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Updated: Aug 14, 2026
Assessment of Social Interaction Behaviors
Published on: February 25, 2011
The Four Habits Coding Scheme: validation of an instrument to assess clinicians' communication behavior
Edward Krupat1, Richard Frankel, Terry Stein
1Harvard Medical School, 260 Longwood Avenue, 384 MEC, Boston, MA 02115, USA. ed_krupat@hms.harvard.edu
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.
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