Bensing, J., Verheul, W. Towards a better understanding of the dynamics of patient provider interaction: the use of sequence analysis. Patient Education and Counseling: 2009, 75(2), 145- 146 This is a NIVEL certified Post Print, more info at http://www.nivel.eu Postprint Version 1.0 Journal website http://dx.doi.org/10.1016/j.pec.2009.03.002 Pubmed link http://www.ncbi.nlm.nih.gov/pubmed/19341873 DOI 10.1016/j.pec.2009.03.002 This is a NIVEL certified Post Print, more info at http://www.nivel.eu Towards a better understanding of the dynamics of patient provider interaction: The use of sequence analysis JOZIEN BENSING, WILLIAM VERHEUL NIVEL (Netherlands Institute for Health Services Research) P.O. Box 1568, 3500 BN Utrecht, The Netherlands Ever since, in the early eighties, Inui and Carter published their classic series of articles on doctor-patient interaction analysis [1] and [2], there is a recurrent debate on the most adequate strategies for analyzing the often complex interactions between patients and their health care providers. At that time, patient-provider communication was usually examined by presenting frequencies of coded communication behaviors and using correlation-based statistical techniques to analyze relations between those frequencies, thus ignoring the interactions between the two main players: the doctor (or nurse) and the patient. This led Inui and Carter to their provoking statement that most researchers reduced the medical encounter to a flat bundle of statistics, as if Hamlet would be described as “a play with 21 principal characters, a ghost, a group of players, and various numbers of lords, ladies, officers, soldiers, sailors, messengers, and attendants – one of whom is already dead, one of whom dies by drowning, one poisoned by drink, two by poisoned sword and one by poisoned sword and drink” [3]. A more vivid way to describe the lack of dynamics in patient-provider communication studies could hardly be given. Qualitative studies were generally seen as the most adequate way of revealing the micro dynamics of patient-provider interaction. It is only fairly recently that researchers also started to use quantitative techniques to zoom in on the interaction between doctor and patient, for example by analyzing turn-taking [4], or applying sequence analysis on the coded data [5]. Sequence analysis, which is not a single statistical technique, but a body of questions about how social processes emerge and a collection of techniques to study those [6] - has recently become quite popular among health communication studies, as was shown by Zimmermann et al in their recent review [5]. Sequence analysis studies, other than frequency association studies, allow an understanding of the temporal relationship between events, focusing on interactions in terms of what precedes and follows specified target behaviour [5]. Strictly spoken, these methods do not permit causal inferences, just like it is the case in frequency- based association studies. However, there is no doubt that analysing the order of events may give a better idea of how the interaction between doctor and patient proceeds over time under influence of the other participants’ contribution. Therefore, sequence analysis is, in itself, a valuable contribution to the methodology of patient-provider communication studies. In this issue, an important paper is published on the analysis of verbal interaction sequences in dyadic clinical communication [7]. In that paper, different methods of sequence analysis are presented, together with their strengths and flaws and examples of their use, which will provide much guidance for researchers who are interested in applying sequence analysis to