The Four Habits Coding Scheme: Validation of an instrument to assess clinicians' communication behavior

Edward Krupat, Richard Frankel, Terry Stein, Julie Irish

Research output: Contribution to journalArticle

151 Scopus citations


Objective: To present preliminary evidence for the reliability and validity of the Four Habits Coding Scheme (4HCS), an instrument based on a teaching model used widely throughout Kaiser Permanente to improve clinicians' communication skills. Methods: One hundred videotaped primary care visits were coded using the 4HCS, and the data were assessed against a previously available data set for these visits, including the Roter Interaction Analysis System (RIAS), back channel responses, measures of nonverbal behavior, length of visit, and patients' post-visit assessments. Results: Levels of inter-rater reliability were acceptable, and the distribution of ratings across items indicated that physicians' modal responses varied widely. Correlations between 4HCS ratings, RIAS, back channel responses, and non-verbal measures provided evidence of the instrument's construct validity. Conclusions: The Four Habits Coding Scheme, an instrument that combines both evaluative and descriptive elements of physician communication behavior and is derived from a conceptually based teaching model, has the potential to be of utility to researchers and evaluators as well as educators and clinicians. Practice Implications: The Four Habits Coding Scheme provides a template for both guiding and measuring physician communication behaviors.

Original languageEnglish (US)
Pages (from-to)38-45
Number of pages8
JournalPatient Education and Counseling
Issue number1
StatePublished - Jul 1 2006


  • Interaction analysis
  • Patient-centered care
  • Physician-patient communication

ASJC Scopus subject areas

  • Medicine(all)

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