The third meeting of the Verona Network on Sequence Analysis
Finding common grounds in defining patient cues and concerns and the appropriateness of provider
responses
Verona, 4th – 5th February 2005
Lidia Del Piccolo, Claudia Goss & Christa Zimmermann
Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology,
University of Verona, 37134 Verona, Italy.
Corresponding address:
Tel +39 - 045 8076412 Fax +39 - 045 585871
On 4th – 5th February this year twenty researchers from seven different countries (England, The Netherlands,
Norway, Switzerland, Germany, Italy and USA) met in Verona to attend the third invitational workshop of
the “Verona Network on Sequence Analysis”, hosted by the University of Verona, and organized by Christa
Zimmermann and her colleagues. Differently from the previous two meetings (see PEC 50, 107-109 (2003)
and PEC 53, 395-396 (2004)) this year’s attention was focused on finding a common ground on the
definition of cue and concern and on what to consider an appropriate provider response to these patient
expressions.
Include picture here
Why finding a consensus on cue concern definition.
Cues and concerns refer to the emotional aspect of patient-provider communication and they represent one of
the most challenging topics for the interaction analyses of medical consultations. Indeed the most frequently
analyzed patient-provider sequences in the studies presented at the 2004 Workshop on sequence analysis in
Verona regarded patient cues or concerns and the subsequent provider responses. Despite there seemed to be
an unspoken common understanding among the participants on what a cue or a concern is, the adopted
definitions applied divergent and sometimes conflicting criteria to define these two phenomena. Attempts to
compare results from different studies became quite difficult and the participants decided in the closure
session of the 2004 workshop to launch a comparative coding exercise, based on a sample of six transcribed
interviews in English language. The aim was to identify patient cues and/or concerns according to the
respective classification systems adopted. Twelve colleagues, each familiar with one of eleven classification
methodologies, provided the codings: Lidia Del Piccolo (Verona Medical Interview Classification System
(VR-MICS), Young-Mi Kim (Provider Responsiveness to Client Active Communication), Linda Zandbelt
(Patient-centred Behaviour Coding Instrument (PBCI), Johanna Ruusavuori (Conversation Analysis), Ian
Fletcher and Cathy Heaven (Medical Interview AURAL Rating System (MIARS), Phyllis Butow
(Psychological distress in Oncology classification,) Sandra van Dulmen and Wolfgang Langewitz (Roter
Interaction Analysis System (RIAS), Arnstein Finset (Empathic Opportunities), Ludwien Meeuwesen (a
combination of RIAS and the Verbal Response Mode (RIAS/VRM) and Greg Makoul (Empathic
Communication Coding System (ECCS).
The results of the comparative coding exercise showed how differently sensitive and specific the different
systems were in picking out what was considered cue/concern. A revision and the attempt to find common
ground was felt as urgent and the agenda of the 2005 workshop was dedicated to this enterprise.
Arnstein Finset and Christa Zimmermann chaired the workshop.
After a welcome by Christa Zimmermann, Arnstein Finset gave a short introduction and a summary of the
results of the comparative coding exercise and nine participants exposed briefly the cue/concern definitions
of the adopted systems. Then three work sessions, each followed by a plenary session, took place involving
four parallel work groups, with changing members at each session.
Session 1: consensus finding on cue/concern definition (Rapporteurs Young-Mi Kim and Hanneke de Haes)
The aim of the first parallel work session for each of the four subgroups was to arrive at a definition of
cue/concern and the criteria that would allow their identification by analyzing two transcribed interviews
chosen from the comparative coding exercise. In the subsequent plenary session the four group outcomes
were compared and discussed. Some consensus criteria for the definition of cues and concerns emerged,
although no agreement on a single definition was reached.
A cue was roughly defined as a hint, which might be an expression or signal, mostly verbal but also non
verbal (particularly emotionally charged expressions such as crying), which indirectly indicates an issue of
presumed importance (unresolved, current, relevant?) for the patient and implies an emotion, worry or
uncertainty that the patient would like to bring up, or a move to another topic, that should demand an
exploration from the provider.
A concern was defined as a verbal expression, which explicitly indicates an issue of importance for the
patient.
The main discussion points were:

The degree of importance to the patient
All agreed that cues and concerns should be something of importance to the patient that deserved health
carers’ attention. The importance of a cue for the patient would not always be evident. There was also a
discussion about relevance and urgency as criterion but no conclusions were drawn.

The degree of explicitness
All agreed that concern is a more explicit and cue a more implicit expression. A cue is a hint, signal or
trigger of a patient’s concern and tends to be ambiguous or incomplete, whereas concerns tend to be
unambiguously or clearly stated.

Emotional expression or content
After a long discussion participants did not come to an agreement on whether cues and concerns have to
include words expressing feelings. All agreed that expressions about a sensory aspect (“It hurts”) should
not be considered a concern.

Patient initiated or doctor elicited
All agreed that the definitions should include all patient initiated cues and concerns. However, there was
no agreement on whether cues and concerns that are elicited by the doctor should also be included.

Possibility to introduce a new definition “psych”
This referred to expressions of intense emotional distress without a stated issue of importance, which is
not linked to a particular topic of the consultation and cannot be defined as either cue or concern, but is a
category of its own.
There were also suggestions to make efforts to create definitions that were not overly dependent on subtle
connotations of a specific word in a particular language – definitions have to be freely translatable among the
various languages of the group.
Session 2: application of consensus criteria of cue and concern definition (Rapporteur Linda Zandbelt)
The aim of the second parallel work session was to verify the applicability of the consensus-defined criteria
in identifying cues/concerns on two other interview transcripts. Each group had to identify cues/concerns
according to the consensus criteria defined during the previous plenary session, and to signal those
expressions where doubts emerged, and the reasons of uncertainty. The groups then compared their results in
the plenary session and revised the consensus criteria defined during the first parallel session.
The main points of discussion were:

Content and emotion
A first question was how to combine the two different aspects -emotion and content- that contribute to
define a cue or a concern. There could be different levels of explicitness of an emotion (no emotion,
implicit or explicit emotion) and specificity of a content (unspecified issue and specified issue). The
combination of the different levels of these two dimensions may contribute to clarify what a cue or a
concern is. A concern should have both, a content and an expression of emotion. Another topic of
discussion, related to these two levels, was the issue of their priority (is the emotion more important than
the content?). Consequently, a new category was suggested and called “explicit emotion”, referring to an
emotion expressed without a specified issue of importance e.g. “I’m quite anxious”. Another debate
emerged about how to intend words such as “tense”, “tired” or “relaxed”. Are they emotional” or not?

Patient or doctor initiated
It was agreed that both cues and concerns might be doctor or patient initiated and it was therefore
suggested to add the coding “d” and “p” to differentiate them

Repeated concerns and cues
The question was whether repeatedly expressed cues or concerns should be coded each time they
occurred. It was agreed to code a given topic only once when repeated within a turn, to give separate
codes to new topics or emotion arising within a turn, but also to topics, which the patient is clearly
presenting again after a doctor’s non-response. A suggestion was also to code as “elaboration of previous
concern” when the patient continued to express the same concern in a new turn and was facilitated in
doing so by the doctor.
The difficulty was mentioned to code on transcripts since non verbal aspects, like intonation of voice,
could make a big difference when deciding for example to code “I’m so tired” as concern or not.
Session 3: definition of appropriateness of provider responses (Rapporteurs Sandra van Dulmen and Helge
Skirbekk)
The aim for each group was to indicate the appropriateness of provider responses to cues and concerns,
which had been selected in the two transcripts of the second session and on which a consensus had emerged
in the second plenary session. During this evaluation task, the group had to define the criteria for
appropriateness and inappropriateness on the basis of a ranking where: –1 was inappropriate; 0 was
neutral/non applicable and 1 was the appropriate response. Each group was also asked to formulate
alternative appropriate expressions when absent. In the final plenary discussion group findings were
compared with the attempt to set common criteria for appropriateness on the basis of provider responses
identified as correct by most participants.
The feedback from the four subgroups reflected a broad variety of issues related to the definition of what
constitute appropriate provider responses to patient cues and concerns. At the end, although most of
participants concurred which were the appropriate/inappropriate responses, no common definition on what to
consider appropriate emerged and therefore clear rules were not established.
The main points of discussion were:

Coding appropriateness
Three problems were raised: to consider utterances or turns; to incorporate or not the subsequent
provider expression in defining the former as appropriate or not, and if to take into account patient’s
reaction to provider’s expression.
Another argument was the role of silence, (when it is appropriate) and the difficulty to recognize the
appropriateness on transcripts without the support of non-verbal information. The aim, which the
provider pursues in the consultation, should be taken into account when defining appropriateness.
There was full agreement that minimizing, normalizing or avoiding the patient’s problem were
inappropriate responses.

The “neutral” category
This category should be used when it is not clear what the doctor said or when it is ambiguous

Individual factors
The belief system of the rater determines what s/he considers appropriate or not. Individual differences
between patients may ask for different responses.

Changing topic
It was not clearly stated whether a change of topic or an interruption was to consider always as
inappropriate. Moving away from the present topic against the patient’s wishes is clearly inappropriate.
An interruption can be acceptable if the intent is to clarify or is a return to the most important matter. As
a help in deciding if a change of topic was appropriate it was proposed to observe patient’s subsequent
response.

Responding to an emotion
An educated guess can be appropriate when the provider thereby moves to the heart of the matter. The
concomitant non-verbal communication is also very important in handling patient’s emotions
appropriately.

Difficulty in applying rules
Sometimes the rater could judge the expression as clinically inappropriate but following strictly the rules
such expression would have to be coded as appropriate.
A similar issue regarded the observation that a provider may return to a previously discussed topic which
may be appropriate for that patient, but this provider expression will be coded as inappropriate taken
alone as it is.
Session 4: closure of the meeting
Jozien Bensing chaired the closure of the meeting on Saturday afternoon. She appreciated the collaborative
atmosphere of the meeting and encouraged future collaborations by suggesting, in continuity with this year’s
workshop, some stimulating research initiatives, for example the development of a common approach in
coding non-verbal cues by observing videotapes of interviews, and to examine such cues in relation to
concomitant verbal expressions and subsequent verbal and non verbal provider responses.
In synthesis, the two days workshop has been intensive; the discussions were very productive and raised
many questions that left some of the main issues related to the definitions of cue/concern and appropriateness
unresolved. For this reason the participants delegated a small group of participants to reconsider the
conceptual framework and to prepare a draft of a core definition of cue and concern, that could conciliate the
main aspects which had emerged in the first and second parallel sessions. This draft would be sent to all
participants for feedback, in order to refine a final agreement. Such an ultimate “filtered “definition could
then be used for another coding exercise or for a collaborative reliability study. The discussion on
appropriateness raised much more questions than answers. A main argument regarded the relationship
between the judgment of an appropriate response to cue/concern and the phase of the medical consultation in
which this response occurred. From this point of view the concept of appropriateness seems then strictly
related to what is the ideal model of a medical consultation. The conclusion was that the issue of
appropriateness needed to be reconsidered more thoroughly and therefore might be one possible topic for the
fourth meeting of the Verona Network on Sequence Analysis in 2006.