Open Access Research article

Engaging communication experts in a Delphi process to identify patient behaviors that could enhance communication in medical encounters

Jaya K Rao1*, Lynda A Anderson2, Bhuvana Sukumar3, Danielle A Beauchesne3, Terry Stein4 and Richard M Frankel5

Author Affiliations

1 Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 2202 Kerr Hall, CB 7573, Chapel Hill, NC 27599, USA

2 Healthy Aging Program, Centers for Disease Control and Prevention 4770 Buford Highway NE, MS K-45, Atlanta, GA 30341, USA

3 ICF Macro International Inc, 3 Corporate Square, Suite 370, Atlanta, GA 30329, USA

4 The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, CA 94612, USA

5 Center for Implementing Evidence Based Practice, Roudebush VA Medical Center, 1481 West 10thStreet, Indianapolis, Indiana, 46202, USA

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BMC Health Services Research 2010, 10:97  doi:10.1186/1472-6963-10-97

Published: 19 April 2010



The communication literature currently focuses primarily on improving physicians' verbal and non-verbal behaviors during the medical interview. The Four Habits Model is a teaching and research framework for physician communication that is based on evidence linking specific communication behaviors with processes and outcomes of care. The Model conceptualizes basic communication tasks as "Habits" and describes the sequence of physician communication behaviors during the clinical encounter associated with improved outcomes. Using the Four Habits Model as a starting point, we asked communication experts to identify the verbal communication behaviors of patients that are important in outpatient encounters.


We conducted a 4-round Delphi process with 17 international experts in communication research, medical education, and health care delivery. All rounds were conducted via the internet. In round 1, experts reviewed a list of proposed patient verbal communication behaviors within the Four Habits Model framework. The proposed patient verbal communication behaviors were identified based on a review of the communication literature. The experts could: approve the proposed list; add new behaviors; or modify behaviors. In rounds 2, 3, and 4, they rated each behavior for its fit (agree or disagree) with a particular habit. After each round, we calculated the percent agreement for each behavior and provided these data in the next round. Behaviors receiving more than 70% of experts' votes (either agree or disagree) were considered as achieving consensus.


Of the 14 originally-proposed patient verbal communication behaviors, the experts modified all but 2, and they added 20 behaviors to the Model in round 1. In round 2, they were presented with 59 behaviors and 14 options to remove specific behaviors for rating. After 3 rounds of rating, the experts retained 22 behaviors. This set included behaviors such as asking questions, expressing preferences, and summarizing information.


The process identified communication tasks and verbal communication behaviors for patients similar to those outlined for physicians in the Four Habits Model. This represents an important step in building a single model that can be applied to teaching patients and physicians the communication skills associated with improved satisfaction and positive outcomes of care.