Abstract
We have previously used the Roter Interaction Analysis System (RIAS) to analyze differences between online and face-to-face medication counseling. In our previous research, students have commented that the built-in camera on their laptops makes it difficult to make eye contact and communicate effectively. Furthermore, there is a lack of research on the impact of eye contact in online medical communication. Therefore, this study aimed to investigate the effects of eye contact on online medication counseling. Two simulated patients (SPs) and 10 pharmacy students acting as pharmacists were enrolled in this clinical study (ID:2022-001). Participants were divided into 2 groups: one using cameras designed to naturally align eye contact and another using standard device cameras. The dialogues were segmented into meaningful minimal units (utterances), categorized using RIAS according to their nature, and analyzed. Scenarios with aligned eye contact significantly increased the total number of SP utterances and the occurrence and proportion of “Check” utterances by students, confirming their understanding. The increase in the total utterance count of SPs was associated with a corresponding increase in the number of “Agree” utterances indicating agreement and understanding. Thus, eye contact enhances the clarity of patient responses and proactively confirms patient understanding, thereby mitigating the difficulty of assessing comprehension and conducting bidirectional communication online. This study’s findings quantitatively suggested that eye contact in online medication counseling enhances proactive engagement in communication for pharmacy students and SPs.
INTRODUCTION
The outbreak of the coronavirus disease 2019 (COVID-19) pandemic has accelerated the implementation of online medical practice. This approach may aid in addressing problems such as medical overpopulation and increased workload even after the end of the pandemic.1–3) Thus, ensuring adequate access to online exercises, practical training, and various types of active learning is crucial, with multiple studies being conducted in this domain.4–9) We have used the Roter Interaction Analysis System (RIAS),10,11) a method for analyzing medical communication, to quantify and evaluate the effect of clinical practice experience on the communication skills of pharmacy students.12) Additionally, we have evaluated the effect of a role-play method using video call.13) The position of the camera on the device affects the line of sight in online communication.14–16) This results in difficulty in maintaining eye contact, potentially hindering effective communication. Few studies have evaluated the effect of eye contact on online medical communication. Furthermore, face-to-face communication training is essential in medical education, we believe its combination with online training is also worthwhile to keep pace with digitalization. Therefore, this study aimed to quantitatively analyze the effect of eye contact on online communication using RIAS and develop an effective online medical communication training method based on our research experience.
MATERIALS AND METHODS
Participants
Ten students (5 males and 5 females) from the School of Pharmaceutical Sciences (a 6-year program) and Graduate School of Life Sciences at Hokkaido University who had completed practical pharmacy training were enrolled in this study. In addition, 2 female volunteers from the general public were enrolled as simulated patients (SPs). Informed consent was obtained from all participants after providing a comprehensive explanation of the aims and objectives of this study.
Setup of the Eye Contact Device
A small web camera, KANO Camera 1013 (KANO Computing Limited, London, U.K.), was used during the role-play sessions such that the participants were able to make eye contact when looking at the face of their interaction partner. The camera was connected to a laptop via a flexible arm and positioned unobtrusively on the screen (hereafter referred to as the “eye contact device”).17,18) Based on previous studies, the camera was placed approximately 2.5 cm from the side of the face as it appeared on the screen.19) A standard notebook PC terminal with a built-in camera was also used (hereafter referred to as the “standard device”).
Recording and RIAS Analysis of Dialogues
The same scenario was role-played twice by the SP and student playing the role of the pharmacist; once using the “eye contact device” and once the “standard device” (hereafter referred to as “eye contact” and “standard,” respectively). A training session was conducted for the students and SPs beforehand to ensure a thorough understanding of the scenario. However, the students may provide medication instructions more fluently during the second role-playing session owing to increased familiarity. Therefore, the evaluation was performed after dividing the students into 2 groups: the students in the first group role-played “eye contact” first, whereas those in the second group role-played “standard” first. The 2 groups included equal numbers of participants, with 1 and 2 licensed pharmacist graduate students in each group, respectively; moreover, the male-to-female ratios were equivalent. A washout period was implemented between the first and second role-play sessions to mitigate memory effects. Table 1 lists the details of these scenarios. The RIAS used in this study follows the same procedure described in our previous study.20) All dialogues were coded by segmenting them into the smallest unit of “utterance.” Further details regarding the methodology can be found in our previous publication.20) The Pearson’s correlation coefficient was calculated for all scripts to determine the inter-coder reliability. Pearson’s correlation coefficient was 0.99, indicating high inter-coder reliability.
Table 1. Structure of the Role-Playing Scenario
| Structure of the scenario |
Online medication counseling in home healthcare |
| Situation |
Visits from pharmacies to provide medicine, check living conditions, physical condition/effects, and side effects of drug treatment. Ensure there are no leftover medications (residual medication management). |
| Interacting with home healthcare patients concerned regarding recurrent strokes, attempting to administer their medications appropriately, and having a strong interest in communicating with people other than their family members due to loneliness. |
| Basic patient information |
| Sex |
Female (Assumed sex of the SP) |
| Age |
68 years old |
| Patient family structure |
Living with spouse and daughter living in the neighborhood |
| Personality |
Serious, somewhat pessimistic |
| Medical history |
| Previous medical history |
Cerebral infarction (paraplegia of the left lower extremity) |
| Family history |
Father: died of stroke 5 years ago; Mother: died of heart failure 10 years ago |
| Medication history |
| Prescription drugs |
Current prescription: |
| Anticoagulant: Warfarin (1 mg) |
| Antihypertensive: Enalapril tablets (5 mg) |
| Each: 1 tablet, once daily after breakfast, for 14 d (starting from tomorrow) |
| Previous Prescription (14 d ago): |
| Warfarin (1 mg) |
| Enalapril tablets (5 mg) |
| Each: 1 tablet, once daily after breakfast, for 14 d |
| Allergy history |
None |
| Side effect history |
None |
| Current physical condition and living situation |
|
| Physical condition |
Good |
| Blood pressure status |
The systolic and diastolic blood pressure is approximately 130/90 mmHg, respectively |
| Side effect |
None |
| Diet |
Eating 3 meals a day |
| Bowel & Urination |
Bowel movements: Once every 1–2 d; urination: 4–5 times daily |
| Sleep |
Bedtime around 11 p.m., often wakes up at 4 a.m. and cannot fall back asleep; thus, naps during the day |
| Bathing |
Baths twice a week (wants to bathe more often but needs assistance and feels hesitant) |
A questionnaire was administered to the students via Google Forms after completing the role-playing sessions to obtain their feedback.
Ethics
This study was approved by the Ethics Review Committee of the Graduate School of Pharmaceutical Sciences at Hokkaido University (Approval No.: 2022-001).
Statistical Analysis
Wilcoxon signed-rank test was used for RIAS analysis and to compare the duration of role-play. The significance level was set at p < 0.05. All statistical analyses were performed using JMP Pro version 17 (SAS Institute, Cary, NC, U.S.A.).
RESULTS
Duration of Medication Counseling Role-Play
The median interaction time for “eye contact” was 458.0 s, with an interquartile range (IQR) of 401.0–541.0 s. The median interaction time for “standard” was 454.0 (IQR, 391.8–563.8) s. No statistically significant difference was observed between the 2 role-playing conditions. The median interaction time for the first role-play session was 469.5 (IQR, 394.3–563.8) s. The median interaction time for the second role-play session was 442.5 (392.5–541.0) s. No statistically significant difference was observed between the 2 sessions.
Number of Utterances Analyzed Using RIAS
Table 2 categorizes utterances into the “eye contact” and “standard” conditions for students and SPs. A comparison of the total number of student utterances in these scenarios revealed no significant difference between the “eye contact” and “standard” conditions. The median number of utterances for SPs was 90.5 (IQR, 61.0–107.5) for the “eye contact” condition and 80.0 (IQR, 60.8–93.3) for the “standard” condition (p < 0.05), indicating a significant intergroup difference.
Table 2. Comparison of Utterance Counts by RIAS Category: “Eye Contact”
versus “Standard” for Students and SPs
| Category in this study |
RIAS category |
Abbreviation |
Student |
|
SP |
|
| Eye contact |
Standard |
Eye contact |
Standard |
| Median (IQR) |
Median (IQR) |
Median (IQR) |
Median (IQR) |
| Partnership behaviors |
Personal remarks, social conversation |
Personal |
6.0 (4.5–7.5) |
7.0 (5.5–7.8) |
|
5.0 (3.0–6.0) |
4.5 (3.3–5.0) |
|
| Laughs and tells jokes |
Laughs |
0.5 (0.0–1.8) |
0.5 (0.0–1.8) |
|
0.5 (0.0–1.0) |
0.5 (0.0–1.0) |
|
| Shows approval—direct |
Approve |
7.0 (5.3–11.3) |
8.5 (5.5–11.8) |
|
1.5 (1.0–2.0) |
2.0 (1.3–3.0) |
|
| Gives compliment—general |
Comp |
0 |
0 |
|
N/A |
N/A |
|
| Shows disapproval—direct |
Disapprove |
0 |
0 |
|
0.0 (0.0–1.0) |
N/A |
|
| Shows criticism—general |
Crit |
0 |
0 |
|
0.0 (0.0–0.8) |
0.0 (0.0–0.8) |
|
| Shows agreement or understanding |
Agree |
17.5 (15.3–20.8) |
17.0 (13.5–19.5) |
|
22.0 (17.0–29.8) |
17.0 (15.0–23.3) |
* |
| Back-channel responses |
BC |
9.0 (6.0–10.0) |
6.5 (4.3–10.0) |
|
14.0 (2.5–26.0) |
10.5 (4.8–18.0) |
|
| Remediation |
Remediation |
0.0 (0.0–0.8) |
0.5 (0.0–2.0) |
|
0.0 (0.0–1.0) |
0.0 (0.0–0.8) |
|
| Empathy statements |
Empathy |
2.0 (1.0–3.8) |
3.0 (2.0–3.0) |
|
0 |
0 |
|
| Legitimizing statements |
Legit |
0.0 (0.0–0.8) |
0 |
|
0 |
0 |
|
| Shows concern or worry |
Concern |
0 |
N/A |
|
4.0 (3.0–4.0) |
2.0 (1.0–2.8) |
|
| Reassures, encourages, or shows optimism |
R/O |
1.0 (0.3–2.0) |
0.0 (0.0–1.8) |
|
0 |
N/A |
|
| Asks for reassurance |
?Reassure |
0 |
0 |
|
0 |
N/A |
|
| Partnership statements |
Partner |
0.0 (0.0–1.0) |
0.0 (0.0–0.8) |
|
0 |
0 |
|
| Self-disclosure statements |
Sdis |
0 |
0 |
|
0 |
0 |
|
| Subtotal |
|
|
50.0 (40.3–60.5) |
48.5 (37.0–55.0) |
|
49.0 (31.3–69.8) |
43.0 (26.0–54.3) |
** |
| Question asking |
Asks open-ended questions about medical condition |
?Med |
1.0 (1.0–1.0) |
1.0 (1.0–1.0) |
|
0 |
0 |
|
| Asks closed-ended questions about medical condition |
[?]Med |
0.0 (0.0–0.8) |
0.0 (0.0–1.0) |
|
0 |
0 |
|
| Asks open-ended questions about the therapeutic regimen |
?Thera |
N/A |
0.0 (0.0–0.8) |
|
1.0 (1.0–1.0) |
1.0 (0.3–1.0) |
|
| Asks closed-ended questions about the therapeutic regimen |
[?]Thera |
5.5 (4.3–6.8) |
5.0 (4.3–6.8) |
|
1.5 (0.3–2.0) |
1.0 (0.0–1.8) |
|
| Asks open-ended questions about lifestyle information |
?L/S |
1.0 (0.0–1.0) |
0.0 (0.0–0.8) |
|
0 |
0 |
|
| Asks closed-ended questions about lifestyle information |
[?]L/S |
4.0 (3.3–4.0) |
4.0 (3.0–5.8) |
|
0 |
N/A |
|
| Asks open-ended questions about psychosocial information |
?P/S |
2.0 (1.0–2.8) |
2.0 (1.3–2.8) |
|
0 |
0 |
|
| Asks closed-ended questions about psychosocial information |
[?]P/S |
0 |
N/A |
|
0 |
0 |
|
| Asks open-ended questions about other |
?Other |
0 |
0 |
|
0 |
0 |
|
| Asks closed-ended questions about other |
[?]Other |
N/A |
0 |
|
N/A |
0 |
|
| Asks for opinion |
?Opinion |
1.0 (0.3–2.0) |
2.0 (1.0–2.0) |
|
0 |
0 |
|
| Asks open-ended questions about online† |
?Online |
0 |
0 |
|
0 |
0 |
|
| Asks closed-ended questions about online† |
[?]Online |
N/A |
N/A |
|
0 |
0 |
|
| Subtotal |
|
|
15.0 (13.5–18.3) |
16.0 (14.3–18.5) |
|
2.5 (2.0–3.0) |
1.5 (1.0–2.8) |
|
| Information giving |
Gives information about the medical condition |
Gives-Med |
N/A |
0.0 (0.0–0.8) |
|
1.0 (1.0–1.8) |
2.0 (2.0–2.0) |
|
| Gives information about the therapeutic regimen |
Gives-Thera |
7.0 (5.5–9.8) |
6.5 (5.0–10.3) |
|
8.0 (7.3–8.0) |
6.5 (6.0–8.0) |
|
| Gives information about lifestyle information |
Gives-L/S |
N/A |
0 |
|
7.5 (7.0–9.8) |
7.5 (7.0–9.0) |
|
| Gives information about psychosocial information |
Gives-P/S |
0 |
0.0 (0.0–0.8) |
|
8.0 (6.3–8.8) |
8.0 (7.0–8.8) |
|
| Gives information about other |
Gives-Other |
0 |
0 |
|
N/A |
N/A |
|
| Gives information about online† |
Gives-Online |
0 |
0 |
|
N/A |
0 |
|
| Subtotal |
|
|
8.0 (5.5–9.8) |
6.5 (6.0–10.3) |
|
24.5 (22.3–29.8) |
25.0 (21.5–28.3) |
|
| Counsel behaviors |
Counsels or directs behavior about the medical condition |
C-Med |
0 |
0.0 (0.0–0.8) |
|
0 |
0 |
|
| Counsels or directs behavior about the therapeutic regimen |
C-Thera |
8.0 (6.5–12.3) |
8.5 (6.3–14.0) |
|
0 |
0 |
|
| Counsels or directs behavior about lifestyle information |
C-L/S |
1.0 (0.0–1.8) |
1.5 (0.3–2.8) |
|
0 |
0 |
|
| Counsels or directs behavior about psychosocial information |
C-P/S |
0 |
N/A |
|
0 |
0 |
|
| Subtotal |
|
|
9.0 (6.5–14.5) |
11.0 (8.8–15.3) |
|
0 |
0 |
|
| Others |
Gives orientation, instructions |
Orient |
6.0 (3.0–7.8) |
6.0 (5.0–7.0) |
|
0 |
0 |
|
| Paraphrase/checks for understanding |
Check |
13.0 (10.0–17.5) |
9.5 (5.5–12.0) |
* |
3.0 (2.0–4.8) |
2.0 (1.3–4.8) |
|
| Asks for permission |
?Permission |
2.0 (1.0–2.8) |
1.5 (1.0–2.0) |
|
0 |
0 |
|
| Asks for understanding |
?Understand |
0 |
0 |
|
0 |
0 |
|
| Bid for repetition |
?Bid |
N/A |
N/A |
|
N/A |
0 |
|
| Requests for services or medication |
?Service |
0 |
0 |
|
0 |
N/A |
|
| Transition words |
Trans |
13.0 (10.0–18.5) |
15.5 (9.0–19.3) |
|
5.0 (4.3–6.8) |
5.0 (4.0–6.0) |
|
| Unintelligible utterances |
Unintell |
0 |
0 |
|
0 |
N/A |
|
| Subtotal |
|
|
32.0 (28.0–38.8) |
32.0 (19.0–37.5) |
|
9.0 (6.3–10.8) |
8.0 (6.0–9.8) |
|
| Total |
|
|
119.5 (104.5–132.8) |
121.0 (86.5–145.5) |
|
90.5 (61.0–107.5) |
80.0 (60.8–93.3) |
* |
|
|
|
|
|
|
|
* p < 0.05, ** p < 0.01 |
|
The RIAS encodes conversations between healthcare professionals and patients into units called “utterances” according to their function and content. This table lists all RIAS categories used in this study and compares the median and IQR of the number of utterances per category for the “eye contact” and “standard” categories for students and SP, respectively. Abbreviations preceded by a question mark (or a question mark in square brackets) represent the categories of utterances containing the question to be asked by the partner. The symbols “*” and “**” represent comparisons of the results of “eye contact” and “standard” interaction between the student and SP, respectively (Wilcoxon signed-rank test). 0, no relevant utterances were observed. N/A, insufficient data for calculation. The categories marked with the symbol “†” are new categories added to the existing categories under our previous study.
Abbreviations: RIAS: Roter Interaction Analysis System; IQR: interquartile range; SP: simulated patients.
Among the 5 clusters of “Partnership behaviors,” “Question asking,” “Information giving,” “Counsel behaviors,” and “Others,” the cluster of “Partnership behaviors” had a higher number of SP utterances in the “eye contact” condition (p < 0.01) (Table 2).
Regarding the individual categories, the “Agree” category (indicating agreement or understanding) within the “Partnership behaviors” of the SP cluster was significantly higher in the “eye contact” condition (p < 0.05). The number of utterances in the “Check” category, including utterances indicating confirmation of understanding, accurate communication, and paraphrasing for clarification, was significantly higher for students in the “eye contact” condition (p < 0.05). The proportion of student utterances in the “Check” category was significantly higher as a percentage of the total number of utterances (p < 0.05), increasing from a median of 7.9% in the “standard” condition to 11.8% in the “eye contact” condition.
Results of Post-role-play Questionnaire for Students
Seven of 10 participants found explaining easier in the “eye contact” condition with the eye contact camera. For Question 1, 6 felt neither condition resembled a face-to-face conversation, while 1 felt both did; for Question 5, 7 felt neither condition made them conscious of the partner’s gaze. Detailed results are shown in Supplementary Table 1.
DISCUSSION
Nonverbal communication, such as eye gaze and gestures, plays an essential role in effective communication and enriches conversation by providing additional information and revealing emotional states that are not expressed verbally.21) Eye contact (gaze) plays an important role in communication, with infants exhibiting a preference for direct eye contact from birth.22) Eye contact has important functions such as giving and receiving speech rights during conversation and facilitating speech.23) Eye contact is effective in demonstrating empathy and rapport from a medical provider to a patient in the medical field.24–26) A physician’s gaze toward a patient is positively related to patient outcomes such as the level of trust in the physician, medication adherence, and physical and cognitive function.27–30) However, few studies have quantitatively analyzed the effect of eye contact on medical communication. To the best of our knowledge, this is the first study of its kind to be conducted within the context of online medication counseling. RIAS was used to quantify and objectively evaluate the effect of eye contact on communication in giving online medication instructions in this study. The SPs who made eye contact had a significantly higher total number of utterances (Table 2). Eye contact also facilitates dialogue. Providing more information becomes easier when medical professionals make greater eye contact with patients.31) Eye contact in online communication facilitates understanding concepts.32) This study quantitatively demonstrated that eye contact facilitates online communication. Several studies have reported the effects of the lack of eye contact on communication. Lack of eye contact between instructors and learners overloads learning activities in classroom settings.33) A study on medical students revealed that video calls are not a suitable medium for emotion-based interactions owing to the difficulty in establishing eye contact.34) The present study revealed an increase in the “Check” category of RIAS among the students in the eye contact group. Thus, utilizing our online tool, which alleviates the difficulty of eye contact, may address the unique challenges associated with eye contact in online communication by encouraging medical professionals to prompt patients to speak.
Analyzing the 5 categories revealed that utterances in the “Partnership behavior” cluster of SPs in the “eye contact” condition were significantly higher (Table 2). Likewise, the number of utterances in the “Agree” category of SPs was significantly higher in the “eye contact” condition; thus, increasing the total number of SP utterances. The number of utterances in the “Check” category of students was significantly higher in the “eye contact” condition than in the “standard” condition. Responses to the “Check” category utterances are coded as “Agree” in RIAS. Therefore, the high number of utterances of “Agree” by SPs in “eye contact” is a response to the high number of “Check” by students. Eye contact facilitated utterances to confirm the understanding of the other party. Eye contact facilitates giving up the turn of the conversation, plays a role in speech monitoring, and prevents as well as repairs interruptions.23) Seven of 10 students indicated that they found it easier to explain to their partner in the “eye contact” condition (Supplementary Table 1). This may have contributed to smoother communication, helping with the sharing of opinions and feelings, confirming that the patient was listening, and encouraging patient responses. However, mixed responses to Question 1 (to which 1 student answered “True for both” and 6 answered “True for neither”) and Question 5 (to which 7 answered “True for neither”) suggest that factors beyond eye contact, such as the presence of the external camera, may have influenced their experience. The minimal gaze awareness in both conditions suggests that the eye contact camera functioned naturally without drawing undue attention. While this raises concerns about whether the observed effects are solely attributable to eye contact, the increased number of utterances in the “Check” category suggests that visual feedback may have supported patient understanding during medication counseling. Further verification, including eye-tracking analyses, is required in future studies.
RIAS analysis was performed to quantify and objectively evaluate the effect of eye contact on communication in online medication counseling in this study. Our findings suggest that SPs communicate more when eye contact is made. Furthermore, the proportion of utterances that confirm whether the patient understood increased among students playing the role of pharmacists, thereby encouraging interactive dialogue. Our previous study revealed that gauging the level of understanding of another party is difficult in online communication, which hinders 2-way communication.13) However, patient responses could be captured more clearly by supplementing eye contact with tools, with students actively confirming the patients’ level of understanding. Thus, this study’s findings quantitatively suggested that natural eye contact in online medication counseling promotes mutual speech and enhances students’ attitudes toward proactive engagement in communication. These findings indicate that tools supporting nonverbal elements may play a valuable role in facilitating 2-way communication in online settings.
Research Limitations and Future Suggestions
The limitations of this study include its small sample size, the potential influence of student temperament, SP compatibility, the trial with students and SPs, and unconscious bias in device assignment order. Future studies with larger sample sizes, minimal extraneous influences, and comparative analyses are necessary.
Funding
This work was partially supported by JSPS KAKENHI Grant Numbers: JP22H04159 and JP24H02505 (provided by A.M.), the “Medical Human Resource Development Project for New Medical Treatment in the With-Corona Era” from MEXT, and “R&T (Researcher & Technician) collaboration project” from Hokkaido University Core Station for the Management of Open Facility and Skills (provided by A.M.).
Conflict of Interest
The authors declare no conflict of interest.
Supplementary Materials
This article contains supplementary materials.
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