Cross-cultural adaptation of the Four Habits Coding Scheme (4HCS) for teaching and assessing patient-centered communication skills in Brazil

Brazilian educational guidelines reinforce patient-centered care communication skills as an important competence for medical students. The Four Habits Coding Scheme (4HCS) is an instrument used for teaching and assessing clinicians' communication skills in a person-centered care approach. We aimed to translate and culturally adapt the 4HCS into Brazilian Portuguese. The translation process was accomplished in seven stages: initial translation, reconciliation, back translation, review by the author, independent review, consensus version through Delphi technique, review by a language coordinator, and pretest. During pretest, three independent observers assessed four medical consultations, which were performed by medical students and residents, that had been recorded in a real healthcare scenario. Reviewers had difficulty in reaching consensus on expressions referring to understanding the person as a whole, such as Engage in small talk, Expansion of concerns, Elicit full agenda, Use patient's frame of reference, and Explore plan acceptability. They also had difficulty in reaching consensus on the translation of the word clinician, which was first translated as physician. Historical and cultural issues in the physician-patient relationship may have influenced this result. The Brazilian 4HCS is a culturally, conceptually, semantically and operationally sound instrument. It may represent an important advance for strengthening the person-centered care model in Brazil.