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Background The ratings of physician-patient communication are an important indicator of the quality of health care delivery and provide guidance for many important decisions in the health care setting and in health research. But there is no gold standard to assess physician-patient communication. Thus, depending on the specific measurement condition, multiple sources of variance may contribute to the total score variance of ratings of physician-patient communication. This may systematically impair the validity of conclusions drawn from rating data. Objective To examine the extent to which different measurement conditions and rater perspectives, respectively contribute to the variance of physician-patient communication ratings. Methods Variance components of ratings of physician-patient communication gained from 32 general practitioners and 252 patients from 25 family practices in Germany were analyzed using generalizability theory. The communication dimensions “shared decision making”, “effective and open communication” and “satisfaction” were considered. Results Physician-patient communication ratings most substantially reflect unique rater-perspective and communication dimension combinations (32.7% interaction effect). The ratings also represented unique physician and rater-perspective combinations (16.3% interaction effect). However, physicians’ communication behavior and the observed communication dimensions revealed only a low extent of score variance (1% physician effect; 3.7% communication dimension effect). Approximately half of the variance remained unexplained (46.2% three-way interaction, confounded with error). Conclusion The ratings of physician-patient communication minimally reflect physician communication skills in general. Instead, these ratings exhibit primarily differences among physicians and patients in their tendency to perceive shared decision making and effective and open communication and to be satisfied with communication, regardless of the communication behavior of physicians. Rater training and assessing low inferential ratings of physician-patient communication dimensions should be considered when subjective aspects of rater perspectives are not of interest.

Hayes et al. [15] argued for abandoning the term "level" using "approach" instead, as research projects can use a combination and as there are no clear-cut boundaries. Zeitschrift für Rheumatologie Originalien Online survey and interviews with experts (Study 1) The PRPs and both researcher groups determined together all communication situations included in the online survey. Discussion of findings The PRPs and researchers agreed on the areas of communication to be included in the training based on the results of the online survey. Literature Studies on"Social participation of persons with RMDs" and "Communication of persons with RMDs." Creation of v ersion 1 of the training manual by one researcher group Discussion of Version 1 The PRPs and both researcher groups discussed and agreed on changes to the manual. Creation of version 2 of the training manual by one researcher group Review of manual The revised version was reviewed by PRPs, members of the management of the GLR and researchers. Creation of version 3 of the training manual by one researcher group Pilot groups The feasibility and acceptance of KOKOS-Rheuma was tested in two pilot groups, each conducted by one PRP and one researcher. Creation of version 4 of the training manual by one researcher group Cluster-randomised evaluation (in three regional organisations of the GLR) The training was evaluated by participants, trainers (volunteers of the GLR, PRPs, researchers) and observers (members of one research group) with short evaluation sheets and a questionnaire survey with three measurement points. Train-the-trainer course (TTT course) Volunteers from the three regional organisations of the GLR were trained to become trainers of the communication skills training program. Creation of final version of the training manual by one researcher group Feedback on training contents One research group created a table with topics, examples and potential training contents based on findings of Study 1, and the PRPs commented on and added to the table. Discussion with members of the management of GLR Basic conditions for the training (e.g., length) were agreed on. Feedback on previous training PRPs provided feedback regardinga previous communication training via telephone or face-to-face. Pre-test of questionnaires Survey questionnaires were pre-tested with a small number of respondents 2 Both studies were registered in the German Clinical Trials Register (Study 1 =DRKS00008323 and Study 2 = DRKS00008054).