Boosting nonverbal physician-patient communication in medical education

Método: Traduzimos a RCS-O em sete etapas: tradução inicial, reconciliação, retrotradução, revisão pelo autor, revisão independente, consenso pela técnica Delphi, revisão por um coordenador de linguagem e pré-teste. Utilizamos gravações de quatro consultas médicas realizadas por estudantes de Medicina e residentes para pré-testar o instrumento. Durante essa fase, três observadores independentes avaliaram o desempenho de estudantes de Medicina e residentes em cenários reais de assistência médica por meio do uso das gravações.


INTRODUCTION
Nonverbal communication is an important part of medical interviewing 1 , corresponding to nearly 60% of doctor-patient interactions [2][3][4][5] . Nonverbal communication has been widely researched outside the medical field 6,7 . In the medical literature, studies have suggested that nonverbal communication plays an important role in the physician-patient relationship 8 , being associated with patient satisfaction [9][10][11] , emotional distress 12 , symptom resolution 13 , and malpractice claims 14 .
Despite such evidence, nonverbal skills are still underestimated in medical education. Few interventions designed to improve medical students' nonverbal behavior are reported in the medical education research field. Uncertainties on whether nonverbal behavior may be developed through educational interventions might explain this paucity of evidence 10,[15][16][17] . Some authors believe nonverbal behavior is innate 18 , while others admit that this behavior is culture-specific and can be learned 19 . We assume that nonverbal communication skills are determined by a fusion of these extremes 5 .
Considering nonverbal communication -posture, gesture, eye contact, tone of voice, and proximity, that is, aspects of an actor's demeanor that frame the message content -as a trainable skill 8,20,21 , the existence of appropriate instruments for teaching and assessing the nonverbal behavior of physicians and medical students is mandatory. The Relational Communication Scale for Observational measurement of doctor-patient interactions (RCS-O) is an instrument specifically developed to measure the relational communication aspects of the doctor-patient interaction. It is practical to administer and can be used in formative assessments of medical students and physicians 22 . Since the RCS-O has been originally developed in the United States, its use in other countries must be preceded by the adequate processes of translation, cultural and linguistic adaptation 23 . Such processes are particularly important as nonverbal skills vary between different situations and cultures [24][25][26] .
The RCS-O is used for the direct observation of the doctor-patient relationship, with good psychometric properties for the majority of its items and domains. To the best of our knowledge, the RCS-O is the only validated instrument that was specifically developed to measure the relational aspects of non-verbal behavior during the interaction between doctor and patient 22 .
This research reinforces the importance of nonverbal communication as a powerful medical skill and aims to translate and culturally adapt the RCS-O to Brazilian Portuguese. The scale will be used to assist medical educators in designing and evaluating educational interventions tailored to improve students' nonverbal communication with patients.

METHODS
This is a cross-cultural adaptation study, which was approved by the local research ethics committee, carried out after permission by Judee Burgoon, the instrument's author.

Instrument
The RCS-O is a validated version for third-party observers of doctor-patient interactions of the Burgoon and Hales' relational communication scale (RCS) 22,[27][28][29][30] . The scale was specifically developed to produce a global measure of the relational component of doctor-patient interactions, handled primarily through nonverbal channels 22 . It comprises 34 items arranged in six dimensions.
The six dimensions are divided as follows: (1) intimacy -IA immediacy/affection -the degree to which closeness or distance is expressed, (2) intimacy (SD -similarity/depth)the degree to which the interactants feel alike or different, (3) intimacy (RT -receptivity/trust) -the degree to which interest and concern or lack of interest and disregard are expressed, (4) composure (C) -the degree to which one is calm or anxious, (5) formality (F) -the degree to which the interaction is formal or relaxed and (6) dominance (D) -the degree to which power is shared or unequal 22 .
The instrument can be used in formative assessment of physicians and medical students 22 . Answers are rated on a seven-point Likert scale ranging from ''strongly disagree'' to ''strongly agree'' . Scores range from 34 to 228, with higher scores indicating the ability to put the patient at ease and develop an equal partnership with the patient. Doctors with higher scores demonstrate openness by revealing a professional demeanor that is friendly, approachable, and relaxed. The RCS-O is a psychometrically sound instrument used to measure relational communication skills not only in patient-centered, but also in doctor-centered approaches 22,27,28,30 .

Translation and cultural adaptation
The translation and cultural adaptation of the instrument were performed according to international guidelines 31,32 ( Figure 1). In the first stage -forward translation -two bilingual translators native of Brazilian Portuguese produced two independent translations of the instrument from English into Brazilian Portuguese. In the second stage, a bilingual healthcare professional native of Brazilian Portuguese performed the reconciliation of the previous translations. In the third stage (back translation), an American translator fluent in Portuguese translated the reconciled version back into the original language. In the fourth stage, the author of the instrument made comments on the back-translated version. The questionnaires answered by the independent reviewers comprised the entire translation process and were available to the reviewers during the whole process, which totaled three rounds. The process was completed after meeting at least 80% of consensus among the participants 36,37 . The instrument was then sent for evaluation by a language coordinator and for a new analysis by the author (stage six), to produce the pre-final version.

Pre-test
Three interns, three medical residents, and six patients

RESULTS
The RCS-O title and items "The physician did not want a deeper relationship with the patient" (IA2), "The physician communicated coldness rather than warmth" (IA5), and "The physician seemed to desire further communication with the patient" (SP13) were reviewed after the back translation and the author's comments. These items were then analyzed through the modified Delphi technique rounds. The item IA5 reached consensus (100% agreement) only after four rounds (Table 1).
At the end of the translation process, the language coordinator adjusted nine (26.4%) items. The adjustments were grouped into five categories: Conventionality pragmatic level,

RT
The physician did not want a more intimate relation with the patient b

Pre-final O(a) médico(a) não quis uma relação mais próxima com o(a) paciente b
IA5 item The physician communicated coldness rather than warmth b

RT
The physician communicated in a cold way, rather than warmly b

Pre-final O(A) médico(a) transmitiu frieza ao invés de cordialidade b
SP13 item The physician seemed to desire further communication with the patient  Table 2). Items that required modification generally belonged to the intimacy domains I and II. Items IA2, IA5, and SP13 required more than one change. In the item IA2, both changes were in the combinality category. Five items were adjusted due to ambiguity/polysemy ( Table 2).
All pre-test observers considered the instrument comprehensible and easy to apply. One of them, aiming to ensure familiarity in identifying clues related to certain nonverbal behaviors, strengthened the importance of previous training with the scale. Another observer suggested that the instrument should be used for teaching and assessing not only physicians and medical students, but also other health professionals.

DISCUSSION
Although nonverbal communication is present in every social interaction, it is still underestimated in scientific studies 8 . To our knowledge, this is the first Brazilian translation and cultural adaptation study of an instrument for teaching and assessing nonverbal medical students' and physicians' skills in relational communication in the clinical encounter.
During the translation process, words were changed in order to remove the sexual connotation that could arise from overintimacy in the physician-patient relationship. The words "stimulating", "warmth", "desire", "relaxed", "conversation to a deeper level", "deeper relationship", "casual", and "intensely" were changed in the consensus stage by independent reviewers, the  Likewise, on account of polysemic meanings in Brazilian Portuguese, we decided to change the words "relaxed" (item C23) and "casual" (item F27). In English, "relaxed" is an adjective that represents concepts of being calm, not anxious38 and it does not have the pejorative connotation of carelessness or displeasure on the part of the doctor towards the patient, as it may be case in Brazilian Portuguese 45 . "Casual", on the contrary, is also a polysemic word in English, and we chose the adjective "descontraída" to convey the non-formal connotation intended by the scale. "Relaxed" and "casual" could also sound as lack of professionalism in the physician-patient relationship. Although some studies have claimed that nonverbal behavior is mandatory for good medical care, there still is a limited comprehension of the meaning of nonverbal clues, especially concerning the physician-patient interaction 46 .
Assessing this behavior requires caution , since many factors may change the "reading" of the nonverbal behavior.