Talking about psychosocial problems: An observational study on changes in doctor–patient communication in general practice between 1977 and 2008

Objective

To examine whether GPs’ communication styles have changed since the introduction and implementation of clinical guidelines for psychosocial problems in Dutch general practice in the 1990s.

Methods

From a database of 5184 consultations videotaped between 1977 and 2008, 512 consultations assessed by GPs as ‘completely psychosocial’ were coded with RIAS (Roter Interaction Analysis System). The 121 consultations prior to and 391 consultations after implementation of guidelines were analyzed whether communication styles have changed over time.

Results

We found that GPs were more likely to consider consultations to be mainly (17%) or completely (12%) psychosocial after the implementation of guidelines. They gave more biomedical and psychosocial information and advice in the second period compared to the first period. We also found that empathy decreased over time (frequency of empathic statements by GPs changed from 2.9–3.2 to 1.4–1.6 between periods).

Conclusion

Communication in psychosocial consultations has changed; GPs have become more focused on task-oriented communication (asking questions, giving information and advice) and less on showing empathy.

Practice implications

GPs face the challenge of integrating an evidence-based approach of applying guidelines that promote active symptom exploration with understanding patients’ personal contexts and giving room to their emotions.     

Negative emotions in cancer care: Do oncologists’ responses depend on severity and type of emotion?

Objective

To examine how type and severity of patients’ negative emotions influence oncologists’ responses and subsequent conversations.

Methods

We analyzed 264 audio-recorded conversations between advanced cancer patients and their oncologists. Conversations were coded for patients’ expressions of negative emotion, which were categorized by type of emotion and severity. Oncologists’ responses were coded as using either empathic language or blocking and distancing approaches.

Results

Patients presented fear more often than anger or sadness; severity of disclosures was most often moderate. Oncologists responded to 35% of these negative emotional disclosures with empathic language. They were most empathic when patients presented intense emotions. Responding empathically to patients’ emotional disclosures lengthened discussions by an average of only 21 s.

Conclusion

Greater response rates to severe emotions suggest oncologists may recognize negative emotions better when patients express them more intensely. Oncologists were least responsive to patient fear and responded with greatest empathy to sadness.

Practice implications

Oncologists may benefit from additional training to recognize negative emotions, even when displayed without intensity. Teaching cancer patients to better articulate their emotional concerns may also enhance patient–oncologist communication.     

Turkish migrant GP patients’ expression of emotional cues and concerns in encounters with and without informal interpreters

Objective

The aim of this study was to compare patients’ expressions of emotional cues and concerns, and GPs’ responses during consultations with and without informal interpreters. Furthermore, informal interpreters’ expression of emotional cues and concerns and their responses were examined too.

Methods

Twenty-two audiotaped medical encounters with Turkish migrant patients, eleven with and eleven without an informal interpreter, were coded using the Verona Coding Definitions of Emotional Sequences (VR-CoDES) and the Verona Codes for Provider Responses (VR-CoDES-P).

Results

In encounters with informal interpreters, patients expressed less emotional concerns than in encounters without informal interpreters. Only half of all patients’ cues is being translated by the informal interpreter to the GP. Furthermore, 20% of all cues in encounters with informal interpreters is being expressed by the interpreter, independent of patients’ expression of emotions.

Conclusion

The presence of an informal interpreter decreases the amount of patients’ expression of emotional concerns and cues. Furthermore, a substantial amount of cues is being expressed by the informal interpreter, corroborating the often-made observation that they are active participants in triadic medical encounters.

Practice implications

GPs should be trained in communication strategies that enable elicitation of migrant patients’ emotions, in particular in encounters with informal interpreters.     

Developing and maintaining patients’ trust during general practice consultations: The case of smoking cessation advice

Objective

The aim of this paper is to describe how the process of developing and maintaining trust is related to how and if smoking cessation advice is given in general practice consultations.

Methods

The study consisted of interviews with six Danish GPs and with 11 of their patients, on the basis of observations of their consultations.

Results

According to the findings of this study, both the GPs and the patients expected GPs to demonstrate in interaction with the patients their intent to evaluate and possibly resolve the patient's health problem. The GPs were also expected to show that they recognized the patient's health problem. Both GPs and patients felt that this would help to develop patients’ trust in their GPs. Smoking cessation advice during consultations could negate these demonstrations of GPs intents. Smoking cessation advice, however, could demonstrate interest and a desire to help and so develop trust.

Conclusion

Smoking cessation advice has the potential both to put trust under strain and to strengthen trust. The outcome depends on whether the advice conforms to what both patients and GPs expect from the interaction in general practice consultations.

Practice implications

To develop and maintain patients’ trust GPs should consider the specific expectations from the interaction with patients during consultations when giving smoking cessation advice.     

How doctors move from generic goals to specific communicative behavior in real practice consultations

Objective

To understand how recommendations for communication can be brought into alignment with clinical communication routines, we explored how doctors select communicative actions during consultations.

Methods

We conducted stimulated recall interviews with 15 GPs (general practitioners), asking them to comment on recordings of two consultations. The data analysis was based on the principles of grounded theory.

Results

A model describing how doctors select communicative actions during consultations was developed. This model illustrates how GPs constantly adapt their selection of communicative actions to their evaluation of the situation. These evaluations culminate in the selection of situation-specific goals. These multiple and often dynamic goals require constant revision and adaptation of communication strategies, leading to constant readjustments of the selection of communicative actions. When selecting consultation goals GPs weigh patients’ needs and preferences as well as the medical situation and its consequences.

Conclusions

GPs’ selection of communicative actions during consultations is situational and goal driven.

Practice implications

To help doctors develop communicative competence tailored to the specific situation of each consultation, holistic communication training courses, which pay attention to the selection of consultation goals and matching communication strategies besides training specific communication skills, seem preferable to current generic communication skills training.     

Avoiding the term ‘obesity’: An experimental study of the impact of doctors’ language on patients’ beliefs

Objective

GPs sometimes use euphemisms rather than medical terms. The present study aimed to explore the relative impact of using the term ‘obese’ compared to GPs’ preferred euphemism on patients’ beliefs about the problem.

Methods

A cross sectional survey followed by an experimental study was used with two conditions: the term ‘obese’ versus the GPs’ preferred euphemism. In the cross sectional survey, GPs’ (n = 19) described their preferred use of term. In the experimental study, patients (n = 449) from one General Practice in West London then completed a set of ratings about their beliefs following a vignette using either the term ‘obese’ or the GPs’ preferred euphemism.

Results

The first stage of the study showed that GPs avoided using the term ‘obese’ and preferred to use a euphemism. The most commonly used euphemism was ‘your weight may be damaging your health’. The second stage showed that the term ‘obese’ made patients believe that the problem had more serious consequences and made them feel more anxious and upset than when the same symptoms were labelled using the euphemism. When analysed according to the patient's own BMI, however, the results showed that the term ‘obese’ had a greater emotional impact than the euphemism only on patients who were not obese; obese patients found the euphemism more upsetting.

Conclusion

GPs avoid using the term ‘obese’ for fear of upsetting patients. This term, whilst making the problem appear more serious is only more upsetting for non-obese patients.

Practice implications

GPs choice of term therefore needs to reflect whether they want the patients to be upset or whether they want them to accept the seriousness of their problem.     

A 3-stage model of patient-centered communication for addressing cancer patients’ emotional distress

Objective

To describe pathways through which clinicians can more effectively respond to patients’ emotions in ways that contribute to betterment of the patient's health and well-being.

Methods

A representative review of literature on managing emotions in clinical consultations was conducted.

Results

A three-stage, conceptual model for assisting clinicians to more effectively address the challenges of recognizing, exploring, and managing cancer patients’ emotional distress in the clinical encounter was developed. To enhance and enact recognition of patients’ emotions, clinicians can engage in mindfulness, self-situational awareness, active listening, and facilitative communication. To enact exploration, clinicians can acknowledge and validate emotions and provide empathy. Finally, clinicians can provide information empathetically, identify therapeutic resources, and give referrals and interventions as needed to help lessen patients’ emotional distress.

Conclusion

This model serves as a framework for future research examining pathways that link clinicians’ emotional cue recognition to patient-centered responses exploring a patient's emotional distress to therapeutic actions that contribute to improved psychological and emotional health.

Practical implications

Specific communicative and cognitive strategies are presented that can help clinicians better recognize a patient's emotional distress and respond in ways that have therapeutic value.     

Physician communication styles in initial consultations for hematological cancer

Objective

To characterize practices in subspecialist physicians’ communication styles, and their potential effects on shared decision-making, in second-opinion consultations.

Methods

Theme-oriented discourse analysis of 20 second-opinion consultations with subspecialist hematologist-oncologists.

Results

Physicians frequently “broadcasted” information about the disease, treatment options, relevant research, and prognostic information in extended, often-uninterrupted monologs. Their communicative styles had one of two implications: conveying options without offering specific recommendations, or recommending one without incorporating patients’ goals and values into the decision. Some physicians, however, used techniques that encouraged patient participation.

Conclusions

Broadcasting may be a suboptimal method of conveying complex treatment information in order to support shared decision-making. Interventions could teach techniques that encourage patient participation.

Practice implications

Techniques such as open-ended questions, affirmations of patients’ expressions, and pauses to check for patient understanding can mitigate the effects of broadcasting and could be used to promote shared decision-making in information-dense subspecialist consultations.     

Counseling overweight in primary care: An analysis of patient–physician encounters

Objective

The aim of this study was to assess general practitioners’ (GPs’) and patients’ practices and attitudes regarding overweight encountered during preventive counseling talks.

Methods

Twelve GPs audiotaped their preventive counseling talks with overweight patients, including the assessment of individual risk profiles and further medical recommendations. Fifty-two dialogues were transcribed and submitted to qualitative content analysis.

Results

Dietary advice and increased physical activity are mostly discussed during talks. Recommendations appear to be more individual if patients are given the chance to reflect on causes of their overweight during counseling talks.

Conclusions

A dialogue approach affects the strength and quality of weight loss counseling in primary care. However, physicians and overweight patients rarely agreed on weight loss goals during the physician–patient talks.

Practical implications

Patient centeredness, particularly the integration of patients’ perceptions towards weight management, might be an important step towards improving weight counseling in primary care.     

Emotional and informational patient cues: The impact of nurses’ responses on recall

Objective

To investigate older cancer patients’ informational and emotional cues, how nurses respond to these cues and the effect of cues and responses on patients’ information recall.

Methods

105 cancer patients (aged ≥65 years) completed a recall questionnaire after an educational session preceding chemotherapy treatment. Recall was checked against the actual communication in videorecordings of the consultations. Patients’ emotional and informational cues and subsequent responses by the nurse were rated using an adaptation of the Medical Interview Aural Rating Scale (MIARS).

Results

Patients gave more informational than emotional cues. The most frequent response to emotional cues was distancing followed by acknowledgement. Nurses gave appropriate information in response to the majority of informational cues. Patients’ expression of emotional or informational cues did not influence recall; neither did nurses’ responses to informational cues. Responses to emotional cues did affect recall. The more nurses responded by giving ‘minimal’ encouragements (e.g. ‘Hmmm’), the more patients recalled, while distancing responses (e.g. switching focus) were associated with lower recall scores.

Conclusion

Responding to patients’ emotions is likely to impact information recall.

Practice implications

These results highlight the importance of addressing patients’ expressions of emotions in the context of patient education, as it enhances information recall.     

Are GP patients’ needs being met? Unfulfilled information needs among native-Dutch and Turkish-Dutch patients

Objective

This study aims to assess unfulfilled information needs of native-Dutch and Turkish-Dutch general practitioner (GP) patients in the Netherlands. In addition, the relation between perceived and recorded information provision by GPs is studied.

Methods

Unfulfilled information needs of native-Dutch (N = 117) and Turkish-Dutch patients (N = 74) were assessed through pre- and post-consultation questionnaires. Audiotapes of GP consultations were made to code GPs’ information provision.

Results

Turkish-Dutch patients experience more unfulfilled information needs than native-Dutch patients, in particular those who identify equally with Dutch and Turkish culture. Overall, perceived information provision is hardly related to recorded information provision.

Conclusion

GPs insufficiently provide Turkish-Dutch patients and, to a lesser extent, native-Dutch patients as well, the information they need.

Practice implications

GPs should be trained in giving adequate, tailored information to patients with various ethnic and cultural backgrounds.     

Sequence-analysis of video-recorded practitioner–patient communication about smoking in general practice: Do smokers express negative statements about quitting?

Objective

To examine the extent to which smokers express negative statements about quitting and the extent to which these statements influence general practitioners’ (GPs’) and practice nurses’ (PNs’) (dis)continuation of guideline-recommended smoking cessation care.

Methods

Fifty-two video-consultations were observed (GP-consultations: 2007–2008; PN-consultations: 2010–2011). Dialogues were transcribed verbatim and professionals’ and patients’ speech units were coded and analysed using sequential analyses (n = 1424 speech units).

Results

GPs focused on asking about smoking (GPs: 42.4% versus PNs: 26.2%, p = 0.011) and advising them to quit (GPs: 15.3% versus PNs: 3.5%, p < 0.001), whereas PNs focused on assisting them with quitting (GPs: 25.4% versus PNs: 55.2%, p < 0.001). Overall, patients expressed more negative statements about quitting than positive statements (negative: 25.3% versus positive: 11.9%, p < 0.001), especially when PNs assessed their willingness to quit (OR 3.61, 95% CI 1.44–9.01) or assisted them with quitting (OR 2.23, 95% CI 1.43–3.48).

Practice implications

An alternative approach to smoking cessation care is proposed in which GPs’ tasks are limited to asking, advising, and arranging follow-up. This approach seems the least likely to evoke negative statements of patients about quitting during dialogues with GPs and is compatible with the tasks and skills of PNs who could, subsequently, assist smokers with quitting.     

Developing a model of decision-making about complementary therapy use for patients with cancer: A qualitative study

Objective

To improve our understanding of patient participation in health care consultations and decision-making by exploring a consultation that lies at the interface between mainstream care and complementary therapies.

Methods

Thirty-four holistic consultations were observed at centres offering complementary therapies for cancer, followed by interviews with patients and focus groups with professionals.

Results

A model of decision-making about complementary therapy use emerged from the data: ‘Advice: Assessor led decision’, ‘Confirmation: Joint decision’, ‘Access: Patient-led decision’ and ‘Informed: Patient-led decision’. Decision-making style was contingent on identifiable communication strategies in the preceding information-sharing and discussion phases of the consultation.

Conclusion

This study confirms the importance of gauging patients’ preferences for level of participation in decision-making. Models of consultations are generally based on the assumption that a greater degree of patient participation is a good thing that access to information and decision-making power is sought by all patients. Data from this study suggest that, in this context at least, this is not necessarily the case. The study also stresses the dynamic nature of the consultation, in which roles are fluid rather than fixed.

Practice implications

Insight were gained into professionals’ communication strategies and patients’ role preferences in decision-making, which may be applicable more widely.     

Patients’ reflections on communication in the second-opinion hematology–oncology consultation

Objective

The nature of communication between patients and their second-opinion hematology consultants may be very different in these one-time consultations than for those that are within long-term relationships. This study explored patients’ perceptions of their second-opinion hematology–oncology consultation to investigate physician–patient communication in malignant disease at a critical juncture in cancer patients’ care and decision-making.

Methods

In-depth telephone interviews with a subset of 20 patients from a larger study, following their subspecialty hematology consultations.

Results

Most patients wanted to contribute to the consultation agenda, but were unable to do so. Patients sought expert and honest advice delivered with empathy, though most did not expect the consultant to directly address their emotions. They wanted the physician to apply his/her knowledge to the specifics of their individual cases, and were disappointed and distrustful when physicians cited only general prognostic statistics. In contrast, physicians’ consideration of the unique elements of patients’ cases, and demonstrations of empathy and respect made patients’ feel positively about the encounter, regardless of the prognosis.

Conclusions

Patients provided concrete recommendations for physician and patient behaviors to enhance the consultation.

Practice implications

Consideration of these recommendations may result in more effective communication and increased patient satisfaction with medical visits.     

Residents’ and standardized patients’ perspectives on empathy: Issues of agreement

Objective

We investigated correlations between residents’ scores on the Jefferson Scale of Empathy (JSE), residents’ perceptions of their empathy during standardized-patient encounters, and the perceptions of standardized patients.

Methods

Participants were 214 first-year residents in internal medicine or family medicine from 13 residency programs taking standardized patient-based clinical skills assessment in 2011. We analyzed correlations between residents’ JSE scores; standardized patients’ perspectives on residents’ empathy during OSCE encounters, using the Jefferson Scale of Patient Perceptions of Physician Empathy; and residents’ perspectives on their own empathy, using a modified version of this scale.

Results

Residents’ JSE scores correlated with their perceptions of their own empathy during encounters but correlated poorly with patients’ assessments of resident empathy.

Conclusion

The poor correlation between residents’ and standardized patients’ assessments of residents’ empathy raises questions about residents’ abilities to gauge the effectiveness of their empathic communications. The study also points to a lack of congruence between the assessment of empathy by standardized patients and residents as receivers and conveyors of empathy, respectively.

Practice implications

This study adds to the literature on empathy as a teachable skill set and raises questions about use of OSCEs to assess trainee empathy.     

Patients’ explanations for unsuccessful weight loss after laparoscopic adjustable gastric banding (LAGB)

Objective

Not all morbidly obese patients attain sufficient weight loss after laparoscopic adjustable gastric banding (LAGB). We examined patients’ explanations for unsuccessful weight loss and self-awareness regarding food intake.

Methods

Interviews with 11 patients (10 female/1 male; mean age 46 years) with unsuccessful weight loss were transcribed and analyzed with the MAXqda2 program.

Results

Interviewees were disappointed with the postoperative outcome. Some showed no awareness of their own role, while others were inefficacious to continue the actions needed to maintain weight loss, especially during times of stress. Typical statements that distinguished interviewees were: ‘It didn’t work out’, ‘I don’t care anymore’, ‘I know I have to do it’, ‘I know I can do it’.

Conclusion

Some patients with unsuccessful weight loss after LAGB are insufficiently aware that their own effort is needed to maintain weight loss. Others have self-awareness, but find it difficult to turn awareness into action.

Practice implications

This group could perhaps be helped by tailoring postoperative guidance to the stage of change of an individual patient. Counseling could include increasing awareness of the need to self-control eating and offering assistance to turn intentions into action and to deal with stress, emotions and physical problems.     

A comparison of GP,pharmacist and nurse prescriber responses to patients’ emotional cues and concerns in primary care consultations

Objective

Recognising patients’ cues and concerns is an important part of patient centred care. With nurses and pharmacists now able to prescribe in the UK, this study compared the frequency, nature, and professionals’ responses to patient cues and concerns in consultations with GPs, nurse prescribers and pharmacist prescribers.

Methods

Audio-recording and analysis of primary care consultations in England between patients and nurse prescribers, pharmacist prescribers and GPs. Recordings were coded for the number of cues and concerns raised, cue or concern type and whether responded to positively or missed.

Results

A total of 528 consultations were audio-recorded with 51 professionals: 20 GPs, 19 nurse prescribers and 12 pharmacist prescribers. Overall there were 3.5 cues or concerns per consultation, with no difference between prescriber groups. Pharmacist prescribers responded positively to 81% of patient's cues and concerns with nurse prescribers responding positively to 72% and GPs 53% (PhP v NP: U = 7453, z = −2.1, p = 0.04; PhP v GP: U = 5463, z = −5.9, p < 0.0001; NP v GP: U = 12,070, z = −4.9, p < 0.0001).

Conclusion

This evidence suggests that pharmacists and nurses are responding supportively to patients’ cues and concerns.

Practice implications

The findings support the importance of patient-centredness in training new prescribers and their potential in providing public health roles.     

Communication skills training for general practitioners to promote patient coping: The GRIP approach

Objective

To develop, perform and test the effects of a communication skills training program for general practitioners (GPs). The program specifically addresses the patients’ coping and resources despite more or less severe psychological or physical illness.

Methods

A training model was developed, based on cognitive therapy and solution-focused therapy. The training was given the acronym GRIP after its main content:

•

Get a measure of the patient's subjective complaints and illness attributions.

•

Respond to the patient's understanding of the complaints.

•

Identify resources and solutions.

•

Promote positive coping.

The study involved a quasi-experimental design in which 266 consultations with 25 GPs were video recorded. Forty hours of communication skills training were given to the intervention group.

Results

Consultation duration, patient age and distress determined the frequency of the GRIP communication. There was a significant effect of training on four particular subcategories of the GRIP techniques. The effect of the training was most evident in a subgroup of GPs who used little or no resource-oriented communication before training.

Conclusion

This pilot training model may help change the GPs’ communicative pattern with patients in some situations.

Practice implication

Communication skills training programmes that emphasize patient attributions and personal resources should be developed further and tested in general practice settings with an aim to promote patient coping.