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Objective: To describe the Emoty-Com training, its impact on medical students' attitudes towards doctors' emotions and to explore the association between students' empathy, emotional intelligence (EI), and attachment style (AS) with post-training performance scores., Methods: The 16-hour Emoty-Com training was delivered to all second-year medical students of Verona and Milan (Italy) Universities. At pre-training, students filled out three questionnaires assessing empathy, AS and EI and responded to three questions on attitudes towards doctors' emotions in the doctor-patient encounter. The same three questions and a final evaluation test were proposed at post-training., Results: 264 students participated in the study. The training reduced students' worry about managing emotions during doctor-patient relationships. Gender was associated with specific subscales of empathy, EI, and AS. Final performance scores were associated with students' attitudes towards emotions but not with empathy, EI, and AS., Conclusion: The Emoty-Com training increased students' self-efficacy in handling their own emotions during consultations. Students' performance scores were related to their attitude towards doctors' emotions in clinical encounters., Practice Implications: The Emoty-Com training suggests ways to teach and evaluate emotion-handling skills for medical students. Possible links between empathy, EI, AS, and the attitudes towards doctors' emotions during the years of education are highlighted., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: (1) To report the number and type of emotional expressions (cues/concerns) raised by breast cancer patients; (2) to identify the influence of setting, patient characteristics, and doctor-patient interaction on emotional expression., Methods: 308 Italian-speaking female patients were recruited at their first breast cancer consultation. The visits were audio-recorded and analysed for number and type of emotional expressions (VR-CoDES). Oncologists' interaction skills were rated by the VR-COPE. Socio-demographic, clinical and personality variables were gathered before the consultation. Clinical variables and oncologists' evaluations of the patient were collected after., Results: Breast cancer patients raised emotional issues mainly as cues. The setting (centre where the consultations took place), the oncologist's attribution of anxiety, regardless of anxiety test screening (STAI-X1) score before the consultation, and the oncologist's ability to pick up on patient's worries, handle emotional needs or understand psychosocial condition were all positively related with the number of emotional expressions. More tightly structured consultations had fewer emotional expressions., Conclusion: Both contextual and interactional aspects have an impact on patient emotional expressions., Practice Implications: Oncologists need to be trained to manage both the content and the process of medical consultation. Work organization of the consultation setting needs to be taken into account., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To assess the effectiveness of a brief training program in relational/communication skills (RCS) for medical residents., Methods: This longitudinal study enrolled 64 medical residents who participated in a RCS training program in small groups. Teaching was based on interviews with standardized patients and reflective practice. Video-recorded consultations were coded according to the Verona-Coding-Definitions-of-Emotional-Sequences (VR-CoDES) and a coding system developed to assess ten communication skills for breaking bad news. The outcome measures were: independent raters' score in RCS for breaking bad news and the percentage of providing space and empathic responses, by comparing baseline (T1) skills with those after three-days (T2) and three-months (T3)., Results: After the training program residents provided more space for further disclosure of cues and concerns according to VR-CoDES definitions. There were significant improvements in seven of the ten communication skills for breaking bad news. All of these improvements were observed either at T2 or at T3., Conclusion: This study demonstrates the effectiveness of a brief RCS training program designed to improve medical residents' ability to respond appropriately to patients' cues and concerns and to conduct a breaking bad news encounter., Practice Implications: Brief RCS training programs adopting multiple approaches, should be offered as mandatory during residency programs., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: The aim of the study was to investigate the effect of physicians' supportive communication on analogue patients' (APs) heart rate variability (HRV) and recall, while watching a video of palliative treatment being explained to a female patient., Methods: Sixty healthy women, acting as APs, were randomly assigned to watch one of two versions (standard vs. affective) of a scripted video-vignette of a bad news consultation to a female patient. The physician's communication differed only in the delivery of four supportive comments. Empathy, support and engagement perception were assessed by three questions. APs' HR was recorded during video-observation and recall was assessed immediately after. HRV was determined through measures defined in time and frequency domains., Results: Data of 54 APs (27 + 27) were included. The group with supportive communication perceived the physician as more empathic and supportive. Intra- and Inter-group comparisons suggested a greater sense of stress in the standard communication group. Recall did not differ in the two groups., Conclusion and Practice Implications: Findings show that the use of supportive expressions contribute to the perception of the physician as more empathic, potentially buffer patients' arousal after a bad news announcement, but does not confirm a positive impact on general recall., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To investigate how patients' autonomic responses are related to verbal or non-verbal communication during clinical encounters., Methods: The SCOPUS database was searched to identify papers. Studies were included if measures of autonomic arousal were related to patients' emotions or patient-clinician interaction during clinical consultations such as psychotherapy, counseling or medical interviews. The search was conducted according to PRISMA criteria. The included studies were assessed using the 16 item quality assessment tool QATSDD., Results: A total of 24 publications were identified. The studies varied greatly in design and quality. However, a few trends could be observed across studies. Patients' expressions of emotions were associated with significant autonomic arousal. Clinician behavior affected arousal levels; and in a few studies, a patient centered way of presenting information was found to attenuate arousal level, interpreted as stress reduction. There was a general, but not consistent, trend in the reduction of arousal level over time within the consultation. Examples of individual differences in autonomic responses were found., Conclusion and Practice Implications: Increased awareness of potential impact of clinician behavior on patient' arousal level may be helpful for clinicians, in particular how different communication styles may augment or attenuate arousal in response to stressors., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: The Verona Coding Definitions of Emotional sequences (VR-CoDES) system has been applied in a wide range of studies, in some of these, because of its attention on healthcare provider's ability to respond to patient emotions, it has been used as a proxy of patient-centeredness. The paper aims to discuss how the VR-CoDES can contribute to the broader concept of patient-centeredness and its limitations., Methods: VR-CoDES and patient-centeredness concept are briefly described, trying to detect commonalities and distinctions. The VR-CoDES dimensions of Explicit/non explicit responding and Providing or Reducing Space are analysed in relation to relevant aspects of patient-centred communication., Results: Emotional aspects are encompassed within patient-centeredness model, but they represent only one of the numerous dimensions that contribute to define patient-centeredness as well as Explicit/non explicit responding and Providing or Reducing Space serve different functions during communication., Conclusion: The VR-CoDES can contribute to operationalize the description of emotional aspects emerging in a consultation, by inducing coders to adopt a factual attitude in assessing how health providers react to patient's expression of emotions., Practice Implications: To better define empirically which measure affective aspects and dimensions of health provider responses are relevant and may contribute to patient-centeredness in different clinical settings., (Copyright © 2017. Published by Elsevier B.V.)

Objective: To explore the applicability, need for modifications and reliability of the VR-CoDES in a veterinary setting while also gaining a deeper understanding of clients' expressions of negative emotion and how they are addressed by veterinarians., Methods: The Verona Coding Definitions of Emotional Sequences for client cues and concerns (VR-CoDES-CC) and health provider responses (VR-CoDES-P) were used to analyse 20 audiotaped veterinary consultations. Inter-rater reliability was established. The applicability of definitions of the VR-CoDES was identified, together with the need for specific modifications to suit veterinary consultations., Results: The VR-CoDES-CC and VR-CoDES-P generally applied to veterinary consultations. Cue and concern reliability was found satisfactory for most types of cues, but not for concerns. Response reliability was satisfactory for explicitness, and for providing and reducing space for further disclosure. Modifications to the original coding system were necessary to accurately reflect the veterinary context and included minor additions to the VR-CoDES-CC., Conclusion: Using minor additions to the VR-CoDES including guilt, reassurance and cost discussions it can be reliably adopted to assess clients' implicit expressions of negative emotion and veterinarians' responses., Practice Implications: The modified VR-CoDES could be of great value when combined with existing frameworks used for teaching and researching veterinary communication., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: To describe how emotions are disclosed during psychiatric diagnostic consultations and the contribution of the psychiatrists in facilitating their expression., Methods: Descriptive naturalistic study. Sixteen psychiatrists recorded their first consultations with 104 patients. Emotions and the immediate response given by the psychiatrist were coded with the Verona Coding Definitions of Emotional Sequences. For each disclosed emotion, the potential link to preceding expressions with affective content (cue or concern) was checked and the immediate response given by the psychiatrist was coded., Results: Most emotions were expressions of anxiety in terms of psycho-physiological or cognitive correlates. Concerns were present in 94% of the consultations, 47.6% were not linked to previous cues/concerns. Cues which became concerns and concerns which were further elaborated by the patient were those that had been acknowledged and handled by the psychiatrist by actively providing space to their expression. Compared to all other diagnostic groups, patients with mood disorders talked more explicitly and more often about their feelings., Conclusion: The type and frequency of expressed emotions varies with patient diagnosis, suggesting different cognitive processes underlining psychopathology., Practice Implications: Psychiatrist's competence in providing space by using active listening skills is essential to uncover patients emotions., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: To illustrate how patients introduce cues and concerns during clinical consultations and how psychiatrists respond to them., Method: Sixteen psychiatrists recorded 104 first diagnostic consultations, coded with the Verona Coding Definitions of Emotional Sequences (VR-CoDES). Cues, concerns and responses were analyzed in relation to patient gender and ICD-10 diagnosis, and psychiatrists' age, gender, clinical experience and consultation process., Results: Cues were more frequent among female patients and were equally distributed among diagnostic categories. Concerns were more frequent among patients with "Mood" or "Neurotic" disorders. Psychiatrists' responses to cues tended to "provide space" without being explicit. Referral to the affective part was restricted to concerns which had been solicited by the psychiatrist. Empathic responses were infrequent. Cues and concerns received more attention by female psychiatrists., Conclusion: The study confirms gender differences in expressing and dealing with emotions both by patients and psychiatrists. Females tend to give more space to this topic. Psychiatrists 'responses differed according to cues, concerns, gender, diagnosis and to who prompted the cue/concern, showing a preference for topics introduced by themselves., Practice Implications: The VR-CoDES is a useful tool to define the strategies psychiatrists adopt when handling patients' emotions in terms of cues and concern., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: To present the Verona Coding Definitions of Emotional Sequences (VR-CoDES CC), a consensus based system for coding patient expressions of emotional distress in medical consultations, defined as Cues or Concerns., Methods: The system was developed by an international group of communication researchers. First, consensus was reached in different steps. Second, a reliability study was conducted on 20 psychiatric consultations., Results: A Cue is defined as a verbal or non-verbal hint which suggests an underlying unpleasant emotion that lacks clarity. A Concern is defined as a clear and unambiguous expression of an unpleasant current or recent emotion that is explicitly verbalized with or without a stated issue of importance. The conceptual framework sets precise criteria for cues and concerns and for whom (health provider or patient) elicits the cue/concern. Inter-rater reliability proved satisfactory (agreement 81.5%, Cohen's Kappa 0.70)., Conclusion: The VR-CoDES CC will facilitate comparative research on provider-patient communication sequences in which patients express emotional distress., Practice Implications: The VR-CoDES CC may be used to help clinicians in recognizing or facilitating cues and concerns, thereby improving the recognition of patients' emotional distress, the therapeutic alliance and quality of care for these patients., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: To present a method to classify health provider responses to patient cues and concerns according to the VR-CoDES-CC (Del Piccolo et al. (2009) [2] and Zimmermann et al. (submitted for publication) [3]). The system permits sequence analysis and a detailed description of how providers handle patient's expressions of emotion., Methods: The Verona-CoDES-P system has been developed based on consensus views within the "Verona Network of Sequence Analysis". The different phases of the creation process are described in detail. A reliability study has been conducted on 20 interviews from a convenience sample of 104 psychiatric consultations., Results: The VR-CoDES-P has two main classes of provider responses, corresponding to the degree of explicitness (yes/no) and space (yes/no) that is given by the health provider to each cue/concern expressed by the patient. The system can be further subdivided into 17 individual categories. Statistical analyses showed that the VR-CoDES-P is reliable (agreement 92.86%, Cohen's kappa 0.90 (±0.04) p<0.0001)., Conclusion: Once validity and reliability are tested in different settings, the system should be applied to investigate the relationship between provider responses to patients' expression of emotions and outcome variables., Practice Implications: Research employing the VR-CoDES-P should be applied to develop research-based approaches to maximize appropriate responses to patients' indirect and overt expressions of emotional needs., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: To provide psychometric characteristics of the Italian language version of the OPTION scale and descriptive statistics on patients' involvement. The OPTION scale assesses the extent to which clinicians involve patients in therapeutic decisions. The English language version has a Cohen's kappa score for individual items ranging from 0.45 to 0.98 and an intraclass correlation coefficient (ICC) for the total score of 0.77., Methods: Six male GPs provided 235 audiotaped consultations with consecutive patients who had attended for a new illness episode over a 2-month period. Thirty interviews were rated by two raters to assess inter- and intra rater as well as test-retest reliability of the Italian language version of the OPTION scale. Based on the whole sample, Cronbach's alpha and an exploratory factor analysis were performed to assess internal validity and to determine factor loadings., Results: Cohen's kappa values were comprised between 0.29 and 0.73, the ICC at test and retest was 0.85 and 0.81 and Cronbach's alpha 0.82. The ratings for each OPTION item showed a skewed distribution: the majority of scores (>70%) were between 0 (behaviour absent) and 2 (minimum skill level)., Conclusion: The reliability indices were satisfactory and similar to those reported for the original OPTION., Practice Implications: OPTION can be used for both teaching purposes and research, as well as for future cross-national comparisons.

Objective: This study aimed to assess the inter-rater and intra-rater reliability of the English translation of the original Italian version of the VR-MICS and to evaluate its sensitivity by comparing the coding of English and Italian general practice consultations with emotionally distressed and non-distressed patients, as defined by the 12-item General Health Questionnaire (GHQ-12)., Method: Six male GPs from Manchester (UK) and six from Verona (Italy) each contributed five consultations, which were coded using the VR-MICS. Intra-rater and inter-rater reliability were assessed both for the division of interviews into speech units and the speech unit coding. Interaction and main effects of GHQ-12 status and nationality on patient and GP expressions were assessed by two-way ANOVA., Results: Agreement indices for the division of speech units varied between 88-96 and 87-93% for GP and patient speech, respectively; those for coding categories between 88-91 and 82-86%, with Cohen's Kappa values between 0.86-0.91 and 0.80-0.85 for GP and patient speech, respectively. Cross-cultural comparisons of patient and GP speech showed no interaction effects between GHQ-12 status and nationality. The Italian GPs were more 'doctor-centred', while the UK GPs tended to use a more 'sharing' consulting style. Independent of nationality, distressed patients talked more, gave more psychosocial cues and increased amounts of positive talk compared to non-distressed patients. GPs in both settings, when interviewing distressed patients, reduced social conversation and increased psychosocial information-giving, checking questions and reassurance., Conclusion: The English translation of the VR-MICS showed satisfactory reliability indices and similar sensitivity to patients' verbal behaviours in relation to their emotional state in the two settings., Practice Implications: The VR-MICS may be an useful coding instrument to support collaborative research on doctor-patient communication between the two countries.

Factor analysis (FA) is a powerful method of testing the construct validity of coding systems of the medical interview. The study uses FA to test the underlying assumptions of the Verona Medical Interview Classification System (VR-MICS). The relationship between factor scores and patient characteristics was also examined. The VR-MICS coding categories consider the three domains of the biopsychosocial model and the main functions of the medical interview-data gathering, relationship building and patient education. FA was performed on the frequencies of the VR-MICS categories based on 238 medical interviews. Seven factors (62.5% of variance explained) distinguished different strategies patients and physicians use to exchange information, build a relationship and negotiate treatment within the domains of the biopsychosocial model. Three factors, Psychological, Social Inquiry and Management of Patient Agenda, were related to patient data: sociodemographic (female gender, age and employment), social (stressful events), clinical (GHQ-12 score), personality (chance external health locus of control) and clinical characteristics (psychiatric history, chronic illness, attributed presence of emotional distress).