Interaction analysis of physician-patient communication: the influence of trait anxiety on communication and outcome

Little attention has been paid to how patients' personality traits interfere with the communication and the outcome of physician-patient interaction. We performed an experimental study with students with high and low trait anxiety as patients. One physician conducted a single consultation with 41 students applying two beforehand-specified consultation styles. Patients completed questionnaires concerning emotional state and satisfaction. The actual content of the consultations was analyzed by Roter interaction analysis system (RIAS). The physician gave more biomedical information to low-anxiety students than high-anxiety students. Students who provided a lot of biomedical information themselves were less tense after the consultation. However, students with high anxiety were more dependent on the physician actively asking biomedical questions for them to be able to deliver that same information. In contrast to low-anxiety students, those with high anxiety were less satisfied after consultations involving many psychosocial questions posed by the physician and a good deal of emotional talk on their own part. Compared to low-anxiety students, students with high anxiety were less satisfied and tenser after consultations with much positive emotional talk on the part of the physician. We conclude that physicians and educators should be aware that psychological and emotional communication may be experienced as intrusive and inappropriate by patients with high trait anxiety when they present minor somatic problems.     

Electronic medical record use and physician-patient communication: an observational study of Israeli primary care encounters

OBJECTIVES: Within the context of medical care there is no greater reflection of the information revolution than the electronic medical record (EMR). Current estimates suggest that EMR use by Israeli physicians is now so high as to represent an almost fully immersed environment. This study examines the relationships between the extent of electronic medical record use and physician-patient communication within the context of Israeli primary care. METHODS: Based on videotapes of 3 Israeli primary care physicians and 30 of their patients, the extent of computer use was measured as number of seconds gazing at the computer screen and 3 levels of active keyboarding. Communication dynamics were analyzed through the application of a new Hebrew translation and adaptation of the Roter Interaction Analysis System (RIAS). RESULTS: Physicians spent close to one-quarter of visit time gazing at the computer screen, and in some cases as much as 42%; heavy keyboarding throughout the visit was evident in 24% of studied visits. Screen gaze and levels of keyboarding were both positively correlated with length of visit (r = .51, p < .001 and F(2,27) = 2.83, p < .08, respectively); however, keyboarding was inversely related to the amount of visit dialogue contributed by the physician (F(2,27) = 4.22, p < .02) or the patient (F(2,27) = 3.85, p < .05). Specific effects of screen gaze were inhibition of physician engagement in psychosocial question asking (r = -.39, p < .02) and emotional responsiveness (r = -.30, p < .10), while keyboarding increased biomedical exchange, including more questions about therapeutic regimen (F(2,27) = 4.78, p < .02) and more patient education and counseling (F(2,27) = 10.38, p < .001), as well as increased patient disclosure of medical information to the physician (F(2,27) =3.40, p < .05). A summary score reflecting overall patient-centered communication during the visit was negatively correlated with both screen gaze and keyboarding (r = -.33, p < .08 and F(2,27) = 3.19, p < .06, respectively). DISCUSSION: The computer has become a 'party' in the visit that demanded a significant portion of visit time. Gazing at the monitor was inversely related to physician engagement in psychosocial questioning and emotional responsiveness and to patient limited socio-emotional and psychosocial exchange during the visit. Keyboarding activity was inversely related to both physician and patient contribution to the medical dialogue. Patients may regard physicians' engrossment in the tasks of computing as disinterested or disengaged. Increase in visit length associated with EMR use may be attributed to keyboarding and computer gazing. CONCLUSIONS: This study suggests that the way in which physicians use computers in the examination room can negatively affect patient-centered practice by diminishing dialogue, particularly in the psychosocial and emotional realm. Screen gaze appears particularly disruptive to psychosocial inquiry and emotional responsiveness, suggesting that visual attentiveness to the monitor rather than eye contact with the patient may inhibit sensitive or full patient disclosure. PRACTICAL IMPLICATIONS: We believe that training can help physicians optimize interpersonal and educationally effective use of the EMR. This training can assist physicians in overcoming the interpersonal distancing, both verbally and non-verbally, with which computer use is associated. Collaborative reading of the EMR can contribute to improved quality of care, enhance the decision-making process, and empower patients to participate in their own care.     

Brief psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression

Background  

Psychological therapies provided in primary care are usually briefer than in secondary care. There has been no recent comprehensive review comparing their effectiveness for common mental health problems. We aimed to compare the effectiveness of different types of brief psychological therapy administered within primary care across and between anxiety, depressive and mixed disorders.     

Comorbidity of generalized social anxiety disorder and depression in a pediatric primary care sample

Background: Comorbidity between adult social anxiety disorder and major depression is extensive. Considerably less information about this relationship is available among youth. Methods: A randomly selected (from enrollees in a pediatric primary care clinic) sample of 190 families with children between the ages of 8 and 17 responded by mail to questionnaires assessing social anxiety, depression, and social functioning. Parents also completed a semi-structured telephone diagnostic interview about their child. Results: The generalized type of social anxiety disorder was highly comorbid with major depression, generalized anxiety disorder, specific phobias, and ADHD, while little comorbidity was present for the nongeneralized subtype of social anxiety disorder. Logistic regression analyses indicated that generalized social anxiety disorder was the only anxiety disorder associated with an increased likelihood of major depression (OR=5.1). In all cases, social anxiety disorder had a significantly earlier age of onset than major depression. Limitations: This study relies on cross-sectional data and diagnoses are based on parent reporting of child behavior. Conclusions: Generalized social anxiety disorder is strongly associated with depressive illness in youth. Screening and treatment approaches that consider both social anxiety and depressive symptoms are necessary. Early intervention to treat social anxiety disorder may prevent later depressive disorders.     

Influence of ethnicity and language concordance on physician-patient agreement about recommended changes in patient health behavior

The purpose of this study is to examine the association of ethnicity and language concordance with physician-patient agreement about physicians' recommendations for patient health behavior in the following areas: diet, exercise, medication, smoking, stress, and weight. Twenty-seven resident physicians at the University of New Mexico's internal medicine and family practice clinics and 427 of their patients participated. Random effects models were used to estimate the influence of ethnicity and language concordance on whether patients and physicians agreed about specific recommended changes in patient behavior. Ethnicity concordance was not significantly associated with physician-patient agreement. Language concordance positively influenced the likelihood of agreement about exercise but negatively influenced agreement about medications. The lowest percentage of agreement occurred in the area of medication regimens (60%). The results from this study indicate that language is an important barrier to physician-patient agreement, while ethnicity concordance has no effect. However, the influence of whether the physician and patient speak the same language on agreement is unclear and warrants further research.     

Gender differences in the prevalence of depression: a survey in primary care.

Epidemiological surveys demonstrate that unipolar depression is more common in females than in males. Gender-specific cultural and social factors may contribute to the female preponderance. This study explores this possibility in a cross-cultural sample of general-practice patients systematically recruited in the WHO study "Psychological Problems in Primary Care" conducted in 14 countries with identical sampling and assessment strategies. Although absolute prevalence rates are broadly varying between centers proposing that the gender ratio is nearly constant with 1:2. The cultural context does not contribute substantially to the female preponderance. This study lends some support to previous observations that the magnitude of female preponderance is associated with the number of symptoms associated with depression requested for caseness and inversely related to the degree of social impairment. Matching social role variables (marital status, children, occupational status) between females and males reduces the female excess by about 50% across all centers. Therefore, we conclude that social factors are inducing part of the preponderance of females among depressed cases.     

Effects of communication about uncertainty and oncologist gender on the physician-patient relationship

Objective: Physicians are increasingly expected to share uncertain information, yet there is concern about possible negative effects on patients. How uncertainty is conveyed and by whom may influence patients’ response. We tested the effects of verbally and non-verbally communicating uncertainty by a male vs. female oncologist on patients’ trust and intention to seek a second opinion.Methods: In an experimental video vignettes study conducted in The Netherlands, oncologist communication behavior (verbal vs. non-verbal and high vs. low uncertainty) and gender (male vs. female) were systematically manipulated. Former cancer patients viewed one video variant and reported trust, intention to seek a second opinion, and experience of uncertainty.Results: Non-verbal communication of high uncertainty by the oncologist led to reduced trust (β = -0.72 (SE = 0.15), p < .001) and increased intention to seek a second opinion (β = 0.67 (SE = 0.16), p < .001). These effects were partly explained by patients’ increased experience of uncertainty (β = -0.48 (SE = 0.12), p < .001; and β = 0.34 (SE = 0.09), p < .001 respectively). Neither verbal uncertainty nor oncologists’ gender influenced trust or intention to seek a second opinion.Conclusion: Non-verbal communication of uncertainty by oncologists may affect patient trust and intention to seek a second-opinion more than verbal communication.Practice Implications: Further research to understand and improve oncologists’ non-verbal uncertainty behavior is warranted.     

Gender and symptoms in primary care practices

The authors sought to explore gender differences among patients with physical symptoms who came to see internists. The women were younger, more likely to report stress, endorsed more "other, currently bothersome" symptoms, were more likely to have a mental disorder, and were less likely to be satisfied with their care. The men were slower to improve, but there was no difference between the sexes after 3 months. There were no differences in the number, type, duration, or severity of symptoms or in the expectation of care, costs of visits, intervention received, use of health care services, or likelihood of being considered difficult by their physician. The gender of the clinician had no effect on any outcome.     

Studying physician-patient communication in the acute care setting: The hospitalist rapport study

Objective

To assess the feasibility of studying physician-patient communication in the acute care setting.

Methods

We recruited hospitalist physicians and patients from two hospitals within a university system and audio-recorded their first encounter. Recruitment, data collection, and challenges encountered were tracked.

Results

Thirty-two physicians consented (rate 91%). Between August 2008 and March 2009, 441 patients were referred, 210 (48%) were screened, and 119 (66% of 179 eligible) consented. We audio-recorded encounters of 80 patients with 27 physicians. Physicians’ primary concern about participation was interference with their workflow. Addressing their concerns and building the protocol around their schedules facilitated participation. Challenges unique to the acute care setting were: (1) extremely limited time for patient identification, screening, and enrollment during which patients were ill and busy with clinical care activities and (2) little advance knowledge of when physician-patient encounters would occur. Employing a full-time study coordinator mitigated these challenges.

Conclusion

Physician concerns for participating in communication studies are similar in ambulatory and acute care settings. The acute care setting presents novel challenges for patient recruitment and data collection.

Practice implications

These methods should be used to study provider-patient communication in acute care settings. Future work should test strategies to increase patient enrollment.     

Recognition of depression and anxiety by primary physicians

Ninety-five patients completed rating scales for anxiety and depression prior to their first visit to a primary care physician. Test scores were provided selectively to the physicians, and the medical charts were checked later for entries relating to anxiety or depression. Two thirds of the patients scored in the abnormal range on at least one scale. Physicians noted depression on charts at appropriate levels (27% of patients), but anxiety was much less frequently noted (9%). Chart notations (primarily of depression) were much more common for patients scoring high in both anxiety and depression. Informing physicians of either anxiety or depression scores did not change their rate of recognition of these problems. However, those informed of scores on both rating scales made substantially fewer chart notations.     

Typologies of anxiety, depression and somatization symptoms among primary care attenders with no formal mental disorder.

BACKGROUND: Typologies of anxiety, depression and somatization symptoms were investigated in individuals with no formal mental disorders, making no a priori assumptions about symptom distribution and inter-relationship. METHOD: The subjects were 1617 adult primary care attenders from the WHO Collaborative Project on Psychological Problems in General Health Care, with at least three symptoms of anxiety, depression and/or somatization, but with no formal ICD-10 disorders. Analyses were based on the grade of membership model, a multivariate statistical procedure exploring indistinct boundaries between disease categories and preserving the heterogeneity of clinical picture within each category. RESULTS: Six prototype categories (or pure types) best described the structure of symptoms included in analyses. Pure type I included the full set of somatization symptoms. Pure type II was characterized by most anxiety and depression symptoms. Pure type III resembled generalized anxiety disorder. Pure type IV consisted of individuals reporting sporadic symptoms of anxiety, depression or somatization. Pure type V defined individuals with sleep problems. Finally, pure type VI was characterized by anxiety symptoms, including panic-like symptoms. CONCLUSIONS: These findings provide support to the existence of a mixed anxiety-depression category crossing the diagnostic boundaries of current anxiety and depression disorders. Moreover, criteria of anxiety and somatization disorders may be re-examined to assess whether lower diagnostic thresholds can be identified that both preserve the symptom profile and clinical features of current diagnostic categories and allow for a better characterization of individuals with substantial psychopathology though not meeting the high symptom thresholds required for a diagnosis of formal mental disorders.     

Empathic communication and gender in the physician-patient encounter

Although empathy in the physician-patient relationship is often advocated, a theoretically based and empirically derived measure of a physician's empathic communication to a patient has been missing. This paper describes the development and initial validation of such a measure, the Empathic Communication Coding System (ECCS), which includes a method for identifying patient-created empathic opportunities. To determine the extent to which empathic communication varies with physician and patient gender, we used the ECCS to code 100 videotaped office visits between patients and general internists. While male and female patients created a comparable number of empathic opportunities, those created by females tended to exhibit more emotional intensity than those created by males. However, female patients were no more likely than male patients to name an emotion in their empathic opportunities. Physician communication behavior was consistent with the literature on gender differences: female physicians tended to communicate higher degrees of empathy in response to the empathic opportunities created by patients. The ECCS appears to be a viable and sensitive tool for better understanding empathy in medical encounters, and for detecting modest gender differences in patients' creation of empathic opportunities and in physicians' empathic communication.