Physicians,emotion, and the clinical encounter: A survey of physicians’ experiences

ObjectivesTraining in emotion management is not a standard part of medical education. This study’s objective was to understand physicians’ challenges navigating emotion (their own and their patients’) and identify areas for intervention to support physician wellness and enhance patient care.MethodsIn 2019, we surveyed 103 physicians in emergency medicine, internal medicine, family medicine, and neurology. Participants quantitatively reported emotion training, emotions that were challenging, and barriers to addressing emotion. They provided qualitative examples of emotion challenges and successes that we analyzed using an inductive thematic analysis.ResultsThere were no significant differences in responses by specialty. Only 10% reported receiving emotion management training, with no evidence that more recently trained physicians received more. Those who had received training on emotion reported greater comfort in dealing with patients’ emotions and were more likely to engage in teaching on emotion. There were gender and career stage differences regarding which emotions physicians found most challenging. The authors identified central themes of emotion-related challenges and successes.ConclusionsTargeted educational initiatives are needed to advance physicians’ ability to navigate emotion in clinical encounters.Practice implicationsDeveloping strategies for managing patients’ emotions may better prepare physicians for navigating the emotional demands of practicing medicine.     

Examining the context and helpfulness of family companion contributions to older adults’ primary care visits

ObjectiveOlder adults commonly involve family (broadly defined) in their care. We examined communication behaviors of family companions during older adults’ primary care visits, including whether these behaviors vary with respect to how older adults manage their health, preferences for involving family in medical decision-making, and ratings of companion helpfulness.MethodsAnalysis of audio-taped primary care visits of older patients who were accompanied by a family companion (n = 30 dyads) and linked patient surveys.ResultsFamily companions predominantly facilitated doctor and patient information exchange. More than half of companion communication behaviors were directed at improving doctor understanding of the patient. Companions were more verbally active during visits of patients who delegated the management of their health to others than visits of patients who co-managed or self-managed their health. Companions were rated as more helpful by patients who preferred active involvement of family in medical decision-making.ConclusionFamily companion participation and helpfulness in primary care communication varies by patients’ preferences for involving family in medical decision-making and approach to manage their health.Practice implicationsResearch to examine the effects of clarifying patient and family companion expectations for primary care visits could inform strategies to improve the patient-centeredness of medical communication.     

Patient's evaluations and expectations of primary care medicine in Israel revisited after two decades — Health Service Research

BackgroundThe European Task Force on Patient Evaluations of General Practice's (EUROPEP) internationally-validated questionnaire measures patients' satisfaction with their primary care physicians. A study published in 1999 showed positive evaluations of primary care among patients across Europe and included 1603 Israeli patients. Major changes have taken place during the past 20 years, in Israel's society, in the healthcare system, and particularly in primary care clinics.ObjectivesThe study aims to reevaluate patients' satisfaction with their primary care physicians and care clinics in Israel and compares the results to the 1999 survey.MethodsA survey based on the EUROPEP questionnaire was conducted among 1617 people. Data collection was carried out by an internet panel for the Hebrew speaking population and by a phone questionnaire for the Arabic speaking population.ResultsThe study's results show a significant reduction in satisfaction. Notably, patients' satisfaction with physicians' support relating to emotional problems and physicians' explanations about referrals and workup plans have dramatically deteriorated.ConclusionsThe decrease in patients' satisfaction with primary care physicians and clinics found in the current study is concerning and requires recognition and further exploration.Practice implicationsThe results may be used as a baseline for future assessments of trends in patients' satisfaction.     

Mind the gap: Disclosure of dietary supplement use to hospital and family physicians

ObjectiveWe aim to compare patients’ perspectives on communication with their hospital physicians (HPs) and primary care physicians (PCPs) on patients' dietary and herbal supplements (DHS) use.MethodsWe conducted a cross-sectional prospective study among in-patients using structured questionnaires on DHS use. Multivariate logistic regression models assessed variables influencing doctor-related reasons for patients' nondisclosure of supplement use.ResultsOf 452 DHS users identified, 133 (29.4%) used herbs and 319 (70.6%) used non-herbal supplements. DHS users reported that PCPs were more aware of DHS consumption than HPs (70.1% vs. 34.1%, P < 0.0001). PCPs initiative to detect supplement use was higher compared with HPs (P < 0.0001). Doctor-related reasons for non-disclosure of DHS use were more prominent in a hospital setting. Multivariate logistic regression model suggested association between older patient age and doctor-related non-disclosure (p = 0.03). DHS use was recorded in only 33 patients medical files.ConclusionsDoctor-patient communication concerning DHS use is significantly poorer during hospitalization compared with primary-care settings. A significant barrier for in-hospital disclosure is doctor-related.Practice implicationsContinuity of care between community and hospital physicians regarding patients' DHS use should be improved due to the safety implications of such use. Educating physicians on DHS and improving communication could bridge this gap.     

Functional status and use of health care services: Longitudinal study on the older adult population in Spain

BackgroundFollow-up studies on the association between functional status and use of health care services among the older people are scarce and have studied only a few types of service.ObjectiveTo examine prospectively the relationship between limitation in instrumental activities of daily living (IADL) and utilization of a wide variety of health care services among older adults in Spain.MethodsProspective study from 2001 to 2003 of a cohort of 2806 persons, representative of the non-institutionalized Spanish population aged 60 years and over. Limitation in IADL was measured in 2001 using the Lawton and Brody's test. Data on the use of health care services were collected in 2003 and classified into home services (home visits by physicians and nurses) and non-home services (visits to primary care physicians, visits to hospital specialists, hospital admissions, emergency care, and influenza vaccination). Analyses were performed with logistic regression and adjusted for the main confounders.ResultsCompared to men with no limitation in IADL, a higher percentage of those with limitation in one IADL in 2001 made use of both home (odds ratio [OR] 2.64; 95% confidence interval [95% CI] 1.73–4.03) and non-home services (OR 2.02; 95% CI 1.04–3.93) in the period 2001–2003. Limitation in one IADL among women was associated with a greater utilization of home services (OR 1.50; 95% CI 1.05–2.14) and visits to hospital specialists (OR 1.61; 95% CI 1.21–2.15). In women, however, a greater number of limited IADL at baseline was inversely associated with visits to primary care physicians in the 2-year follow-up (p for linear trend <0.001).ConclusionPopulation aging will increase the demand for health services in general, and for home services in particular.     

Communication behaviors and patient autonomy in hospital care: A qualitative study

BackgroundLittle is known about how hospitalized patients share decisions with physicians.MethodsWe conducted an observational study of patient-doctor communication on an inpatient medicine service among 18 hospitalized patients and 9 physicians. A research assistant (RA) approached newly hospitalized patients and their physicians before morning rounds and obtained consent. The RA audio recorded morning rounds, and then separately interviewed both patient and physician. Coding was done using integrated analysis.ResultsMost patients were white (61%) and half were female. Most physicians were male (66%) and of Southeast Asian descent (66%). All physicians explained the plan of care to the patients; most believed that their patient understood. However, many patients did not. Physicians rarely asked the patient for their opinion. In all those cases, the decision had been made previously by the doctors. No decisions were made with the patient. Patients sometimes disagreed.ConclusionsShared decision-making may not be the norm in hospital care. Although physicians do explain treatment plans, many hospitalized patients do not understand enough to share in decisions. When patients do assert their opinion, it can result in conflict.Practice implicationsSome hospitalized patients are interested in discussing treatment. Improving hospital communication can foster patient autonomy.     

Promoting patient participation in healthcare interactions through communication skills training: A systematic review

ObjectiveTo present literature on training patients in the use of effective communication skills.MethodsSystematic searches were conducted in six databases. References were screened for inclusion through several phases. Extracted data included intervention study design, sample characteristics, content and structure of training programs, outcomes assessed, and findings reported.ResultsA total of 32 unique intervention studies were included. Most targeted primary care or cancer patients and used a randomized controlled study design. Interventions used a variety of training formats and modes of delivering educational material. Reported findings suggest that communication training is an effective approach to increase patients’ total level of active participation in healthcare interactions and that some communication behaviors may be more amenable to training (e.g., expressing concerns). Trained patients do not have longer visits and tend to receive more information from their providers. Most studies have found no relationship between communication training and improved health, psychosocial wellbeing, or treatment-related outcomes.ConclusionsFindings reinforce the importance and potential benefits of patient communication training.Practice implicationsAdditional research is warranted to determine the most efficacious training programs with the strongest potential for dissemination.     

Emotion work in interpreter-mediated consultations: A systematic literature review

ObjectiveTo identify the ways in which physicians, patients and interpreters express emotions, react to emotional expressions and/or coordinate the emotional interaction in interpreter-mediated consultations (IMCs).MethodsWe systematically searched four databases and screened 10 307 articles. The following inclusion criteria were applied: 1) participants are patients with limited proficiency in the host language, physicians and professional interpreters, 2) analysis of patient-physician-interpreter interaction, 3) focus on emotions, 4) in vivo spoken language interpretation, and 5) authentic primary data.ResultsThe results of 7 included studies suggest that physicians, patients and interpreters work together and verbally and paraverbally contribute to the co-construction of emotional communication (EC) in IMCs. However, a decrease in EC might still compromise the patient’s quality of care in IMCs.ConclusionThere is a dearth of scientific evidence of EC as an interactional process between participants in IMCs. More research on under investigated modes of communication and emotions is needed to advance our understanding. For now, EC seems to be subject to the successful interaction between participants in IMCs.Practice implicationsEvidence-based curricula of interprofessional education between physicians and interpreters on EC in IMCs could be beneficial to the effective co-construction of EC in IMCS.     

There’s an app for that: Teaching residents to communicate diagnostic uncertainty through a mobile gaming application

BackgroundClear communication is integral to good clinical care; however, communication training is cost and time intensive. Mobile applications (apps) may provide a useful adjunct to traditional simulation skills training.ObjectiveTo evaluate (1) use of an app for teaching communication skills about diagnostic uncertainty, (2) feedback on app use, and (3) the association between use and skill mastery.Patient involvementThe app under study is designed to improve doctor-patient communication.MethodsThe study was a planned sub-analysis of a randomized controlled waitlist trial with emergency medicine resident physicians randomized to receive immediate or delayed access to an educational curriculum focused on diagnostic uncertainty. The curriculum included a web-based interactive module and the app. Metrics describing participants’ use of the app, feedback on use, and association of use and achieving mastery in communicating diagnostic uncertainty are reported. Differences between groups utilizing the app were analyzed using Chi-squared test; logistic regression assessed the association between app use and achieving mastery of the communication skill.ResultsAmong 109 participants completing the trial, only 34 (31.2%) used the app. Most participants engaged with the app on one occasion for a median of 50 min (IQR 31, 87). Senior residents were more likely to use the app than junior residents (41.3% vs 23.8%, p=0.05). Overall reviews were positive; 76% reported the app helped them learn. There was no significant association between app use and achieving mastery of the communication skill in the trial [OR 2.1, 95% CI (0.91–4.84)].DiscussionDespite positive reviews of app use, overall use was low and there was no association with achieving mastery.Practical valueOffering an app as an auxiliary training opportunity may be beneficial to some residents, but shouldn’t be planned for use as a primary didactic modality unless there is evidence for effectiveness and use is mandated.Availability of data and materialsThe datasets generated and/or analyzed during the current study are not publicly available since some data may be identifiable but are available from the corresponding author on reasonable request.     

A partnership-oriented and culturally-sensitive communication style of doctors can impact the health outcomes of patients with chronic illnesses in Indonesia

ObjectivesA partnership-oriented communication style is globally recommended for medical practice. A culturally-sensitive doctor-patient communication guideline is also needed for Southeast Asia. The ‘Greet-Invite-Discuss’ guideline was established and tested with primary care doctors and their patients in Indonesia.MethodsIn this mixed-methods study, doctors were trained according to the ‘Greet-Invite-Discuss’ guideline, while patients received standard treatment. Two groups of fifteen doctors were assigned to have consultations with 45 patients with hypertension or 51 patients with type-2 diabetes mellitus. Doctors’ self-assessment and patients’ perceptions and their clinical outcomes were longitudinally measured. Six focus group discussions were conducted to explore doctors’ and patients’ experiences.ResultsDoctors’ self-assessments and patients’ perceptions of doctors’ communication skills increased significantly (p < 0.05). Moreover, patients’ blood pressure or fasting blood glucose levels decreased significantly (p < 0.05), except the two-hour blood glucose levels (NS). Qualitatively, doctors demonstrated more partnership and culturally-sensitive communication, and patients expressed more satisfaction, increased comprehension and self-management, of their chronic illnesses.ConclusionsThe ‘Greet-Invite-Discuss’ guideline was useful for primary care doctors for a more partnership-oriented and culturally-sensitive communication with patients in chronic care management.Practice implicationsUsing a partnership-oriented and culturally-sensitive communication guideline, doctors can improve their communication skills with their patients towards optimum health outcomes.     

Negotiating complementary and alternative medicine use in primary care visits with older patients

ObjectiveTo empirically investigate the ways in which patients and providers discuss Complementary and Alternative Medicine (CAM) treatment in primary care visits.MethodsAudio recordings from visits between 256 adult patients aged 50 years and older and 28 primary care physicians were transcribed and analyzed using discourse analysis, an empirical sociolinguistic methodology focusing on how language is used to negotiate meaning.ResultsDiscussion about CAM occurred 128 times in 82 of 256 visits (32.0%). The most frequently discussed CAM modalities were non-vitamin, non-mineral supplements and massage. Three physician–patient interactions were analyzed turn-by-turn to demonstrate negotiations about CAM use. Patients raised CAM discussions to seek physician expertise about treatments, and physicians adopted a range of responses along a continuum that included encouragement, neutrality, and discouragement. Despite differential knowledge about CAM treatments, physicians helped patients assess the risks and benefits of CAM treatments and made recommendations based on patient preferences for treatment.ConclusionRegardless of a physician's stance or knowledge about CAM, she or he can help patients negotiate CAM treatment decisions.Practice implicationsProviders do not have to possess extensive knowledge about specific CAM treatments to have meaningful discussions with patients and to give patients a framework for evaluating CAM treatment use.     

Engagement and Affective Communication During Pediatric Nephrology Clinic Visits: Associations with Medication Adherence

ObjectiveTo evaluate whether engagement and affective communication among adolescents and young adults (AYAs) with chronic kidney disease (CKD), caregivers, and pediatric nephrology providers during outpatient clinic visits predicts antihypertensive medication adherence.MethodsAYAs (n = 60, M age = 15.4 years, SD = 2.7, 40% female, 43% African American/Black) and caregivers (n = 60, 73% female) attended audio-recorded clinic visits with pediatric nephrologists (n = 12, 75% female). Recordings were analyzed using global affect ratings of the Roter Interactional Analysis System. Antihypertensive medication adherence was monitored electronically before and after clinic visits. A linear regression model evaluated associations between affect ratings and post-visit adherence.ResultsAYAs took 84% of doses (SD = 20%) pre-visit and 82% of doses (SD = 24%) post-visit. Higher AYA engagement (β = 0.03, p = .01) and the absence of provider negative affect (β=-0.15, p = .04) were associated with higher post-visit adherence, controlling for pre-visit adherence, AYA sex, age, and race, and clustered by provider.ConclusionsPost-visit adherence was higher when AYAs were rated as more engaged and providers as less negative.Practice ImplicationsAYAs with lower engagement may benefit from further adherence assessment. Communication strategies designed to more actively engage AYAs in their care and diminish provider conveyance of negative affect during clinic visits may positively influence adherence among AYAs with CKD.     

The inseparability of emotional and instrumental care in cancer: Towards a more powerful science of clinical communication

ObjectiveClinical communication literature currently distinguishes clinicians’ emotional care of patients from instrumental aspects of clinical care, and regards clinicians’ explicit emotional engagement with patients as the key to emotional care. Here we critically appraise this view.MethodsWe draw on empirical evidence and recent reviews and critiques focusing on cancer care.ResultsPatients and families do not generally seek explicit emotional engagement from their practitioners; nor does such engagement consistently improve patient outcomes. Instead some evidence indicates that anxious patients and families can be comforted by clinicians’ focus on instrumental care.ConclusionsSuch findings can be interpreted according to the view that clinical relationships evoke attachment processes. In the context of mortal illness, patients are comforted by being able to trust clinicians whom they regard as having the expertize to look after them. From this perspective, instrumental and emotional care are inseparable. Clinicians’ clinical authority and expertize are the basis for the emotional comfort they can provide.Practice implicationsFor researchers and educators, a consequence of appreciating the inseparability of emotional and instrumental care will be greater emphasis on learning from, and collaborating with, clinicians. Clinicians, in turn, can benefit by communication scientists developing new approaches to supporting their communication. These approaches will need to recognize that clinicians’ emphasis on their authority and clinical expertize in communicating with patients can be central to providing emotional comfort, and not necessarily a way to avoid doing so.     

Reduced positive emotion and underarousal are uniquely associated with subclinical depression symptoms: Evidence from psychophysiology,self‐report,and symptom clusters

Multiple models of aberrant emotional processing in depression have been advanced. However, it is unclear which of these models best applies to emotional disturbances in subclinical depressive symptoms. The current study employed a battery of psychophysiological measures and emotional ratings in a picture‐viewing paradigm to examine whether the underarousal, low positive emotion, heightened negative emotion, or emotion context insensitivity model of emotional dysfunction in subclinical depressive symptoms received greatest support. Postauricular reflex and skin conductance response potentiation for pleasant minus neutral pictures (measuring low positive emotion), overall skin conductance magnitude and late positive potential (LPP) amplitude (measuring underarousal), and pleasant minus aversive valence ratings (measuring emotion context insensitivity) and aversive minus neutral arousal ratings (measuring heightened negative emotionality) were all negatively related to depressive symptomatology. Of these, postauricular reflex potentiation and overall LPP amplitude were incrementally associated with depressive symptoms over the other measures. Postauricular reflex potentiation, overall skin conductance magnitude, and aversive minus neutral arousal ratings were incrementally associated with depressive symptomatology after controlling for other symptoms of internalizing disorders. Though no model was unequivocally superior, the low positive emotion and underarousal models received the most support from physiological measures and symptom reports, with self‐report data matching patterns consistent with the emotion context insensitivity model.     

Associations between thin slice ratings of affect and rapport and perceived patient-centeredness in primary care: Comparison of audio and video recordings

ObjectiveTo investigate associations between ratings of “thin slices” from recorded clinic visits and perceived patient-centeredness; to compare ratings from video recordings (sound and images) versus audio recordings (sound only).MethodsWe analyzed 133 video-recorded primary care visits and patient perceptions of patient-centeredness. Observers rated thirty-second thin slices on variables assessing patient affect, physician affect, and patient-physician rapport. Video and audio ratings were collected independently.ResultsIn multivariable analyses, ratings of physician positive affect (but not patient positive affect) were significantly positively associated with perceived patient-centeredness using both video and audio thin slices. Patient-physician rapport was significantly positively associated with perceived patient-centeredness using audio, but not video thin slices. Ratings from video and audio thin slices were highly correlated and had similar underlying factor structures.ConclusionPhysician (but not patient) positive affect is significantly associated with perceptions of patient-centeredness and can be measured reliably using either video or audio thin slices. Additional studies are needed to determine whether ratings of patient-physician rapport are associated with perceived patient-centeredness.Practice implicationsObserver ratings of physician positive affect have a meaningful positive association with patients’ perceptions of patient-centeredness. Patients appear to be highly attuned to physician positive affect during patient-physician interactions.     

Statins for Secondary Cardiovascular Disease Prevention for Older Primary Care Patients

ObjectivesTo examine statin prescribing for secondary cardiovascular disease prevention at primary care visits by older patients in 2005-2006.DesignThe National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey are cross-sectional, using a multistage random sample (112 primary sampling units, physicians and hospitals, patient visits). Characteristics from 4964 primary care visits were abstracted from medical records. c² and logistic regression were performed to investigate associations with statin prescribing.SettingUS nonfederal physician offices and hospital outpatient departments.ParticipantsVisits by patients aged 55 to 80 years with cere-brovascular, ischemic heart or peripheral vascular disease, aortic aneurysm, atherosclerosis, diabetes mellitus, or any 2 risk factors (hyperlipidemia, hypertension, or smoking).MeasurementsThe dependent variable was statin prescribing. Independent variables were age, sex, ethnicity, primary payment source, number of comorbidities, metropolitan statistical area, geographic region, and clinical setting.ResultsStatins were prescribed at 37.7% of visits. Logistic regression negative predictors for statin prescribing included non-Hispanic black ethnicity and Medicaid coverage. Number of comorbidities was a positive predictor.ConclusionStatins are prescribed at much fewer visits by higher-risk older patients, especially non-Hispanic black patients and Medicaid beneficiaries, than would be expected from their comorbidities.