] suggests that there are at least two sorts of

knowledge that are relevant to conversation exchanges

between patients and physicians: the clinical knowledge of

physicians and knowledge concerning the experience,

feelings, fears, and desires of patients. The patients’

experience includes their experience of the disease and of

its treatment. With regard to medication, Kennedy [43]

shows that patients intervene more in discussions when they

have experience with the medication or are already

acquainted with it. On the other hand, all matters biomedical

are part of the physicians’ area of expertise. Our findings

support this conclusion, since, for the Active and

Represcribed medication statuses, which imply that the

patient should have some knowledge or experience with the

medication as it is currently being taken by the patient, there

is greater patient participation in content production as

illustrated by the more frequent adoption of either the

‘‘Listener’’ or ‘‘Participant’’ roles by the physician.

Our findings, we believe, help explain why patients report

feeling that physicians do not sufficiently consider their

point of view. Stewart et al. [21] set out the aspects of

doctor–patient communication that, among other factors,

have been shown to foster the finding of common ground:

exchange of information, negotiation of expectations, an

active role for patients in the discussion, and sensitivity on

the part of physicians to patients’ fears and expectations.

Examination of our findings reveals that: (1) little

negotiation takes place because little dialogue occurs; (2)

physicians often remain silent when patients bring up

attitudes or emotions regarding medications or when they

discuss their observations regarding the effects of the

medications they are taking. Again we must stress that

coders were trained to code for dialogue whenever there was

at least one affirmation–response dyad. To code the

physician as a ‘‘Listener’’ the physician had to be silent

on the topic. The coders worked from audiotapes. It is thus

possible that physicians indicated their interest non-verbally

but it still remains that they did not actively engage in

discussions about issues known to be important to patients

such as the effects of the medications [2,6] or for which we

know there is a major problem (adherence). This represents a

potential gap in physicians attending to patient concerns and

indicates that patient cues are not being picked up. This is

unfortunate as Bajcar suggests that these represent ideal

learning educational moments about the patients’ medica-

tions [44].

We would suggest that all the variations observed in DR

and PI may stem from four factors: (1) the patients’

knowledge of the medication, (2) the physicians’ clinical

expertise, (3) the patients’ experience, and (4) the exercise of

clinical responsibility involved in writing a prescription.

Patients’ knowledge of a drug develops as a function of

their taking it. Patients, even if they have heard of the

treatment through the Internet, media, family or friends, still

have little first-hand knowledge about New Prescriptions. It

seems reasonable to assert that, for these new medications,

patients are still at the beginning of their knowledge-

building and thus would tend to contribute less to the

discussion and tend to migrate more to the Listener role.

Physicians thus frequently adopt the Information Provider

role. However, patients progressively build knowledge about

medications as they gain experience using them and have

had opportunities to read more information after leaving the

doctor’s office. Thus they have more content that they can

potentially add to the conversation exchange during their

encounters with physicians for Active and Represcribed

medications, especially knowledge regarding their own

experience. Patient knowledge would thus mainly affect the

DR. If our contention is correct, and patients’ involvement in

discussions is indeed associated with their knowledge of

medications, their involvement is very likely to increase in

years to come because of the greater accessibility of

information through the media and the Internet [45]. The

medication content themes most affected by patient


knowledge are Designation, Instructions, Warnings, and

Adherence. The first three of these correspond to the type of

more technical or basic information patients need to guide

what Bajcar [46] calls ‘‘Medication-taking acts’’ (the

physical act of taking medications) in her Medication-

taking Practice Model. As for adherence, previous studies

[47–50] indicate, albeit indirectly, that physicians rarely

check on the manner in which patients take their medication.

Our results indicate that when they do, which is a rare event,

they do not engage in a dialogue on this subject therefore

decreasing their chances of recognizing and addressing the

potential of non-adherence.

The second factor we identify, the physicians’ clinical

expertise, is related to areas of physician technical knowl-

edge that patients do not generally share to any great extent.

Consequently, it is up to the physicians to speak about these

matters. The result is a monologue initiated and delivered

essentially by an Information Provider, the physician. For

the themes Possible Main Effect, Possible Adverse Effect and

Indication of Need to Reconsult there is thus very little

variation in the DR or PI. The former is very weak, and the

latter heavily weighted towards the physicians, for discus-

sions of these themes draw on the physicians’ clinical

expertise. For these themes, physicians adopt the role of

Information Provider. However, discussion with patients of

the Possible Adverse Effects of medications and weighing

these against their potential is the basis on which patients

create ‘‘sense-making’’ of their medication-taking. ‘‘Sense-

making’’ is the most important task of patients’ medication-

taking practice in Bajcar’s model as it directly influences a

patient’s approach to decisions about their medication-

taking and can contribute to intentional non-compliance

[44]. Indeed, in synthesizing studies on the issue, Berg,

Dischler, Wagner, Raia, and Palmer [41], report that

approximately 20% of New prescriptions are never filled.

Patients give many explanations for this failure, with over

50% maintaining they believed they did not need the

medication, that it would not help or that they simply did not

want to take it. Therefore physicians should move from an

Information Provider role to an Instigator role to engage the

patient in exchanges on these important subjects if we aim at

improving patient medication-taking practices.

The third factor is patient experience and it affects the

following themes: Observed Main Effect, Observed Adverse

Effect and Attitudes/Emotions. While DRs for the statuses

involved are similar for all three themes, the PI is more

variable. There is thus a preponderance of patient initiative

for Attitudes/Emotions and Observed Adverse Effect, but a

sharing of initiative for Observed Main Effect. Indeed, even

though the theme Observed Main Effect draws on patient

experience, it probably prompts discussion when the

physician must renew a prescription for a drug, since it is

a consideration in evaluating the medication’s effectiveness.

On the other hand, whatever the status of the medication, the

theme Attitudes/Emotions remains an area of unshared

initiative because it is based strictly on the patients’

knowledge and experience and they are the ones best able to

talk about them [51]. Though physicians, through adopting a

role of Listener, seem receptive to this content, there is no

indication they actively seek it out as they rarely initiate this

topic or contribute to its development. One might

hypothesize that physicians do not try to elicit discussions

on attitudes and emotions because of lack of time or that they

feel they do not master the necessary interpersonal skills to

explore emotions appropriately. Yet it is precisely these

emotional factors that may constitute major barriers to the

patients’ taking their medications [34]. Makoul et al. [11]

and Stevenson et al. [6] underline the importance patients

ascribe to these topics even though they are not often

broached during encounters. Moreover, Leventhal and

Cameron [34] and Prochaska and DiClemente [52] stress

the importance of the role played by affective factors in the

adoption and maintenance of new types of behavior,

including medication adherence. Our findings show that

physicians pay little heed to these factors by not verbally

responding to patient prompts.

The fourth explanatory factor we put forward is the

assumption of physician responsibility, that is, the act of

prescribing. No matter which medication content theme that

is analyzed, writing a new prescription and renewing an

existing one seem to be related to a high prevalence of

physician initiating the conversation. Physicians have

complete responsibility for New prescriptions; they cannot

rely on the patient having any knowledge or experience

regarding the medication as they can for Represcribed

medications. On the other hand, renewing prescriptions

involves a more direct assumption of physician responsi-

bility than does the mere discussion of active ongoing

medications. This assumption of responsibility seems to be

the reason why, for almost every theme except Attitudes/

Emotions, physician preponderance is lowest for Active

medications and rises for Represcribed drugs and New

prescriptions.

4.1.2. Methodological issues

A few methodological issues merit consideration. We

chose to consider the medication as our unit of analysis

because we were concerned by the potential loss of

information in the process of grouping medications within

the interviews. This presented interesting statistical chal-

lenges that we have addressed by including two types of

analyses: the first considering the data as independent and

the second controlling for repeated measures, accounting for

the fact that the same physicians could contribute more than

one consultation to the study and that one interview could

contain more than one medication. To compute the repeated

measures logistic regression analyses requires observations

by the same physician in each medication status. This

substantially decreased the number of observations included

in the analyses with the result that many ORs could not be

evaluated (Possible Main Effect, Warnings and Adherence).

However, when both approaches could be used, they did not


yield important differences in the results. Out of the 10

content themes, Observed Main Effect came up in the

logistic regression analysis with a statistically but not

clinically significant difference that did not appear in the

ANOVA. There were a few discrepancies between where

differences lied between statuses but we are confidant that

treating our data as independent measures did not constitute

a major problem.

We also chose to study medication-related discussions for

different statuses of medications. This broader scope stems

from the following considerations. In primary care, patients

may be followed by the same general practitioner for many

years, and the prescription of a new medication is a rather

less frequent occurrence than is the renewal of a prescription

or simply the discussion of an active ongoing drug. Indeed, a

majority of patients are followed for chronic diseases for

which the same medications will be prescribed again and

again. In order to maintain patient behavior, such as taking

one or more medications on a continuous basis, physicians

should take opportunities to reinforce it throughout the life

of the prescription. In addition, Scherwitz et al. [10] and

Sleath et al. [9] have shown that discussions about drugs vary

with the status of the medication. The findings reported here

confirm these observations.

We have introduced three important concepts that aim at

capturing the extent of contribution of each party to

medication-related discussions during medical encounters:

Dialogue Ratio, Preponderance of Initiation, and Dialogical

Roles. These new measures of participation to content

production are intimately related to the MEDICODE coding

scheme the authors have developed and validated [30] in

which coders indicate if a medication content theme is

discussed by either the physician or the patient alone or if

both contribute content to the discussion. To our knowledge

this is the first attempt at quantitatively measuring

participation, envisioned as a continuum going from

physician lead discussions through shared discussion

through patient lead discussions or decisions as suggested

recently by Makoul and Clayman [35] in their systematic

review of the concept of shared decision making. Most

existing studies looking at participation have focused on the

evaluation of physician and patient individual use of

‘‘interactive’’ communication behaviors (Question-asking,

expressions of concern or of negative feelings on the part of

patients, or physician supportive or partnership building

talk). To do so, they use simple frequency counts of

occurrences of interactive behaviors or composite measures

that sum individual frequencies as a proxy for participation.

The original measures of participation we have developed

and used in the present study go beyond the traditional

individual count measures of participation by integrating the

aspect of mutuality of production of content when

medications are discussed in medical encounters.

We have focused our analysis on physician behaviors

keeping in mind that each physician behavior has a patient

complementary counterpart in our coding scheme. Of the

four possible roles physicians can adopt, the Instigator and

the Participant roles engage both parties in a dialogue either

by initiating it or by responding to a patient’s initiative.

These roles are important as Street et al. [26] have shown

that even though most interactive participation by patients is

patient initiated, physicians can also influence patient

involvement in the consultation by instigating their

contribution to content development.

4.2. Conclusion

Participation in medical encounters has often been

treated from an interactive perspective, yet the degree to

which physician and patient actually engage in dialogue

rather than merely delivering monologues to each other has

too rarely been studied. We have examined it from the

perspective of each party’s contribution to content on

specific themes related to medications. We have developed

original indicators of this participation; Dialogue Ratio,

Preponderance of Initiative, and Dialogical Roles, as well as

a graphical representation of this information. Our data

indicate a generally low level of dialogue when discussing

medications during primary care encounters since physi-

cian monologues seem to be the rule rather than the

exception, pointing to a lack of mutuality in the exchanges

on medications. Physicians predominantly adopt the

Information Provider role. Patients are thus more often

than not in the role of Listener, seriously curtailing their

input to discussions of medications. These findings point to

the relative absence of co-production of content thus not

lending support to sharing in discussions or, eventually in

decisions relating to medication use. The results we have

presented are descriptive in nature therefore it is not

possible to deduce from them the ‘‘ideal’’ physician

behavior since the ‘‘ideal’’ proportion of each role

associated with positive clinical outcomes is unknown at

this time. The design of our study does not allow us to

answer this important question. Future studies in which

patient and physician outcomes following discussions of

medications in primary care encounters are evaluated will

be necessary to answer this question.

4.3. Practice implications

The factors we have suggested in the interpretation of our

data lead us to suggest that physicians can build on patients’

own medication-related knowledge and experience to

increase dialogue about medications. In doing so, they

invite more active patient participation, which should

improve patient outcomes because participation is now

acknowledged to be a critical element in patients’ ability to

follow their treatment correctly. The concepts of Dialogue

Ratio and Dialogical Roles offer potential in the educational

environment by guiding the development of specific

interventions aiming at increasing dialogue on medications.

We believe these concepts will help physicians progress


from simply Information Providers to dialogue Instigators as

well as from simply Listeners to Participants so as to discuss

medications with patients in a manner that supports them to

develop effective medication-taking practices.

Acknowledgements

This research benefited from an unrestricted educational

grant provided by the Professional Education Office of

Aventis Canada. The authors extend their sincere thanks to

Ms. Celine Monette, director of the office at the time this

research was conducted, for her continued support to this

project. They would also like to thank Mr. Denis Roberge

and Mr. Djammal Berbiche for their support in the

statistical analyses and Drs. Ellen Rosenberg, Suzanne

Kurtz and Jana Bajcar for their helpful comments on this

manuscript.

Appendix A. Coding examples

A.1. Example of dialogues

1. Dialogue initiated by patient; medication: antidepressant;

status: Active; Theme: Observed main effect.

Pt: ‘‘This antidepressant is working for me. I’ve been

feeling better doctor.’’

Dr: ‘‘That’s great.’’

Pt: ‘‘Yeah. I’m really more energetic than I was.

Almost back to normal.’’

Dr: ‘‘That’s what we expected would happen.’’

2. D
ialogue initiated by physician; medication: antidepres-
sant; status: New prescription; Theme: Attitude and

emotion.

Dr: ‘‘Did you have a chance to think about that

antidepressant I suggested last time?’’

Pt: ‘‘Yeah but I’m still concerned about how safe it is

to add to all the other meds I’m on already?’’

Dr: ‘‘I had checked with the pharmacist before

suggesting it to you and there is no problem.’’

Pt: ‘‘I think I’ll give it a try doc since things aren’t

getting any better.’’

Dr: ‘‘I think it’s a good idea to try it. Here’s the

prescription.’’

A.2. Example of monologues

1. Monologue initiated by physician; medication: antide-

pressant; status: Represcribed; Theme: Instructions.

Dr: ‘‘So, my chart indicates you’re due for a renewal

of your antidepressant. You’ve been on it for three

months now and we should continue for another three

months to get the full benefit. Here’s a renewal of your

prescription for the next three months.’’

No patient verbal response.

2. M
onologue initiated by patient; medication: antidepres-
sant; status: Active; Theme: Observed Adverse Effect.

Pt: I’ve been having a hard time sleeping with this

medication. At first I thought it was because of all my

worries but it definitively has something to do with this

pill I’m on.’’

No physician verbal response.

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Documents

Measuring patient and physician participation in exchanges on medications: Dialogue Ratio, Preponderance of Initiative, and Dialogical Roles