RIAS: Manual

The Roter Method of Interaction Process Analysis

Debra Roter, DrPH                                                         Professor, The Johns Hopkins University                          Bloomberg School of Public Health                               Department of Health, Behavior and Society                         624 N. Broadway, Baltimore, MD  21205                            ?Debra Roter, 2008 

Table of Contents

• I. INTRODUCTION
• A. Coding categories
• B. Rules of thumb
• C. Summary rules for coding in ambiguous situations
• D. Interview segments
• E. Coding notes
• F. Abbreviations for RIAS categories
• II. RIAS CODING CATEGORIES
  
• A. Socioemotional Exchange
• 1. Personal remarks, social conversation
• 2. Laughs, tells jokes
• 3. Shows concern or worry
• 4. Reassures, encourages or shows optimism
• 5. Shows approval
• 6. Gives compliment
• 7. Shows disapproval
• 8. Shows criticism
• 9. Shows aggrement or understanding
• 10. Back-channel responses
• 11. Empathy statements
• 12. Legitimizing statements
• 13. Partnership statements
• 14. Self-disclosure statements
• 15. Asks for reassurance
• B. Task-Focused Exchange
• 1. Transition words
• 2. Gives orientation, instructions
• 3. Paraphrase/checks for understanding
• 4. Asks for understanding
• 5. Bid for repetition
• 6. Asks for opinion
• 7. Asks for permission
• C. Summary of Category Definitions
• 1. Medical condition
• a. Gives information
• b. Asks closed-ended questions
• c. Asks open-ended questions
• 2. Therapeutic regimen
• a. Gives information
• b. Asks closed-ended questions
• c. Asks open-ended questions
• 3. Lifestyle information
• a. Gives information
• b. Asks closed-ended questions
• c. Asks open-ended questions
• 4. Psychosocial information
• a. Gives information
• b. Asks closed-ended questions
• c. Asks open-ended questions
• 5. Other information
• a. Gives information
• b. Asks closed-ended questions
• c. Asks open-ended questions
• 6. Counsels or directs behavior
• a. Medical condition/therapeutic regimen
• b. Lifestyle and psychosocial
• c. Requests for services or medication
  
• D. Global Affect Ratings 
• III. USING THE RIAS SCHEME
  
• A. Adaptations of the RIAS Coding Scheme
  
• B. Elaborations of topics of interest
• C. Proficiency checklists

 

I. INTRODUCTION

The Roter Interaction Analysis System (RIAS) is a method of coding doctor-patient interaction during the medical visit.  The system is broadly derived from the seminal work of Robert Bales for assessing patterns of small group interaction during problem-solving and decision-making (Interaction Process Analysis, Cambridge, Mass.: Addison-Wesley, 1950).  The RIAS differs substantially from the original Bale's Process Analysis in four ways:  

    1.  The coding approach is tailored to dyadic exchange specific to the medical encounter.  All patient and physician dialogue is coded into categories that may be applied to each speaker, although some categories may be more common to a particular speaker.

    2.  Categories are tailored to directly reflect the content and context of the routine dialogue between patients and doctors during medical exchanges.

    3.   Identification and classification of verbal events are coded directly from videotapes or audiotapes and not transcripts.

    4.  Since coding is done directly from video or audiotapes, rather than transcripts, assessment of the tonal qualities of interaction is possible. These tonal qualities transmit the emotional context of the visit beyond the significance of the words spoken.  Based on a general affective impression, coders rate both the patient and physician on global affective dimensions such as anger, anxiety, dominance, friendliness and interest.

I.A. Coding Categories

Communication units are defined as "utterances"--the smallest discriminable speech segment to which a classification may be assigned.  The unit may vary in length from a single word to a lengthy sentence.  A sentence is considered one unit if it conveys only one thought or relates to one item of interest.  Compound sentences are often divided at the conjunction.  If a thought or sentence is interrupted or divided by a pause of one second or more, then each sentence fragment is coded as a separate utterance.  If the first portion of the divided thought can be categorized, the content of the second fragment is attributed to the same category as the first.  If, however, the first portion has no content, it stands alone as a transition.  If the fragments lack content or meaning, and therefore cannot fairly be assigned to one of the other categories, they would be coded as transitions. 

                                                                                    The average time for coding an encounter is usually 3 to 4 times the length of the encounter, so that a 15 minute visit would take 45-60 minutes to code.

I.B. Rules of Thumb

1.  While coding rules and category definitions are provided, an interpretive function must also be considered for proper coding.  This is especially evident in terms of how things are said, that is, voice tone and intonation of a statement should be interpreted by the coder in determining the appropriate category. 

                                                                                        2.  Bales suggests that if a decision must be made between categorizing an utterance in a task or affect category, the affect category should be used.  The reason given by Bales is that the explicit content is likely to direct codes to the task-neutral domain; our intuition responds to implicit affective messages which would point to the affect domain.  Since affective interchange is relatively uncommon, when a question of the appropriate code arises it is more likely to be affective than neutral, and intuition should be followed.

                                                                                      3.  Further help in deciding categories may be gained from the manner in which the receiver interprets the statement.  In the example above, if the patient laughs in response to the statement, it would be coded as a joke; if the patient responds as if accepting an apology or statement of concern, it would be coded accordingly.                                                                                                                                     4.  Use caution in automatically assigning key words to specific categories.  Some words have different functions and meanings depending on the context in which they are used and the intent they imply.      

I.C. Summary Rules for Coding in Ambiguous Situations 

1.  Code according to voice tone and emphasis.                      2.  Code using an affective category when there is doubt between a task-neutral and affective category.                     3.  Code according to listener's response.                           4.  Code according to context.                                        

The strength of coding directly from the audio record is that it allows for an expansion of verbal interpretation of a phrase by incorporating voice tone and emphasis into its interpretation.  For example, expressions reflecting concern, disagreement, optimism or approval are conveyed through voice tone and emphasis as well as word content and context.  While tonal and emphatic nuances are difficult to define or describe, they are registered and interpreted, by most people, uniformly.

I.D. Interview Segments 

A typical clinic visit generally follows the pattern of opening, history-taking, physical exam, counseling and closing.  Certain categories of talk typically characterize a segment, although any category can occur within any segment.  These interview segments are distinguished as follows:

• Opening:  This includes the greetings and any initial physician probes regarding the reason for the visit.  The opening ends when closed-ended questions mark the transition to the history-taking segment.
• History:  The history-taking segment begins when the physician follows up on a specific topic or follows a line of questioning about the patient's medical problems, personal and family medical histories, medical background and previous treatments, or other lifestyle or psychosocial concerns.  The history segment usually concludes with the physician making Orientation statements that indicate to the patient that the physical exam will follow.
• Exam:  The exam segment includes the actual physical exam procedures.  The physician and patient may continue to discuss the medical condition or other information during this period, but the primary ongoing activity is the exam.  Orientation statements frequently increase during this interview segment as the physician tells the patient what to do or what is about to happen in relation to exam procedures.  In some cases, the exam segment is clearly concluded when accompanied by verbal statements to that effect and/or when the physician leaves the room in order to allow the patient to dress.  In other cases, the transition to the counseling segment is not so clear, but is usually characterized by changes in verbal exchange.
• Counsel:  The end of the exam segment and the beginning of the counseling segment is generally characterized by a decrease in the number of Orientation statements and an increase in Gives Information (either by the physician or patient) and/or Counsels/Directs Behavior statements.  This interview segment consists of information-giving or counseling regarding the patient's medical condition, proposed therapeutic regimen, and/or other lifestyle or psychosocial information or suggestions.
• Closing:  The counseling segment concludes with the closing remarks.  The closing is often marked by a transitional statement or voice tone that indicates that the visit is being "tidied up."  Of particular interest is the "Oh, by the way..." introduction of new problems, which may occur when the patient becomes aware that the visit is concluding.  By marking the closing of the visit, the dynamics of this portion of the visit may be studied.

I.E. Coding Notes 

In addition to coding the verbal content of the audiotapes into the categories described, the following must also be noted during or immediately after coding each tape:

• Case ID, date of coding, and coder ID.
• Abrupt beginning or end of interview (e.g., greetings were not recorded and tape began with the history segment already in progress; or, tape ran out toward the end of the visit but before the visit was complete).
• Sex of physician and patient.
• Interview segments:  At the appropriate points, note the interview segments.  (If coding onto paper forms, this may be accomplished by either drawing lines to mark the segments--or--by using a new coding form for each segment.) If interview segments are not clear or are in reversed order, note this information.
• Interruptions:  Note any interruptions that occur during the visit (e.g., the physician leaves the room, takes phone calls, etc.)  If the tape continues to record during this period, indicate the approximate length of the interruption.  (Note:  Verbal exchange during the interruption that is not between the physician and patient is not coded.)
• Overall tape quality:  If tape audibility is consistent throughout the tape, note the overall quality after coding (e.g., good, fair, poor).  If a tape contains sections which are difficult to understand or are inaudible, note where these audibility problems occur.
• Third party presence:  If a third party (e.g., another physician, relative of the patient) is present for part or all of the visit, briefly describe the role that this person plays.  In other words, indicate when during the interview the third party was present, approximate length of time present, and degree of involvement.

I.F. Abbreviations for RIAS Categories 

• Personal -- Personal remarks, social conversation
• Laughs -- Laughs, tells jokes                        
• Concern -- Shows concern or worry                                
• R/O -- Reassures, encourages or shows optimism      
• Approve -- Shows approval - direct                              
• Comp -- Gives compliment - general                                
• Disapprove -- Shows disapproval - direct                         
• Crit -- Shows criticism - general                                   
• Agree -- Shows agreement or understanding                  
• BC -- Back-channel responses (Physician only)           
• Empathy -- Empathy statements                                   
• Legit -- Legitimizing statements                                   
• Partner -- Partnership statements (Physician only)            
• SDis -- Self-disclosure statements (Physician only)            
• ?Reassure -- Asks for reassurance                               
• Trans -- Transition words                                              
• Orient -- Gives orientation, instructions                        
• Check -- Paraphrase/Checks for understanding        
• ?Understand -- Asks for understanding                 
• ?Bid -- Bid for repetition 
• ?Opinion -- Asks for opinion (Physician only)         
• ?Permission -- Asks for permission (Physician only)           
• [?]Med -- Asks closed-ended questions-Medical condition
• [?]Thera -- Asks closed-ended questions-Therapeutic regimen 
• [?]L/S -- Asks closed-ended questions-Lifestyle 
• [?]P/S -- Asks closed-ended questions-Psychosocial   
• [?]Other -- Asks closed-ended questions-Other             
• ?Med -- Asks open-ended questions-Medical condition  
• ?Thera -- Asks open-ended questions-Therapeutic regimen
• ?L/S -- Asks open-ended questions-Lifestyle                
• ?P/S -- Asks open-ended questions- Psychosocial          
• ?Other -- Asks open-ended questions-Other                
• Gives-Med -- Gives information-Medical condition         
• Gives-Thera -- Gives information-Therapeutic regimen
• Gives-L/S -- Gives information-Lifestyle                       
• Gives-P/S -- Gives information- Psychosocial              
• Gives-Other -- Gives information-Other                   
• C-Med/Thera -- Counsels-Medical condition/Therapeutic regimen (Physician only)                                          
• C-L/S-P/S  -- Counsels-Lifestyle/Psychosocial (Physician only) 
• ?Service -- Requests for services (Patient only)               
• Unintell -- Unintelligible utterances

II. RIAS CODING CATEGORIES

II.A. Socioemotional Exchange

II.A.1. Personal remarks, social conversation (Personal)

1.  Greetings, initiating contact through friendly statements that are part of a formal greeting, return of friendly gestures and greetings, and goodbyes.  (*Exception:  When the patient responds to a greeting of "How are you?" with a description of medical problems, the question would be coded as Asks for Opinion, as this is the way the question was interpreted.)

                                                                                      2.  Conversation on weather, sports or any non-medical or social topic of general health that is not related directly to the discussion of general health.

                                                                                         In the example above, the segments coded as personal remarks have subsumed the more detailed coding that would have taken place had the exchanges pertained to the medical visit (e.g., agreements, jokes, approvals).                                                                                  Personal remarks and social conversation may occur during procedures as a way of distracting the patient from the task at hand. For example, during mole removal, talk is coded as Personal when discussing the chances of the Broncos having a winning season. However, the talk becomes Lifestyle if it is about the patient's son's football career.  The rationale for coding the patient's talk as Lifestyle is that this is a chance for the doctor to find out about family dynamics, etc., such as the son's football schedule and its impact on the rest of the family.  (If the doctor talks about his or her own son's football career, this may be more correctly coded Personal talk--unless the talk has bearing on a patient problem or concern, in which case the talk would be coded as Self-Disclosure.)

II.A.2. Laughs, tells jokes (Laughs)

1.  Includes friendly jokes, trying to amuse or entertain, kidding around, good-natured teasing, morbid jokes (e.g., "I might blow away in a strong wind"), and all forms of laughter. 2.  Laughter in response to jokes is coded by each utterance, with pauses breaking up laughter making each fragment count as a separate utterance.

II.A.3. Shows concern or worry (Concern)

1.  A statement or non-verbal expression indicating that a condition or event is serious, worrisome, distressing or deserving special attention (such as comforting or other special consideration) and is of particular concern at this point in time.  In other words, these statements have a strong and immediate emotional or psychosocial component, and do not refer to a more general frame of mind or past issues (see Gives Information-Psychosocial or Counsels-Lifestyle/Psychosocial).  Voice tone, intonation or verbal content may disclose worries, concerns, stress, nervousness, personal preferences or uncertainties that are of immediate concern.

                                                                                      2.  Includes negative emotional descriptions of the medical situation or discussions of somewhat non-specific feelings, even if describing a physical state: 

                                          

 3.  Includes statements that ask for pardon and indicate concern for the other's feelings (but does not include routine social amenities).

                                          

 4.  Includes self-criticism:

II.A.4. Reassures, encourages or shows optimism (R/O)            

1.  Includes statements indicating optimism, encouragement, relief of worry or reassurance.  Reassures statements are differentiated from Approvals or Compliments in that they are more intensely personal, intimate or immediate (in other words, reflecting how the patient or physician feels at this point in time).  Also includes prognostic statements that are related to physical or emotional consequences.  More positive than Concern/Worry statements:           

                                                                                       2.  Includes positive emotional descriptions of one's self, the medical situation, or discussions of somewhat non-specific (e.g., "awesome" or "fantastic") feelings, even if describing a physical state.      

                                                                                       3.  Includes statements that show an awareness of the other's feelings in a positive upbeat way, or respond to a request for reassurance

II.A.5. Shows approval-direct (Approve)

1.  Compliments, expressions of approval, gratitude, praise, reward, respect or admiration directed to the other person present.

Includes such statements as "Thank you," "You're welcome," and "Nice to have met you" when stated at or near the end of the interview.                                                              When the doctor responds in an approving manner to something that the patient says but for which the patient is not directly responsible, this is coded as Reassures/Optimism, not Approval.    

                                                                                 When the doctor instructs the patient during the exam, the doctor's response of "Good" may indicate approval that the patient has responded correctly.

                                                                                       2.  Exclamations that convey positive feeling in response to something the other said:

                                  

 3.  A compliment of something attributed specifically to the other:

II.A.6. Gives complement-general (Comp)

1.  Compliments, expressions of approval, gratitude, praise, reward, respect or admiration directed to another not present during the exchange:

                                                                                         In certain contexts an approving statement may be a Reassures/Optimism statement:

                                                                                         2.  A compliment of something attributed specifically to another:

II.A.7. Shows disapproval-direct (Disapprove)

1.  Any indication of disapproval, criticism, complaint, rejection, coolness or disbelief directed expressly to the other person present. This includes statements that contradict or refute something said by the other, or imply disagreement with or rejection of the other's hypotheses, ideas or opinions:

                                                                                       2.  Sarcasm:

                                                                                         3.  Protests/defensive statements:           

                                                                                     4.  Often differentiated from statements showing concern by the intent to contradict:  

II.A.8. Shows criticism-general (Crit)     

1.  Any indication of disapproval, complaint, rejection, coolness, or disbelief directed toward another not involved in the exchange.  Includes statements that contradict or refute something said by another, or imply disagreement with or rejection of another's hypotheses, ideas or opinions:         

                                  

2.  Sarcasm: 

                                

3.  Defensive statements:     

II.A.9. Shows agreement or understanding (Agree)

1.  Included in this category are signs of agreement or understanding:

                                                                                       2.  Includes conceding a point, social amenities and apologies that do not indicate particular concerns for the other's feelings (see description of Concern/Worry statements for more expansive apologies):

                                                                                      3.  Includes agreements phrased negatively:       

                                        

II.A.10. Back-channel response (Physician category) (BC)

1.  Indicators of sustained interest, attentive listening or encouragement emitted by the doctor when he or she does not hold the speaking floor.

                              

These responses are differentiated from others in that they do not serve to "take the floor" from the speaker.  They are usually an almost inaudible "under-talk" that accompanies the patient's story or monologue, encouraging the speaker to continue talking or signifying the listener's continued interest in what the patient is saying.

(Note: If multiple back-channels occur during a single thought, the coder may need to ?catch up? by entering multiple, sequential back-channel codes--or back-channel and agreement codes if there is a change in floor--at the end of the speaker?s utterance.) 

Back-channel responses should be thought of as a sub-set of the larger Agreement category.  When in doubt, code as Agreement.

Note:  When the physician's "OK" or "Mm-huh" communicates "I've heard you," "I understand," or signifies receipt of an answer to a question and when the "OK" or "Mm-huh" is followed by a physician question or statement that serves to "take the floor" (even after a pause during which the patient had the opportunity to continue to talk)--the "OK" is coded as an Agreement.  When an "OK" serves to mark the conclusion of discussion of one topic and movement to another topic, the "OK" would be coded a Transition.  Similarly, "Yeah" may communicate information (and be coded Gives Information) or may serve to confirm the other's understanding (e.g., after a Check) and therefore should be coded an Agreement.

II.A.11. Empathy statements (Empathy)

1.  Statements that paraphrase, interpret, name or recognize the emotional state of the other person present during the visit.

II.A.12. Legitimizing statements (Legit)     

1.  Statements that indicate that the other's emotional situation, actions, or thoughts are understandable and normal.

                                                                                    These statements indicate that it is understandable why the other feels or thinks a certain way, and not merely that they feel or think this way.          

2.  Statements that normalize the other's actions, emotions or thoughts by making them universal.

II.A.13. Partnership statements (Physician category) (Partner) 

1.  Statements that convey the physician's alliance with the patient in terms of help and support, decision-making, or the development of the therapeutic plan.

II.A.14. Self-disclosure statements (Physician category) (SDis)   

1.  Statements that describe the physician's personal experiences in areas that have medical and/or emotional relevance for the patient.  Self-disclosure statements are distinguished from Personal remarks in that Personal talk is generally characterized as friendly conversation or social "chit-chat," whereas Self-disclosure statements are a reflection of the physician's own life experiences that may be shared by, or have significance for, other people.  Self-disclosure is the revealing of a non-public personal component.    

II.A.15. Asks for reassurance (?Reassure)

1.  Questions of concern that convey the need or desire to be reassured or encouraged.  Voice tone, intonation and emotional content may be of significance when distinguishing questions that ask for reassurance from other questions.

                                                                                        2.  Includes demonstration of concern in question form, during exam or procedure, when the speaker is asking for reassurance that it is alright to continue:     

II.B. Task-Focused Exchange

II.B.1. Transition words (Trans)

1.  Sentence fragments that indicate movement to another topic or area of discussion, train of thought or action.  Includes statements or fragments that are place-holders, if the utterance stands alone and is separated from other utterances by a pause of one second or more:

                                                                                      2.  If the pause between a transition and a more substantial utterance is less than one second, the transition is superseded by the second utterance (this rule pertains only to transitions):

II.B.2. Gives orientation, instructions (Orient)    

1.  Orientation statements tell the other person what is about to happen, what is expected during the interview or exam, or serve to orient the other to the major topics of discussion or the physical flow of the visit.  The purpose of these statements is to guide the other person (usually the patient) in terms of what to expect during the visit.  This is basically a narrow category of statements that serves to direct the other's behavior and facilitate the process of the visit.  In other words, Orientation statements are mechanisms that help the other to cooperate, thus moving the visit on.   

                                                                                     2.  Instruction statements include those directive statements or instructions relating to the exam or clinic visit, including those phrased in the imperative form.  These statements are often used to facilitate progress through the visit.  Includes statements relating to procedural or administrative aspects of the visit:

                                                                                      3.  When in doubt about the informative quality of an utterance, a more substantial category takes priority:

II.B.3. Paraphrase/checks for understanding, accuracy, confirmation, clarification (Check)    

1.  Mechanisms by which the speaker re-states or reflects back information he or she has just been told by the other for the purpose of checking for accuracy of information, or for confirming a shared understanding of the facts or issues being discussed.  These re-statements may be in either question or statement form, but the function of the speaker's utterance is to clarify, or ask for clarification of, the other's communication (i.e., in essence asking, "Do I understand what you are saying?" "Do I have it right?" or "Am I on the right track?").       

                                                                                       2.  Includes paraphrases or repetitions of the other's communication in either declarative or interrogative form:    

                                                                                        3.  Includes re-statements that label a contextual fact the other has expressed but did not explicitly label, feeds back the essence of a verbal message, or finishes the other?s statement to confirm a shared understanding:

                                                                                      This use of a check (to finish another?s statement) may allow the other party to correct the understanding, or disagree. 

                                                                                      4.  Includes re-statements of information given by the other person earlier in the visit, when there is reference to the earlier statement: 

                                                                                      5.  Includes statements made during chart review that are a clear review of common knowledge.  In these situations, the review is of obviously shared information and does not include any new information.  If in doubt, the statement should be coded in the appropriate Gives Information category.

                                                                                      6.  A dictation at the end of a visit is not considered a Check, even if the patient has heard most of the information during the visit.  In this case, it is considered a reinforcement of what already has been said, and is coded in the appropriate Gives Information category.      

II.B.4. Asks for understanding (?Understand)        

1.  Mechanism by which the doctor or patient quickly checks with the other to see if information that was just said has been followed or understood (i.e., in essence asking, "Do you understand what I'm saying?").  Includes asking for agreement: 

II.B.5. Bid for repetition (?Bid)                 

1.  Mechanism for requesting repetition of the other's previous statement.  Bids are used when words or statements have not been clearly heard, and therefore need repetition, and are often signs of perceptual difficulties.  They follow right after or shortly after the statement needing repetition.    

II.B.6. Asks for opinion (Physician category) (?Opinion)

1.  Questions that ask for the patient's opinion, point of view or perspective relating to diagnosis, treatment, etiology, prevention or prognosis. Includes questions that invite the patient's judgment, or ask for the patient's preferences (what the patient wants or would like), expectations, or survey of the problem.

                                                                                        2.  Includes these very broad probes for information or questions:        

II.B.7. Asks for permission (Physician category) (?Permission) 

1.  Questions that specifically ask for permission to give information or to proceed:

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