Relations between verbal behavior of the orthodontist and communicative cooperation of the patient in regular orthodontic visits U. Klages, PhD, H. G. Sergl, DMD, and I. Burucker, Cand. phil. Mainz, FederalRepublic of German), A study of interrelationships between orthodontist and patient communication characteristics on the basis of audiotape recordings is reported. The subjects were 66 patients from an orthodontic outpatient clinic who were treated by seven orthodontists. Strong relationships (partial correlations) were found between clinicians encouraging behavior (listener signals and symmetrical answering) and patient communicative cooperation (speech volume, detailed answering, questions, initiatives); whereas orthodontists guiding behavior showed lower correlations, only the clinicians' direct questions were significantly related to patient participation. For communication content, relations to patient activity depended on how strongly orthodontists discussed social or therapy topics. Discussion characteristics of both parties were not related to the patient's age, sex, and duration of therapy. However, patient communication differed with the personality of the dentist. Results are discussed with reference to literature, orthodontic consulting practice, and future research. (AM J ORTHOD DENTOFACORTHOP 1992;102:265-9.)
T h e success of an orthodontist's efforts depends on patient-cooperation, which has at least two facets of following instructions at home t and showing cooperative communication behavior in the orthodontist's office. In our study, we deal with the aspect of communicative cooperation. Miller and Larson 2 described the problem: Adolescent patients can be very uncommunicative and may not answer properly when confronted with an authority, who they often perceive an orthodontist to be. Sarnat et al. 3 defined cooperative behavior patterns of children in restorative dental treatment. The ideal patient offers information, initiates light conversation, and gives positive responses. A prerequisite to good advice, which has the opportunity of being followed, is sufficient knowledge of the patient's personal conditions by the dentist, 4 and the degree of dental sophistication and interest by the patient. 5 Patient comnuuzicative cooperation. The cooperative patient takes an active part in communication. This is expressed in the volume of his speech or in the number of sentences he used during a visit. Another aspect is whether he answered in detail the orthodontist's questions. A linguistic criterion is the number of complete sentence answers. On the other hand, activity is shown by the patient by asking questions. ~ If a matter is o f special interest for him, he does not wait until the orthodontist brings up this topic but takes the initiative arid
811134328
changes the subject (category: number of initiatives). 7 Orthodontist encouraghzg behavior. Among all counseling behaviors, two basic skills can be identified: encouraging (interpersonal oriented) and guiding (task oriented) behaviors. 8 To obtain information, the clinician tries to initiate conversation with the patient. As the listener, he uses listener signals to acknowledge the patient as the speaker. These signals include nonlexical expressions like "hmm," briefly restating one or two words, or sentence completion. 9 By responding in detail to the patients' questions, the clinician encourages activity and interest of the patient. SiegrisP ~ calls this reaction style of clinicians "symmetrical answering." It is opposed to answering modes such as vagueness, postponing, change of addressee, and nonanswers, which are reported to be found often in round discussions. ~~ A more complex behavior for encouragement is called paraphrash~gH and involves restating the patient's remarks in the clinician's own words. This encourages the patient to clarify his ideas and observations. Orthodontist guidance behavior. Besides acknowledging the patient's ideas and observations, the orthodontist should guide the conversation to obtain information he needs. With this method, the patient learns what the intentions of the orthodontist are. One method of guidance is asking questions. They can be formulated in two ways, as more closed (dichotomous) or more open (e.g., direct) questions. Dichotomous questions restrict the patient in his 265
266
Klages, Sergl, attd Burttcker
answers to "yes" or "no," e.g., "Did you wear your appliances?" Whereas direct (why, what, when) questions require more lengthy answers, 7 e.g., "When did you wear your appliances?" When a patient's response drifts in an undesired direction, the clinician can take the initiative by changing the subject. This is the strongest form of influence on the flow of conversation. In his role as a speaker, the orthodontist can assure that the patient is still attentive by speaker signals ("isn't it," "don't you"). He reestablishes contact by directly addressing the patient. 9 Discussion themes. Two general topics in communication content of interest are therapeutic matters (the "official" reason for the visit) and social exchange. Discussing social themes encourages good rapport. 6 Personal characteristics. It has been observed that orthodontists can have different and stable communication styles with their patients. 'Z These styles are dependent only on the personality of the orthodontists. On the patient side, therapy duration, sex, and age might influence the communication behavior of both. t.3 An initial approach for identifying beneficial orthodontist behavior is the study of correlations between the discussion features of the orthodontist and the communicative cooperation of the patient as measured by audiotaped transcripts of orthodontic visits. The present study attempted to identify the relationship of encouraging and guiding behaviors, as well as discussion topic preference of the clinician as related to patient communicative cooperation behavior in regular orthodontic visits. The second topic is concerned with the question of how orthodontists differ in their communication skills and how communication varies with the patient's gender, age, and therapy duration. MATERIAL AND METHODS
Sixty-six patient-orthodontist routine contacts from the university outpatient orthodontic clinic in Mainz were recorded with a wireless microphone and stored on tape. Patients had agreed to their participation and were aware of the recording. Participants reported they were not stressed by the fact of audiotaped observation and had behaved in the usual manner. Thirty-four patients were boys, and 32 were girls. Theirages were 8 to 17 years (mean = 13.8 years; SD = 2.4 years). Mean therapy duration at this time was 3.0 years (SD = 1.8 years). Three orthodontists were men, and four were women. In 46 therapy contacts, the orthodontist was a woman, 20 patients had a male orthodontist. The audiotape recordings were transcribed. Coding-rules were derived from three sources, the Uhn Manual for the Evahtation of Round Discussion. ~ Duncan and Fiske's 9 definitions for listener- and speaker-signals, and a classification
Am. J. Orthod. Dentofac. Orthop. September 1992
system for counseling skills by Hill et al." Five psychology students completed a training course for using the instruction leaflet with discussion transcripts, which were not included in the study. For statistical analyses, only those communication characteristics that had a sufficient frequency in all discussions were considered. Reliabilities between different coders were between r = 0.71 (symmetrical answering) and r = 0.96 (speech quantity of orthodontist). RESULTS
The number of sentences used by the orthodontists and patients during a visit had a correlation of r = 0.56. To investigate relationships between the communication characteristics of both parties, this influence should be eliminated as much as possible. Therefore partial correlations were calculated with the speech quantity of the orthodontist as a control variable. Table I shows the results of partial correlation analyses between the orthodontist's encouraging behavior and the patient's participation in discussions. Listener signals of the clinicians correlated with all four patient discussion activities at a level of p < 0.001 from r = 0.36 (questions) to r = 0.53 (number of sentences). The orthodontists' symmetrical (comprehensive) answering showed significant relations to speech quantity, initiative, and detailed answering of the patient (all minimally p < 0.01). The correlation to patient questions is not calculated because both variables are not independent. The more the clinician paraphrases, the more the patient answers in detail (p < 0.05), but the less he asks questions (p < 0.01). Partial correlations o f orthodontist guiding behavior to patient verbal activity are shown in Table II. Direct questions correlate positively with the patient's speech quantity, initiatives, and complete answers (p < 0.01 o r p < 0.05, respectively), whereas dichotomous questions show no significant relations to the patient's communication behavior. The same is true for speaker signals. Orthodontists who change the subject do not seem to enhance patient activity and are negatively related (r = - 0 . 4 5 , p < 0.001) to asking questions. Table III demonstrates that for an orthodontist who likes to talk about social matters, patients use more sentences (r = 0.53, p < 0.001), answer in more detail (r = 0.38, p < 0.001), and take the initiative to change the subject more often (r = 0.33, p < 0.01). Relations in the opposite direction were found for orthodontists stressing therapeutic themes: To them, patients spoke significantly fewer sentences (r = - 0 . 4 0 , p < 0.001) and answered in less detail (r = - 0 . 2 6 , p < 0.05). The effects of orthodontist and patient personality characteristics on communication behavior were studied in one-way analyses of covariance. Factors were
Vo/umet02 Number 3
Communications in orthodontics
267
Table I. Partial correlations between orthodontist encouraging behaviors and patient
communicative cooperation
Patient Orthodontist
Sentences
Listener signals Paraphrases S y m m e t r i c a l answers
0.53*** 0.13 0.39***
I
Questions
I
Initiatives
0.36*** - 0.30'* --
I
0.39*** 0.09 0.29**
Completeanswers 0.52*** 0.21 * 0.39***
*p < 0 . 0 5 . **p < 0 . 0 1 . ***p < 0 . 0 0 1 .
Table II. Partial correlation between orthodontist's guiding behaviors and patient
communicative cooperation
Patient Orthodontist
Sentetzces
S p e a k e r signals Direct questions D i c h o t o m o u s questions Initiatives
0.05 0.29** 0.10 - 0. l 0
[
Questions
l
0.00 0.05 0.06 - 0.45***
lnitiatives 0.05 0 . 2 !* 0.20 - O. 11
l
Completeanswers - 0.06 0.28* 0.13 - 0.13
*p < 0 , 0 5 . **p < 0 . 0 1 . ***p < 0 . 0 0 1 .
Table III. Partial correlations between number of sentences spoken on social or therapy themes and patient
communicative cooperation
Patient Orthodontist
Sentences
Social themes T h e r a p y themes
0.53*** - 0.40"**
I
Questions
I
0.01 - 0.03
Initiatives
Complete answers
0.03** - 0.06
0.38*** - 0.26*
*p < 0 . 0 5 . **p < 0 . 0 1 . ***p < 0 . 0 0 1 .
patient's sex, and covariates were the age of the patient and the therapy duration. In none of the 11 analyses, neither age, sex, nor therapy duration had a significant influence on discussion features of either the orthodontist or the patient. To investigate whether the orthodontist as a person shows stable communication patterns, one-way analyses of variance with the seven orthodontists as a factor were performed. They differed significantly in asking dichotomous questions (F = 4.0, p < 0.01) and in using listener signals (F = 3.4, p < 0.01). Patients behaved differently toward the orthodontists in the quantity of sentences spoken (F = 3.7, p < 0.01), in questioning (F = 2.5,
p < 0.05), and in initiating subject change (F = 2.4, p < 0.05). DISCUSSION
In our study, we found statistically significant relationships between orthodontist-patient verbal behaviors. As a correlational approach has been used, causeeffect interpretations can only be proposed with necessary caution. Because of the complementary character of the counseling situation, the patient expects an expert to lead him, help him, encourage him, ~3 it can be assumed that counselor behavior determines client verbal production to a higher degree than vice versa. Our find-
268
Klages, Sergl, and Burucker
ing that orthodontists have stable discussion features on various visits, whereas patients react to the personality and the sex of the orthodontist in different ways, underscores this observation. Another point is that orthodontists are more active than patients. By this, they set more stimuli for discussion than their patients. The correlational analyses demonstrated strong associations of the encouraging orthodontist behaviors (listener signals and symmetrical answering) to patient participation (measured by speech quantity, questioning, initiatives for topic change, and length of answers). In the same way, Elliot8 found that reassuring and understanding behaviors had the strongest relation to the interpersonal aspect of communication. The art of listening is described by Baker. '4 He contends that listening is not a nonbehavior but is an active reassurance of understanding. In a longitudinal analysis of changes in counseling skills, Hill et al. ~5 found that students increased their use of minimal encouragers (like "yes," "good," or one word restating). Thus a skill that is used in everyday communication might be a powerful tool in consultation. The second finding that symmetrical or comprehensive answering is associated with patient compliance demonstrates that respect for the patient and serving as a model for patient answering might facilitate discussion.'~ Correlations of paraphrases were differential. To paraphrasing clinicians, patients gave complete answers and, somewhat surprisingly, less questions. This may be due to an interpretation that restating directs the orientation to one's self. According to Hill et al., ~6 paraphrasing is one of the most helpful response modes in psychotherapy. Effects should be studied in examining patient satisfaction and orthodontic cooperation. Among the guiding behaviors, the use of speaker signals and dichotomous questioning showed no relation to patient communication. Speaker signals assure the communicator that his partner is listening. Therefore they may be neither activity enhancing nor suppressing. They might be related to other criteria, e.g.~ recall of information. Yes-no questions give the speaking turn to patients, but they allow little room for verbal productivity. They are suitable for the working context of appliance comfort or discomfort (e.g., "does it hurt?") and have no influence on the interaction. Topic changes have a strong negative relation to patient questions. The orthodontists in our study performed 15 changes during a visit. When too'mhh~"initiatives are presented, the patient could be confused about structure and intention of the conversation and loses curiousity and interest in the questioning.
Am. J. Orthod. Dentofac. Orthop. September 1992
The only leading behavior with positive relations to patient participation is asking direct questions. According to Elliot, s direct questions contribute significantly to the task-oriented helping behavior cluster. Detailed questions stimulate cognitive searching processes and help concretize matters, e.g., "When did you wear your appliances last week?" The orthodontist can thus develop a detailed picture of a situation. Concerning the content of communication, we found the patients were more active (sentences, initiatives, detailed answers) the more the orthodontist discussed social themes and were less active (sentences, answering) the more the orthodontist talked about therapy. This underscores the facilitative character of social conversation. 6 On social topics, patients feel relatively free in their participation, whereas on therapy topics they might not feel competent and restrict their activity. As Bain 6 reports, social exchange is an expression of good relationships between clinician and patient and enhances information recalled during visits. ~7 According to our study of personality characteristics relating to communication, orthodontists do not vary their behavior toward patients with the difference in age, treatment duration, and sex of patients. But between them, they differ in two of seven discussion features (closed questions, listener signals). These results are in line with findings by Getz et al. 12who report that dentists showed stable behavior patterns across a series of children and treatment sessions. On the other hand, adolescents varied in their behavior when confronted with different orthodontists (speech quantity, questioning initiatives). It might be concluded that they react more strongly to the orthodontist than demonstrating their own personal behavioral tendencies. As previously noted, our study did not examine causal relationships. However, the results are hypotheses indicating which orthodontist behaviors might be of relevance for patient verbal cooperation in the office. A future study, including a training program for orthodontists, could help to clarify what specific changes in their behavior could effect changes in patient verbal cooperation. REFERENCES
1. GabrielHF. Motivationof the headgear-patient.Angle Orthod 1968;38:129-35. 2. MillerE, LarsonLL. A theoryof psycho-orthodonticswith practical applicationto officetechniques.AngleOrthod 1979;49:8591. 3. SarnatH, PeriJN, NitzanE, PerlbergA. Factorswhichinfluence cooperationbetweendentist and child. J Dent Educ 1972;36:915. 4. Eijkman MAJ, Karsdorp NE, BoekeB, Karsdorp-Bimmerman EHLM. Experiencewith a trainingcoursein patientcounseling. J Dent Educ 1977;41:623-5. 5. O'Shea RM, Corah NL, AyerWA. Dentists' perceptionsof the
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Communications in orthodontics
Number 3
6. 7.
8.
9. 10.
1I.
12.
'good' adult patient: an exploratory study. J Am Dent Assoc 1983;106:813-6. Bain DJG. Doctor-patient communicationin general practice consultations. Med Educ 1976;125-31. RacherbfiumerJ, Westphale C,.KagelmannJ, SimonsC, K6hle K, Bfck D, Urban H. Manual zur informationsanalyse.Ulm: Psychosomatische Abteilungder Universit~tsklinikUlm, 1979. Elliot R. Helpful and nonhelpfulevents in brief counselinginterviews: an empirical taxonomy. J Couns Psychol 1985;30722. Duncan S, Fiske DW. Face-to-face interaction:research, methods, and theory. New York: J Wiley, 1977. SiegristJ. Asymmetrisehekommunikationbei klinischenvisiten. In: K6hle K, Raspe HH, eds. Das gespr/ich wfihrend der firztlichen visite. Miinchen: Urban und Schwarzenberg, 1982: pp. 16-22. ElliotR, Stile WB, Maher AR, Hill CE, FriedlanderNIL, Margison FR. Primary therapist response mode: comparisonof six rating systems. J Consult Clin Psychol 1987;55:218-33. Getz T, Weinstein P, Demoto P. Intradentist behavioral variability across children and appointments. J Pedodont 1984;16571.
269
13. Hayley J. Strategies of psychotherapy. New York: Grune and Stratton, 1963. 14. Baker EE. Are you listening, doctor. New York J Dent 1984;54:201-2. 15. HillCE, CharlesD, Reed KG. A longitudinalanalysisofchanges in counselingskills during doctoral training in counselingpsychology. J Couns Psychol 1981;28:428-36. 16. Hill CE, Helms JE, Tichener V, Spiegel S, O'Grady KE, Perry ES. Effects of therapist response modes in brief psychotherapy. J Courts Psychol 1988;35:222-33. 17. Bain DJG. Patient knowledgeand contact of the consultationin general practice. Med Educ 1977;I1:347-50. Reprint requests to: Dr. Ulrich Klages Poliklinikftir Kieferorthopaedie der UniversitaetMainz Augustusplatz2 6500 Mainz, Federal Republicof Germany
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the AMERICAN JOURNAL OF ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS are available tO subscribers (only) for the 1992 issues from the Publisher, at a cost of $53.00 ($67.71 Canada and $64.00 international) for Vol. 101 (January-June) and Vol. 102 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact M o s b y - Y e a r Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-33!8, USA; telephone (314)453-4351 or (800)325-4177. S u b s c r i p t i o n s m u s t be in force to qualify. B o u n d volumes are not available in place of a r e g u l a r J o u r n a l s u b s c r i p t i o n .
T h e success of an orthodontist's efforts depends on patient-cooperation, which has at least two facets of following instructions at home t and showing cooperative communication behavior in the orthodontist's office. In our study, we deal with the aspect of communicative cooperation. Miller and Larson 2 described the problem: Adolescent patients can be very uncommunicative and may not answer properly when confronted with an authority, who they often perceive an orthodontist to be. Sarnat et al. 3 defined cooperative behavior patterns of children in restorative dental treatment. The ideal patient offers information, initiates light conversation, and gives positive responses. A prerequisite to good advice, which has the opportunity of being followed, is sufficient knowledge of the patient's personal conditions by the dentist, 4 and the degree of dental sophistication and interest by the patient. 5 Patient comnuuzicative cooperation. The cooperative patient takes an active part in communication. This is expressed in the volume of his speech or in the number of sentences he used during a visit. Another aspect is whether he answered in detail the orthodontist's questions. A linguistic criterion is the number of complete sentence answers. On the other hand, activity is shown by the patient by asking questions. ~ If a matter is o f special interest for him, he does not wait until the orthodontist brings up this topic but takes the initiative arid
811134328
changes the subject (category: number of initiatives). 7 Orthodontist encouraghzg behavior. Among all counseling behaviors, two basic skills can be identified: encouraging (interpersonal oriented) and guiding (task oriented) behaviors. 8 To obtain information, the clinician tries to initiate conversation with the patient. As the listener, he uses listener signals to acknowledge the patient as the speaker. These signals include nonlexical expressions like "hmm," briefly restating one or two words, or sentence completion. 9 By responding in detail to the patients' questions, the clinician encourages activity and interest of the patient. SiegrisP ~ calls this reaction style of clinicians "symmetrical answering." It is opposed to answering modes such as vagueness, postponing, change of addressee, and nonanswers, which are reported to be found often in round discussions. ~~ A more complex behavior for encouragement is called paraphrash~gH and involves restating the patient's remarks in the clinician's own words. This encourages the patient to clarify his ideas and observations. Orthodontist guidance behavior. Besides acknowledging the patient's ideas and observations, the orthodontist should guide the conversation to obtain information he needs. With this method, the patient learns what the intentions of the orthodontist are. One method of guidance is asking questions. They can be formulated in two ways, as more closed (dichotomous) or more open (e.g., direct) questions. Dichotomous questions restrict the patient in his 265
266
Klages, Sergl, attd Burttcker
answers to "yes" or "no," e.g., "Did you wear your appliances?" Whereas direct (why, what, when) questions require more lengthy answers, 7 e.g., "When did you wear your appliances?" When a patient's response drifts in an undesired direction, the clinician can take the initiative by changing the subject. This is the strongest form of influence on the flow of conversation. In his role as a speaker, the orthodontist can assure that the patient is still attentive by speaker signals ("isn't it," "don't you"). He reestablishes contact by directly addressing the patient. 9 Discussion themes. Two general topics in communication content of interest are therapeutic matters (the "official" reason for the visit) and social exchange. Discussing social themes encourages good rapport. 6 Personal characteristics. It has been observed that orthodontists can have different and stable communication styles with their patients. 'Z These styles are dependent only on the personality of the orthodontists. On the patient side, therapy duration, sex, and age might influence the communication behavior of both. t.3 An initial approach for identifying beneficial orthodontist behavior is the study of correlations between the discussion features of the orthodontist and the communicative cooperation of the patient as measured by audiotaped transcripts of orthodontic visits. The present study attempted to identify the relationship of encouraging and guiding behaviors, as well as discussion topic preference of the clinician as related to patient communicative cooperation behavior in regular orthodontic visits. The second topic is concerned with the question of how orthodontists differ in their communication skills and how communication varies with the patient's gender, age, and therapy duration. MATERIAL AND METHODS
Sixty-six patient-orthodontist routine contacts from the university outpatient orthodontic clinic in Mainz were recorded with a wireless microphone and stored on tape. Patients had agreed to their participation and were aware of the recording. Participants reported they were not stressed by the fact of audiotaped observation and had behaved in the usual manner. Thirty-four patients were boys, and 32 were girls. Theirages were 8 to 17 years (mean = 13.8 years; SD = 2.4 years). Mean therapy duration at this time was 3.0 years (SD = 1.8 years). Three orthodontists were men, and four were women. In 46 therapy contacts, the orthodontist was a woman, 20 patients had a male orthodontist. The audiotape recordings were transcribed. Coding-rules were derived from three sources, the Uhn Manual for the Evahtation of Round Discussion. ~ Duncan and Fiske's 9 definitions for listener- and speaker-signals, and a classification
Am. J. Orthod. Dentofac. Orthop. September 1992
system for counseling skills by Hill et al." Five psychology students completed a training course for using the instruction leaflet with discussion transcripts, which were not included in the study. For statistical analyses, only those communication characteristics that had a sufficient frequency in all discussions were considered. Reliabilities between different coders were between r = 0.71 (symmetrical answering) and r = 0.96 (speech quantity of orthodontist). RESULTS
The number of sentences used by the orthodontists and patients during a visit had a correlation of r = 0.56. To investigate relationships between the communication characteristics of both parties, this influence should be eliminated as much as possible. Therefore partial correlations were calculated with the speech quantity of the orthodontist as a control variable. Table I shows the results of partial correlation analyses between the orthodontist's encouraging behavior and the patient's participation in discussions. Listener signals of the clinicians correlated with all four patient discussion activities at a level of p < 0.001 from r = 0.36 (questions) to r = 0.53 (number of sentences). The orthodontists' symmetrical (comprehensive) answering showed significant relations to speech quantity, initiative, and detailed answering of the patient (all minimally p < 0.01). The correlation to patient questions is not calculated because both variables are not independent. The more the clinician paraphrases, the more the patient answers in detail (p < 0.05), but the less he asks questions (p < 0.01). Partial correlations o f orthodontist guiding behavior to patient verbal activity are shown in Table II. Direct questions correlate positively with the patient's speech quantity, initiatives, and complete answers (p < 0.01 o r p < 0.05, respectively), whereas dichotomous questions show no significant relations to the patient's communication behavior. The same is true for speaker signals. Orthodontists who change the subject do not seem to enhance patient activity and are negatively related (r = - 0 . 4 5 , p < 0.001) to asking questions. Table III demonstrates that for an orthodontist who likes to talk about social matters, patients use more sentences (r = 0.53, p < 0.001), answer in more detail (r = 0.38, p < 0.001), and take the initiative to change the subject more often (r = 0.33, p < 0.01). Relations in the opposite direction were found for orthodontists stressing therapeutic themes: To them, patients spoke significantly fewer sentences (r = - 0 . 4 0 , p < 0.001) and answered in less detail (r = - 0 . 2 6 , p < 0.05). The effects of orthodontist and patient personality characteristics on communication behavior were studied in one-way analyses of covariance. Factors were
Vo/umet02 Number 3
Communications in orthodontics
267
Table I. Partial correlations between orthodontist encouraging behaviors and patient
communicative cooperation
Patient Orthodontist
Sentences
Listener signals Paraphrases S y m m e t r i c a l answers
0.53*** 0.13 0.39***
I
Questions
I
Initiatives
0.36*** - 0.30'* --
I
0.39*** 0.09 0.29**
Completeanswers 0.52*** 0.21 * 0.39***
*p < 0 . 0 5 . **p < 0 . 0 1 . ***p < 0 . 0 0 1 .
Table II. Partial correlation between orthodontist's guiding behaviors and patient
communicative cooperation
Patient Orthodontist
Sentetzces
S p e a k e r signals Direct questions D i c h o t o m o u s questions Initiatives
0.05 0.29** 0.10 - 0. l 0
[
Questions
l
0.00 0.05 0.06 - 0.45***
lnitiatives 0.05 0 . 2 !* 0.20 - O. 11
l
Completeanswers - 0.06 0.28* 0.13 - 0.13
*p < 0 , 0 5 . **p < 0 . 0 1 . ***p < 0 . 0 0 1 .
Table III. Partial correlations between number of sentences spoken on social or therapy themes and patient
communicative cooperation
Patient Orthodontist
Sentences
Social themes T h e r a p y themes
0.53*** - 0.40"**
I
Questions
I
0.01 - 0.03
Initiatives
Complete answers
0.03** - 0.06
0.38*** - 0.26*
*p < 0 . 0 5 . **p < 0 . 0 1 . ***p < 0 . 0 0 1 .
patient's sex, and covariates were the age of the patient and the therapy duration. In none of the 11 analyses, neither age, sex, nor therapy duration had a significant influence on discussion features of either the orthodontist or the patient. To investigate whether the orthodontist as a person shows stable communication patterns, one-way analyses of variance with the seven orthodontists as a factor were performed. They differed significantly in asking dichotomous questions (F = 4.0, p < 0.01) and in using listener signals (F = 3.4, p < 0.01). Patients behaved differently toward the orthodontists in the quantity of sentences spoken (F = 3.7, p < 0.01), in questioning (F = 2.5,
p < 0.05), and in initiating subject change (F = 2.4, p < 0.05). DISCUSSION
In our study, we found statistically significant relationships between orthodontist-patient verbal behaviors. As a correlational approach has been used, causeeffect interpretations can only be proposed with necessary caution. Because of the complementary character of the counseling situation, the patient expects an expert to lead him, help him, encourage him, ~3 it can be assumed that counselor behavior determines client verbal production to a higher degree than vice versa. Our find-
268
Klages, Sergl, and Burucker
ing that orthodontists have stable discussion features on various visits, whereas patients react to the personality and the sex of the orthodontist in different ways, underscores this observation. Another point is that orthodontists are more active than patients. By this, they set more stimuli for discussion than their patients. The correlational analyses demonstrated strong associations of the encouraging orthodontist behaviors (listener signals and symmetrical answering) to patient participation (measured by speech quantity, questioning, initiatives for topic change, and length of answers). In the same way, Elliot8 found that reassuring and understanding behaviors had the strongest relation to the interpersonal aspect of communication. The art of listening is described by Baker. '4 He contends that listening is not a nonbehavior but is an active reassurance of understanding. In a longitudinal analysis of changes in counseling skills, Hill et al. ~5 found that students increased their use of minimal encouragers (like "yes," "good," or one word restating). Thus a skill that is used in everyday communication might be a powerful tool in consultation. The second finding that symmetrical or comprehensive answering is associated with patient compliance demonstrates that respect for the patient and serving as a model for patient answering might facilitate discussion.'~ Correlations of paraphrases were differential. To paraphrasing clinicians, patients gave complete answers and, somewhat surprisingly, less questions. This may be due to an interpretation that restating directs the orientation to one's self. According to Hill et al., ~6 paraphrasing is one of the most helpful response modes in psychotherapy. Effects should be studied in examining patient satisfaction and orthodontic cooperation. Among the guiding behaviors, the use of speaker signals and dichotomous questioning showed no relation to patient communication. Speaker signals assure the communicator that his partner is listening. Therefore they may be neither activity enhancing nor suppressing. They might be related to other criteria, e.g.~ recall of information. Yes-no questions give the speaking turn to patients, but they allow little room for verbal productivity. They are suitable for the working context of appliance comfort or discomfort (e.g., "does it hurt?") and have no influence on the interaction. Topic changes have a strong negative relation to patient questions. The orthodontists in our study performed 15 changes during a visit. When too'mhh~"initiatives are presented, the patient could be confused about structure and intention of the conversation and loses curiousity and interest in the questioning.
Am. J. Orthod. Dentofac. Orthop. September 1992
The only leading behavior with positive relations to patient participation is asking direct questions. According to Elliot, s direct questions contribute significantly to the task-oriented helping behavior cluster. Detailed questions stimulate cognitive searching processes and help concretize matters, e.g., "When did you wear your appliances last week?" The orthodontist can thus develop a detailed picture of a situation. Concerning the content of communication, we found the patients were more active (sentences, initiatives, detailed answers) the more the orthodontist discussed social themes and were less active (sentences, answering) the more the orthodontist talked about therapy. This underscores the facilitative character of social conversation. 6 On social topics, patients feel relatively free in their participation, whereas on therapy topics they might not feel competent and restrict their activity. As Bain 6 reports, social exchange is an expression of good relationships between clinician and patient and enhances information recalled during visits. ~7 According to our study of personality characteristics relating to communication, orthodontists do not vary their behavior toward patients with the difference in age, treatment duration, and sex of patients. But between them, they differ in two of seven discussion features (closed questions, listener signals). These results are in line with findings by Getz et al. 12who report that dentists showed stable behavior patterns across a series of children and treatment sessions. On the other hand, adolescents varied in their behavior when confronted with different orthodontists (speech quantity, questioning initiatives). It might be concluded that they react more strongly to the orthodontist than demonstrating their own personal behavioral tendencies. As previously noted, our study did not examine causal relationships. However, the results are hypotheses indicating which orthodontist behaviors might be of relevance for patient verbal cooperation in the office. A future study, including a training program for orthodontists, could help to clarify what specific changes in their behavior could effect changes in patient verbal cooperation. REFERENCES
1. GabrielHF. Motivationof the headgear-patient.Angle Orthod 1968;38:129-35. 2. MillerE, LarsonLL. A theoryof psycho-orthodonticswith practical applicationto officetechniques.AngleOrthod 1979;49:8591. 3. SarnatH, PeriJN, NitzanE, PerlbergA. Factorswhichinfluence cooperationbetweendentist and child. J Dent Educ 1972;36:915. 4. Eijkman MAJ, Karsdorp NE, BoekeB, Karsdorp-Bimmerman EHLM. Experiencewith a trainingcoursein patientcounseling. J Dent Educ 1977;41:623-5. 5. O'Shea RM, Corah NL, AyerWA. Dentists' perceptionsof the
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'good' adult patient: an exploratory study. J Am Dent Assoc 1983;106:813-6. Bain DJG. Doctor-patient communicationin general practice consultations. Med Educ 1976;125-31. RacherbfiumerJ, Westphale C,.KagelmannJ, SimonsC, K6hle K, Bfck D, Urban H. Manual zur informationsanalyse.Ulm: Psychosomatische Abteilungder Universit~tsklinikUlm, 1979. Elliot R. Helpful and nonhelpfulevents in brief counselinginterviews: an empirical taxonomy. J Couns Psychol 1985;30722. Duncan S, Fiske DW. Face-to-face interaction:research, methods, and theory. New York: J Wiley, 1977. SiegristJ. Asymmetrisehekommunikationbei klinischenvisiten. In: K6hle K, Raspe HH, eds. Das gespr/ich wfihrend der firztlichen visite. Miinchen: Urban und Schwarzenberg, 1982: pp. 16-22. ElliotR, Stile WB, Maher AR, Hill CE, FriedlanderNIL, Margison FR. Primary therapist response mode: comparisonof six rating systems. J Consult Clin Psychol 1987;55:218-33. Getz T, Weinstein P, Demoto P. Intradentist behavioral variability across children and appointments. J Pedodont 1984;16571.
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13. Hayley J. Strategies of psychotherapy. New York: Grune and Stratton, 1963. 14. Baker EE. Are you listening, doctor. New York J Dent 1984;54:201-2. 15. HillCE, CharlesD, Reed KG. A longitudinalanalysisofchanges in counselingskills during doctoral training in counselingpsychology. J Couns Psychol 1981;28:428-36. 16. Hill CE, Helms JE, Tichener V, Spiegel S, O'Grady KE, Perry ES. Effects of therapist response modes in brief psychotherapy. J Courts Psychol 1988;35:222-33. 17. Bain DJG. Patient knowledgeand contact of the consultationin general practice. Med Educ 1977;I1:347-50. Reprint requests to: Dr. Ulrich Klages Poliklinikftir Kieferorthopaedie der UniversitaetMainz Augustusplatz2 6500 Mainz, Federal Republicof Germany
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