***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Active participation in the medical consultation has been demonstrated to benefit aspects of patients ’ subsequent psychological well-being . We investigated two interventions promoting patient question -asking behaviour . The first was a question prompt sheet provided before the consultation , which was endorsed and worked through by the clinician . The second was a face to face coaching session exploring the benefits of , and barriers to , question -asking , followed by coaching in question -asking behaviour employing rehearsal techniques .  Sixty patients with heterogeneous cancers , seeing two medical oncologists for the first time , were r and omly assigned to one of three groups : two intervention groups and one control group .  Sociodemographic variables and anxiety were assessed prior to the intervention which preceded the consultation . The consultations were audiotaped and subsequently analysed for question -asking behaviour . Anxiety was assessed again immediately following the consultation . Question naires to assess patient satisfaction , anxiety and psychological adjustment were sent by mail 2 weeks following the consultation . Presentation and discussion of the prompt sheet significantly increased the total number of questions asked and the number of questions asked regarding tests and treatment . Coaching did not add significantly to the effects of the prompt sheet . Psychological outcomes were not different among the groups . We conclude that a question prompt sheet addressed by the doctor is a simple , inexpensive and effective means of promoting patient question asking in the cancer consultation The efficacy of a communication skills training programme was shown through a r and omised trial . Oncologists ( N=160 ) from 34 cancer centres were allocated to written feedback plus course ; course alone ; written feedback alone or control .  Each clinician had 6 – 10 interviews  with patients videotaped at baseline and 3 months postintervention . Analysis of videotapes revealed improvements in the communication skills of clinicians r and omised to training ( n=80 ) compared with others ( n=80 ) . A 12-month follow-up assessment is reported here . Robust Poisson conditional analyses of counts of changes in communication behaviours revealed no demonstrable attrition in those who had shown improvement previously , including fewer leading questions , appropriate use of focused and open-ended questions and responses to patient cues . Additional skills , not apparent at 3 months , were now evident ; the estimated effect sizes corresponded to 81 % fewer interruptions ( P=0.001 ) and increased summarising of information to 38 % ( P=0.038 ) . However , expressions of empathy ( 54 % , P=0.001 ) declined . The overall results show that 12 – 15 months postintervention , clinicians had integrated key communication skills into clinical practice and were applying others . This is the first RCT to show an enduring effect of communication skills training with transfer into the clinic Objective To determine if a self-administered previsit question naire design ed to increase awareness of patients ’ concerns alters the visit duration , content of the discussion , and patient and physician satisfaction . Design A balanced , two-arm trial in which physicians were r and omized . Setting Two primary -care clinics affiliated , with a university hospital . Patients / Participants Ten physicians and 201 continuitycare patients . Interventions In intervention visits , patients completed a previsit question naire asking about the desire for medical information , psychosocial assistance , therapeutic listening , general health advice , and biomedical treatment . Physicians review ed question naires with patients during the visit . Measurements and main results We used audiotapes of encounters to quantify the duration of the encounter and measured the number and type of diagnoses discussed in the visit , and patient and physician satisfaction with the encounter . Intervention visits were 34 % longer ( increase of 6.8 minutes ; 95 % confidence interval , [ CI ] 0.4 , 13.2 ) than control visits with most of the additional time spent in discussion of biomedical diagnoses ( 3.35 minutes ; 95 % CI 0.00 , 6.72 ) and in the performance of the physical examination ( 2.7 minutes ; 95 % CI 0.5 4.9 ) . The number of diagnoses discussed per visit was 30 % higher in intervention visits ( increase of 1.7 diagnoses per visit ; 95 % CI 0.3 , 3.2 ) , but patients ’ satisfaction with these visits tended to be lower . Conclusions Using a previsit question naire to increase awareness of the patients ’ concerns may entail a trade-off between conflicting goals : trying to respond to patient concerns while not significantly increasing the cost per visit . A future challenge is to develop and refine techniques with sufficient efficacy to justify the expense of implementing the intervention and the longer visit needed to respond adequately to patients ’ concerns Abstract Purpose : To evaluate and compare the effects of two types of continuing medical education ( CME ) programs on the communication skills of practicing primary care physicians . Participants : Fifty-three community-based general internists and family practitioners practicing in the Portl and , Oregon , metropolitan area and 473 of their patients . Method : For the short program ( a 4 1/2-hour workshop ) , 31 physicians were r and omized to either the intervention or the control group . In the long program ( a 2 1/2-day course ) , 20 physicians participated with no r and omization . A research assistant visited all physicians ’ offices both one month before and one month after the CME program and audiotaped five sequential visits each time . Data were based on analysis of the content and the affect of the interviews , using the Roter Interactional Analysis Scheme . Results : Based on both t-test analysis and analysis of covariance , no effect on communication was evident from the short program . The physicians enrolled in the long program asked more open-ended questions , more frequently asked patients ’ opinions , and gave more biomedical information than did the physicians in the short program . Patients of the physicians who attended the long program tended to disclose more biomedical and psychosocial information to their physicians . In addition , there was a decrease in negative affect for both patient and physician , and patients tended to demonstrate fewer signs of outward distress during the visit . Conclusion : This study demonstrates some potentially important changes in physicians ’ and patients ’ communication after a 2 1/2-day CME program . The changes demonstrated in both content and affect may have important influences on both biologic outcome and physician and patient satisfaction In a competitive health care environment , clinicians and health plans are eager to achieve the highest quality of care and the highest levels of patient satisfaction . Studies consistently show that effective communication between clinicians and patients is a critical determinant of patient satisfaction ( 1 - 7 ) . To improve patient satisfaction , many organizations provide communication skills training programs for clinicians  . These programs usually include 4 to 8 hours of instruction and are held during regular office hours ( 8 - 12 ) . Because clinicians may need to be relieved from clinical responsibilities to attend , such programs can be expensive for both the clinicians and their organizations . Despite the substantial time and money invested in these programs , little rigorous research has been done to test their actual effect on patient satisfaction ( 11 , 13 ) . Some studies have measured clinicians ' self-ratings of their communication skills or have included an observation of a small number of visits ( 8 , 12 , 14 - 16 ) . Studies of oncologists have shown improvement in such targeted communication skills as breaking bad news ( 17 , 18 ) , but two recent r and omized trials that involved primary care physicians had conflicting results ( 10 , 19 ) . No r and omized trial has tested the effectiveness of a communication skills program delivered to clinicians of diverse specialties , and no study has directly assessed a program 's actual effect on patient satisfaction ( an outcome of great interest to health care users and sponsors ) . As communication programs proliferate , it is essential to critically evaluate whether they are a worthwhile investment of time and re sources for clinicians and their organizations . We performed a r and omized , controlled trial of a 10-hour communication skills program in a sample of primary care and specialty clinicians . We tested the effect of the program on patients ' satisfaction with providers ' communication during office visits.\E Methods Setting and Intervention The study setting was Kaiser Permanente Northwest Division , a 50-year-old , not-for-profit group-model health maintenance organization ( HMO ) with approximately 420 000 members located in and around Portl and , Oregon . The continuing medical education ( CME ) program we evaluated , titled Thriving in a Busy Practice : Physician-Patient Communication , was developed during numerous sessions with more than 1500 clinicians . Several Kaiser Permanente divisions participated in the program 's development , and the program was popular among clinicians . The program consisted of an initial 4-hour group workshop , 2 hours of subsequent homework , and a 4-hour follow-up workshop . The first workshop focused on skills for building effective relationships with patients , including listening actively ; responding to patients ' feelings ; and communicating concern , underst and ing , and respect . The second workshop focused on skills for successful negotiation , particularly in situations of disagreement ( for example , when a patient requests narcotics for chronic pain and the clinician does not think a prescription is appropriate ) . During a 1-month interval between the two workshops , the clinicians were asked to audiotape a minimum of two of their office visits and listen to the recordings . In addition , an instructor called participants during the interval to inquire about the skills they were trying , to ask whether they had questions , and to encourage them to complete the audiotaping . Both workshops were given by two physicians who were experienced teachers and experts in clinician-patient communication . The program was design ed to incorporate educational elements that had effectively changed clinician performance in other CME programs . The workshops included brief didactic components that were related to clinical needs and role-playing that allowed clinicians to practice communication skills while focusing on situations that they found challenging and relevant ( 20 , 21 ) . Instructors taught interactively , encouraging dialogue with and among participants . Recruitment and R and omization All of the approximately 1000 clinicians who belonged to or were employed by the Permanente Medical Group of the Northwest were eligible to participate . To maximize the external validity of the study , the HMO 's CME office advertised the program and managed the initial recruitment of clinicians by using its regular methods and channels . In addition , clinician leaders encouraged enrollment by direct communication with potential participants and by e-mail . The recruitment messages explained the r and omized trial and offered clinicians equal chances to participate immediately or to participate in a later session of the program . The clinicians who were r and omly assigned to the later session provided our control group . The Figure summarizes the flow of recruitment and r and omization . After clinicians notified the CME department of their interest in the course , we sent them an informed consent form and a self- assessment question naire . When the clinician returned the signed informed consent form , we assigned him or her to one of 16 strata on the basis of sex ( male or female ) , specialty ( primary care , medical specialty , surgical specialty , or allied health ) , and previous mean score ( higher or lower than average ) on the overall satisfaction item from the Art of Medicine survey ( HealthCare Research , Inc. , Denver , Colorado ) , which had been used by the HMO during two 6-month periods before our study took place . Mean scores before the study ranged from 6.84 to 8.91 , with a mean and median of 7.92 ; an SD of 0.47 ; and a quartile distribution of 7.56 , 7.92 , 8.28 , and 8.91 . Figure . Recruitment and r and omization . On a weekly basis , as clinicians registered , we r and omly assigned groups to attend immediate or later sessions of the program . In each stratum , we used a r and om-number table to assign persons to the intervention or control group . We started with the lowest r and om number and alternated assignment in order of ascending r and om number . The study was review ed and approved by the Kaiser Permanente Committee for the Protection of Human Subjects . Measurements Our primary experimental measure was the mean difference in score ( before and after participation in the training program ) on a scale that assessed patients ' ratings of clinicians ' communication skills . We obtained these ratings from the Art of Medicine survey , an anonymous question naire that was mailed to patients by a contractor to the HMO within 10 days after patients had participated in a r and omly selected ambulatory medical care visit . The survey was design ed to obtain 100 completed question naires for each clinician during a 6-month period . We used data from three 6-month survey periods : the last half of 1995 and the first and last halves of 1996 . The Art of Medicine survey elicited ratings on seven aspects of a clinician 's communication behavior or the patient 's reaction to it during a specified ambulatory encounter . In addition , the survey asked patients to rate their overall satisfaction with the service they received from the clinician . A complete list of the survey items is provided in the Appendix Figure . Although the Art of Medicine survey was not chosen by the research teamwe took advantage of the ongoing administration of this survey to conduct our study the items in the survey are similar in content to those in other reliable , vali date d , and widely used clinical communication scales , such as the Patient Satisfaction Question naire ( which was developed by the American Board of Internal Medicine ) ( 22 ) . Appendix Figure . The Art of Medicine survey . Communication skills are the most important determinant of patient satisfaction with care ( 23 - 25 ) , and satisfaction with care is the primary determinant of personal decisions to use health plans and hospitals ( 26 , 27 ) . Communication and satisfaction scales , such as the Art of Medicine survey , have been shown to be correlated with observed and experimentally manipulated differences in communication performance ( 28 ) . Satisfaction with patient-clinician communication also improves adherence to treatment ( 29 , 30 ) and decreases the risk for mal practice lawsuits ( 31 ) . In addition , health plans and clinicians institute or attend communication skills programs mostly to improve scores on such measures as the Art of Medicine survey , in part because they are obligated to determine such scores and make them publicly available to patients ( 32 ) . We prospect ively defined the change in the mean value of all eight survey items as our primary outcome measure . We adopted this approach for several reasons . First , the eight items were highly correlated ( Spearman correlation , 0.69 to 0.84 ) . Second , the mean of the first seven communication items was highly correlated with the overall satisfaction item ( Spearman correlation , 0.92 ) . Third , the Cronbach statistic 
    Output:
    
Intervention physicians were more likely than controls to receive higher ratings of their overall communication style and to exhibit specific patient-centered communication behaviors .
Intervention patients obtained more information from physicians and exhibited greater involvement during the visit than controls .
Conclusions : The interventions were associated with improved physician and patient communication behaviors .