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Emotional Communication in HIV Care: An Observational Study of Patients’ Expressed Emotions and Clinician Response


Emotional support is essential to good communication, yet clinicians often miss opportunities to provide empathy to patients. Our study explores the nature of emotional expressions found among patients new to HIV care, how HIV clinicians respond to these expressions, and predictors of clinician responses. Patient-provider encounters were audio-recorded, transcribed, and coded using the VR-CoDES. We categorized patient emotional expressions by intensity (subtle ‘cues’ vs. more explicit ‘concerns’), timing (initial vs. subsequent), and content (medical vs. non-medical). Emotional communication was present in 65 of 91 encounters. Clinicians were more likely to focus specifically on patient emotion for concerns versus cues (OR 4.55; 95% CI 1.36, 15.20). Clinicians were less likely to provide space when emotional expressions were repeated (OR 0.32; 95% CI 0.14, 0.77), medically-related (OR 0.36; 95% CI 0.17, 0.77), and from African American patients (OR 0.42; 95% CI 0.21, 0.84). Potential areas for quality improvement include raising clinician awareness of subtle emotional expressions, the emotional content of medically-related issues, and racial differences in clinician response.

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  1. 1.

    Zolnierek KBH, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826–34.

    PubMed  Google Scholar 

  2. 2.

    Arbuthnott A, Sharpe D. The effect of physician-patient collaboration on patient adherence in non-psychiatric medicine. Patient Educ Couns. 2009;77(1):60–7.

    PubMed  Google Scholar 

  3. 3.

    Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3(1):e001570.

    PubMed  PubMed Central  Google Scholar 

  4. 4.

    Paterson DL, Swindells S, Mohr J, Brester M, Vergis EN, Squier C, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med. 2000;133(1):21–30.

    CAS  Google Scholar 

  5. 5.

    Bangsberg DR, Hecht FM, Charlebois ED, Zolopa AR, Holodniy M, Sheiner L, et al. Adherence to protease inhibitors, HIV-1 viral load, and development of drug resistance in an indigent population. AIDS. 2000;14(4):357–66.

    CAS  PubMed  Google Scholar 

  6. 6.

    Bangsberg DR, Perry S, Charlebois ED, Clark RA, Roberston M, Zolopa AR, et al. Non-adherence to highly active antiretroviral therapy predicts progression to AIDS. AIDS. 2001;15(9):1181.

    CAS  PubMed  Google Scholar 

  7. 7.

    Palella FJ, Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten GA. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. N Engl J Med. 1998;338(13):853–60.

    PubMed  Google Scholar 

  8. 8.

    Flickinger TE, Saha S, Moore RD, Beach MC. Higher quality communication and relationships are associated with improved patient engagement in HIV care. J Acquir Immune Defic Syndr. 2013;63(3):362–6.

    PubMed  PubMed Central  Google Scholar 

  9. 9.

    Flickinger TE, Rose G, Wilson IB, Wolfe H, Saha S, Korthuis PT, et al. Motivational interviewing by HIV care providers is associated with patient intentions to reduce unsafe sexual behavior. Patient Educ Couns. 2013;93(1):122–9.

    PubMed  PubMed Central  Google Scholar 

  10. 10.

    Beach MC, Keruly J, Moore RD. Is the quality of the patient-provider relationship associated with better adherence and health outcomes for patients with HIV? J Gen Intern Med. 2006;21(6):661–5.

    PubMed  PubMed Central  Google Scholar 

  11. 11.

    Halpern J. What is clinical empathy? J Gen Intern Med. 2003;18(8):670–4.

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Flickinger TE, Saha S, Roter D, Korthuis PT, Sharp V, Cohn J, et al. Clinician empathy is associated with differences in patient-clinician communication behaviors and higher medication self-efficacy in HIV care. Patient Educ Couns. 2016;99(2):220–6.

    PubMed  Google Scholar 

  13. 13.

    Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract. 2013;63(606):e76–84.

    PubMed  Google Scholar 

  14. 14.

    Howick J, Moscrop A, Mebius A, Fanshawe TR, Lewith G, Bishop FL, et al. Effects of empathic and positive communication in healthcare consultations: a systematic review and meta-analysis. J R Soc Med. 2018;19:1–13.

    Google Scholar 

  15. 15.

    Menendez ME, Chen NC, Mudgal CS, Jupiter JB, Ring D. Physician empathy as a driver of hand surgery patient satisfaction. J Hand Surg. 2015;40(9):1860–1865.e2.

    Google Scholar 

  16. 16.

    Maguire P, Faulkner A, Booth K, Elliott C, Hillier V. Helping cancer patients disclose their concerns. Eur J Cancer. 1996;32(1):78–81.

    Google Scholar 

  17. 17.

    Goodchild CE, Skinner TC, Parkin T. The value of empathy in dietetic consultations. A pilot study to investigate its effect on satisfaction, autonomy and agreement. J Hum Nutr Diet. 2005;8(3):181–5.

    Google Scholar 

  18. 18.

    Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86(3):359–64.

    PubMed  Google Scholar 

  19. 19.

    Morse DS, Edwardsen EA, Gordon HS. Missed opportunities for interval empathy in lung cancer communication. Arch Intern Med. 2008;168(17):1853–8.

    PubMed  PubMed Central  Google Scholar 

  20. 20.

    Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA. 2000;284(8):1021–7.

    CAS  PubMed  Google Scholar 

  21. 21.

    Pollak KI, Arnold RM, Jeffreys AS, Alexander SC, Olsen MK, Abernethy AP, et al. Oncologist communication about emotion during visits with patients with advanced cancer. JCO. 2007;25(36):5748–52.

    Google Scholar 

  22. 22.

    Farrell MH, Christopher SA. Frequency of high-quality communication behaviors used by primary care providers of heterozygous infants after newborn screening. Patient Educ Couns. 2013;90(2):226–32.

    PubMed  Google Scholar 

  23. 23.

    Del Piccolo L, de Haes H, Heaven C, Jansen J, Verheul W, Bensing J, et al. Development of the Verona coding definitions of emotional sequences to code health providers’ responses (VR-CoDES-P) to patient cues and concerns. Patient Educ Couns. 2011;82(2):149–55.

    PubMed  Google Scholar 

  24. 24.

    Zimmermann C, Del Piccolo L, Bensing J, Bergvik S, De Haes H, Eide H, et al. Coding patient emotional cues and concerns in medical consultations: The Verona coding definitions of emotional sequences (VR-CoDES). Patient Educ Couns. 2011;82(2):141–8.

    PubMed  Google Scholar 

  25. 25.

    Piccolo LD, Finset A, Mellblom AV, Figueiredo-Braga M, Korsvold L, Zhou Y, et al. Verona Coding Definitions of Emotional Sequences (VR-CoDES): conceptual framework and future directions. Patient Educ Couns. 2017;100(12):2303–11.

    PubMed  Google Scholar 

  26. 26.

    Del Piccolo L. VR-CoDES and patient-centeredness. The intersection points between a measure and a concept. Patient Educ Couns. 2017;100(11):2135–7.

    PubMed  Google Scholar 

  27. 27.

    Riley R, Weiss MC, Platt J, Taylor G, Horrocks S, Taylor A. A comparison of GP, pharmacist and nurse prescriber responses to patients’ emotional cues and concerns in primary care consultations. Patient Educ Couns. 2013;91(1):65–71.

    PubMed  Google Scholar 

  28. 28.

    Amundsen A, Nordøy T, Lingen KE, Sørlie T, Bergvik S. Is patient behavior during consultation associated with shared decision-making? A study of patients’ questions, cues and concerns in relation to observed shared decision-making in a cancer outpatient clinic. Patient Educ Couns. 2018;101(3):399–405.

    PubMed  Google Scholar 

  29. 29.

    Del Piccolo L, Danzi O, Fattori N, Mazzi MA, Goss C. How psychiatrist’s communication skills and patient’s diagnosis affect emotions disclosure during first diagnostic consultations. Patient Educ Couns. 2014;96(2):151–8.

    PubMed  Google Scholar 

  30. 30.

    Butalid L, Verhaak PFM, van Dulmen S, Bensing JM. Concerns voiced by patients and GPs’ responses during psychosocial visits in primary care: a historical cross-sectional study. BMC Fam Pract. 2014;25(15):188.

    Google Scholar 

  31. 31.

    Aelbrecht K, De Maesschalck S, Willems S, Deveugele M, Pype P. How family physicians respond to unpleasant emotions of ethnic minority patients. Patient Educ Couns. 2017;100(10):1867–73.

    PubMed  Google Scholar 

  32. 32.

    Cherry MG, Fletcher I, Berridge D, O’Sullivan H. Do doctors’ attachment styles and emotional intelligence influence patients’ emotional expressions in primary care consultations? An exploratory study using multilevel analysis. Patient Educ Couns. 2018;101(4):659–64.

    PubMed  Google Scholar 

  33. 33.

    Del Piccolo L, Mazzi MA, Goss C, Rimondini M, Zimmermann C. How emotions emerge and are dealt with in first diagnostic consultations in psychiatry. Patient Educ Couns. 2012;88(1):29–35.

    PubMed  Google Scholar 

  34. 34.

    Zhou Y, Humphris G, Ghazali N, Friderichs S, Grosset D, Rogers SN. How head and neck consultants manage patients’ emotional distress during cancer follow-up consultations: a multilevel study. Eur Arch Otorhinolaryngol. 2015;272(9):2473–81.

    PubMed  Google Scholar 

  35. 35.

    Gorawara-Bhat R, Hafskjold L, Gulbrandsen P, Eide H. Exploring physicians’ verbal and nonverbal responses to cues/concerns: learning from incongruent communication. Patient Educ Couns. 2017;100(11):1979–89.

    CAS  PubMed  Google Scholar 

  36. 36.

    Del Piccolo L, Pietrolongo E, Radice D, Tortorella C, Confalonieri P, Pugliatti M, et al. Patient expression of emotions and neurologist responses in first multiple sclerosis consultations. PLoS ONE. 2015;10(6):e0127734.

    PubMed  PubMed Central  Google Scholar 

  37. 37.

    Vatne TM, Ruland CM, Ørnes K, Finset A. Children’s expressions of negative emotions and adults’ responses during routine cardiac consultations. J Pediatr Psychol. 2012;37(2):232–40.

    PubMed  Google Scholar 

  38. 38.

    Wright A, Humphris G, Wanyonyi KL, Freeman R. Using the verona coding definitions of emotional sequences (VR-CoDES) and health provider responses (VR-CoDES-P) in the dental context. Patient Educ Couns. 2012;89(1):205–8.

    PubMed  Google Scholar 

  39. 39.

    Finset A, Heyn L, Ruland C. Patterns in clinicians’ responses to patient emotion in cancer care. Patient Educ Couns. 2013;93(1):80–5.

    PubMed  Google Scholar 

  40. 40.

    De Maesschalck S, Deveugele M, Willems S. Language, culture and emotions: exploring ethnic minority patients’ emotional expressions in primary healthcare consultations. Patient Educ Couns. 2011;84(3):406–12.

    PubMed  Google Scholar 

  41. 41.

    Mjaaland TA, Finset A, Jensen BF, Gulbrandsen P. Physicians’ responses to patients’ expressions of negative emotions in hospital consultations: a video-based observational study. Patient Educ Couns. 2011;84(3):332–7.

    PubMed  Google Scholar 

  42. 42.

    Eide H, Eide T, Rustøen T, Finset A. Patient validation of cues and concerns identified according to Verona coding definitions of emotional sequences (VR-CoDES): a video- and interview-based approach. Patient Educ Couns. 2011;82(2):156–62.

    PubMed  Google Scholar 

  43. 43.

    Fletcher I, Mazzi M, Nuebling M. When coders are reliable: the application of three measures to assess inter-rater reliability/agreement with doctor–patient communication data coded with the VR-CoDES. Patient Educ Couns. 2011;82(3):341–5.

    PubMed  Google Scholar 

  44. 44.

    Hsu I, Saha S, Korthuis PT, Sharp V, Cohn J, Moore RD, et al. Providing support to patients in emotional encounters: a new perspective on missed empathic opportunities. Patient Educ Couns. 2012;88(3):436–42.

    PubMed  PubMed Central  Google Scholar 

  45. 45.

    Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health. 2004;94(12):2084–90.

    PubMed  PubMed Central  Google Scholar 

  46. 46.

    Beach MC, Saha S, Korthuis PT, Sharp V, Cohn J, Wilson IB, et al. Patient-provider communication differs for black compared to white HIV-infected patients. AIDS Behav. 2011;15(4):805–11.

    PubMed  PubMed Central  Google Scholar 

  47. 47.

    Laws MB, Lee Y, Rogers WH, Beach MC, Saha S, Korthuis PT, et al. Provider-patient communication about adherence to anti-retroviral regimens differs by patient race and ethnicity. AIDS Behav. 2014;18(7):1279–87.

    PubMed  PubMed Central  Google Scholar 

  48. 48.

    Jones NR, Williamson A, Foote M, Creswell P, Strickland R, Remington P, et al. Cancer health disparities persist among African Americans in Wisconsin. WMJ. 2010;109(5):267–73.

    PubMed  PubMed Central  Google Scholar 

  49. 49.

    Khawja SN, Mohammed S, Silberfein EJ, Musher BL, Fisher WE, Van Buren G. Pancreatic cancer disparities in African Americans. Pancreas. 2015;44(4):522–7.

    PubMed  Google Scholar 

  50. 50.

    Taber DJ, Gebregziabher M, Hunt KJ, Srinivas T, Chavin KD, Baliga PK, et al. Twenty years of evolving trends in racial disparities for adult kidney transplant recipients. Kidney Int. 2016;90(4):878–87.

    PubMed  PubMed Central  Google Scholar 

  51. 51.

    Sims M, Rainge Y. Urban poverty and infant-health disparities among African Americans and whites in Milwaukee. J Natl Med Assoc. 2002;94(6):472–9.

    PubMed  PubMed Central  Google Scholar 

  52. 52.

    Estrada AL. Health disparities among African-American and Hispanic drug injectors–HIV, AIDS, hepatitis B virus and hepatitis C virus: a review. AIDS. 2005;19(Suppl 3):S47–52.

    PubMed  Google Scholar 

  53. 53.

    Andersen R, Bozzette S, M Shapiro, St Clair P, Morton S, Crystal S, et al. Access of vulnerable groups to antiretroviral therapy among persons in care for HIV disease in the United States. HCSUS Consortium. HIV Cost and Services Utilization Study. Health Serv Res. 2000;35(2):389–416.

    CAS  PubMed  PubMed Central  Google Scholar 

  54. 54.

    Fleishman JA, Yehia BR, Moore RD, Gebo KA, Agwu AL. HIV Research Network. Disparities in receipt of antiretroviral therapy among HIV-infected adults (2002-2008). Med Care. 2012;50(5):419–27.

    PubMed  PubMed Central  Google Scholar 

  55. 55.

    Moore RD, Stanton D, Gopalan R, Chaisson RE. Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med. 1994;330(11):763–8.

    CAS  PubMed  Google Scholar 

  56. 56.

    Sheehan DM, Fennie KP, Mauck DE, Maddox LM, Lieb S, Trepka MJ. Retention in HIV care and viral suppression: individual- and neighborhood-level predictors of racial/ethnic differences, Florida, 2015. AIDS Patient Care STDS. 2017;31(4):167–75.

    PubMed  PubMed Central  Google Scholar 

  57. 57.

    Beer L, Bradley H, Mattson CL, Johnson CH, Hoots B, Shouse RL. Trends in racial and ethnic disparities in antiretroviral therapy prescription and viral suppression in the United States, 2009–2013. J Acquir Immune Defic Syndr. 2016;73(4):446–53.

    CAS  PubMed  PubMed Central  Google Scholar 

  58. 58.

    Asch SM, Gifford AL, Bozzette SA, Turner B, Mathews WC, Kuromiya K, et al. Underuse of primary Mycobacterium avium complex and Pneumocystis carinii prophylaxis in the United States. J Acquir Immune Defic Syndr. 2001;28(4):340–4.

    CAS  PubMed  Google Scholar 

  59. 59.

    Shapiro MF, Morton SC, McCaffrey DF, Senterfitt JW, Fleishman JA, Perlman JF, et al. Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study. JAMA. 1999;281(24):2305–15.

    CAS  PubMed  Google Scholar 

  60. 60.

    Schouten BC, Schinkel S. Turkish migrant GP patients’ expression of emotional cues and concerns in encounters with and without informal interpreters. Patient Educ Couns. 2014;97(1):23–9.

    PubMed  Google Scholar 

  61. 61.

    Zhou Y, Lundy J-M, Humphris G, Mercer SW. Do multimorbidity and deprivation influence patients’ emotional expressions and doctors’ responses in primary care consultations?—An exploratory study using multilevel analysis. Patient Educ Couns. 2015;98(9):1063–70.

    PubMed  Google Scholar 

  62. 62.

    Sundler AJ, Höglander J, Eklund JH, Eide H, Holmström IK. Older persons’ expressions of emotional cues and concerns during home care visits. Application of the Verona coding definitions of emotional sequences (VR-CoDES) in home care. Patient Educ Couns. 2017;100(2):276–82.

    PubMed  Google Scholar 

  63. 63.

    Grimsbø GH, Ruland CM, Finset A. Cancer patients’ expressions of emotional cues and concerns and oncology nurses’ responses, in an online patient–nurse communication service. Patient Educ Couns. 2012;88(1):36–43.

    PubMed  Google Scholar 

  64. 64.

    Mazzi MA, Bensing J, Rimondini M, Fletcher I, van Vliet L, Zimmermann C, et al. How do lay people assess the quality of physicians’ communicative responses to patients’ emotional cues and concerns? An international multicentre study based on videotaped medical consultations. Patient Educ Couns. 2013;90(3):347–53.

    PubMed  Google Scholar 

  65. 65.

    Montague E, Chen P, Xu J, Chewning B, Barrett B. Nonverbal interpersonal interactions in clinical encounters and patient perceptions of empathy. J Participat Med. 2013;5:e33.

    Google Scholar 

  66. 66.

    Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282(6):583–9.

    CAS  PubMed  Google Scholar 

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This work was supported by Grants from the NIH (R01 DA037601, U01 DA036935, K24 DA037804 and P30 AI094189).

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Correspondence to Mary Catherine Beach.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Review Board at Johns Hopkins University and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Park, J., Saha, S., Han, D. et al. Emotional Communication in HIV Care: An Observational Study of Patients’ Expressed Emotions and Clinician Response. AIDS Behav 23, 2816–2828 (2019).

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  • Patient-provider communication
  • Patient-centeredness
  • HIV
  • Quality