Patients' negative emotional cues and concerns in hospital consultations: a video-based observational study

Emotion recognition support system: Where physicians and psychiatrists meet linguists and data engineers

An important factor in the course of daily medical diagnosis and treatment is understanding patients’ emotional states by the caregiver physicians. However, patients usually avoid speaking out their emotions when expressing their somatic symptoms and complaints to their non-psychiatrist doctor. On the other hand, clinicians usually lack the required expertise (or time) and have a deficit in mining various verbal and non-verbal emotional signals of the patients. As a result, in many cases, there is an emotion recognition barrier between the clinician and the patients making all patients seem the same except for their different somatic symptoms. In particular, we aim to identify and combine three major disciplines (psychology, linguistics, and data science) approaches for detecting emotions from verbal communication and propose an integrated solution for emotion recognition support. Such a platform may give emotional guides and indices to the clinician based on verbal communication at the consultation time.

Patient coaching: What do patients want? A mixed methods study in waiting rooms of outpatient clinics

Introduction

Effective communication in specialist consultations is difficult for some patients. These patients could benefit from support from a coach who accompanies them to and during medical specialist consultations to improve communication in the consultation room. This study aims to investigate patients’ perspective on interest in support from a patient coach, what kind of support they would like to receive and what characterizes an ideal patient coach.

Methods

We applied a mixed method design to obtain a realistic understanding of patients’ perspectives on a patient coach. Patients in the waiting rooms of outpatient clinics were asked to fill out a short questionnaire which included questions about demographic characteristics, perceived efficacy in patient-provider interaction and patients’ interest in support from a patient coach. Subsequently, patients interested in a patient coach were asked to participate in a semi-structured interview. The quantitative data were examined using univariate analysis and the qualitative interview data were analysed using content analysis.

Results

The survey was completed by 154 patients and eight of them were interviewed. Perceived efficacy in patient-physician interactions was the only variable that showed a significant difference between patients with and without an interest in support from a patient coach. The interviews revealed that a bad communication experience was the main reason for having an interest in support from a patient coach. Before the consultation, a patient coach should take the time to get to know the patient, build trust, and help the patient create an agenda, so take the patient seriously and recognize the patient as a whole person. During the consultation, a patient coach should support the patient by intervening and mediating when necessary to elicit the patient’s agenda. After the consultation, a patient coach should be able to explain and discuss medical information and treatment consequences. An ideal patient coach should have medical knowledge, a strong personality and good communication skills.

Conclusion

Especially patients who had a bad communication experience in a specialist consultation would like support from a patient coach. The kind of support they valued most was intervening and mediating during the consultation. To build the necessary trust, patient coaches should take time to get to know the patient and take the patient seriously. Medical knowledge, good communication skills and a strong personality were considered prerequisites for patient coaches to be capable to intervene in specialist consultations.

Coding the negative emotions of family members and patients among the high-risk preoperative conversations with the Chinese version of VR-CoDES

Background

Little is known about family members' and patients' expression of negative emotions among high‐risk preoperative conversations.

Objectives

This study aimed to identify the occurrence and patterns of the negative emotions of family members and patients in preoperative conversations, to investigate the conversation themes and to explore the correlation between the negative emotions and the conversation themes.

Methods

A retrospective study was conducted using the Chinese version of Verona Coding Definitions of Emotional Sequences (VR‐CoDES‐C) to code 297 conversations on high‐risk procedures. Inductive content analysis was used to analyse the topics in which negative emotions nested. The χ² Test was used to test the association between the cues and the conversation themes.

Results

The occurrence rate of family members' and patients' negative emotions was very high (85.9%), much higher when compared to most conversations under other medical settings. The negative emotions were mainly expressed by cues (96.4%), and cue‐b (67.4%) was the most frequent category. Cues and concerns were mostly elicited by family members and patients (71.6%). Negative emotions were observed among seven themes, in which ‘Psychological stress relating to illness severity, family's care and financial burden’ (30.3%) ranked the top. Cue‐b, cue‐c and cue‐d had a significant correlation (p < .001) with certain themes.

Conclusions

Family members and patients conveyed significantly more negative emotions in the high‐risk preoperative conversations than in other medical communications. Certain categories of cues were induced by specific emotional conversation contents.

Patient Contribution

Family members and patients contributed to data.

How physicians respond to negative emotions in high-risk preoperative conversations

OBJECTIVE

To investigate physicians' responses to negative emotions in high-risk preoperative conversations; and to explore the influencing factors of these responses.

METHODS

One hundred and sixty-two audio recordings were coded using the Chinese Verona Coding Definition of Emotional Sequences (VR-CoDES). Big Five Personality Inventory Brief Version and Emotional Intelligence Scale were administered to explore the influencing factors of physicians' responses. SPSS 24.0 and R 3.6.3 LME4 Package were used for data analysis.

RESULTS

Reduce Space (83%), referring to physicians' responses reducing the opportunities of patients to disclose emotions, was physicians' most frequent response to patients or families' emotions. The main responses were Information-advice (ERIa) and Ignoring (NRIa). Younger age, female, Agreeableness and Openness were factors positively associated with Explicit Provide Space (EP); Neuroticism was negatively correlated with EP. Extroversion was negatively correlated with Explicit Reduce Space (ER); Conscientiousness was negatively correlated with both EP and ER responses. Emotional intelligence had no significant influence on physicians' responses.

CONCLUSION

The majority of physicians were inclined to reduce space by providing information advice or ignoring. Physicians' responses were correlated with their gender, age and personality traits.

PRACTICE IMPLICATIONS

The trainees' gender, age and personality should be considered when conducting doctor-patient communication skills training.

How do National Health Service (NHS) organisations respond to patient concerns? A qualitative interview study of the Patient Advice and Liaison Service (PALS)

OBJECTIVES

To describe the current work of the Patient Advice and Liaison Service (PALS) and assess the service's potential to resolve concerns and contribute to organisational learning.

DESIGN

A qualitative study using semistructured interviews.

SETTING

Four mental health trusts and four acute trusts in the English National Health Service, a total of eight PALS across different trusts.

PARTICIPANTS

Twenty-four participants comprising of PALS staff and clinicians working with PALS teams.

METHODS

Semistructured interviews were undertaken with participants using video conferencing software. The framework method was used for the analysis of the large qualitative dataset, which is a conventional method of analysis, similar to thematic or qualitative content analysis.

RESULTS

PALS teams fulfil their core responsibilities by acting as point of contact for patients, providing information and resolving a variety of recurrent problems, including PALS staff communication, staff attitudes and waiting times. The remit and responsibilities of each PALS has often broadened over time. Barriers to resolving concerns included a lack of awareness of PALS, limited to no policies informing how staff resolve concerns, an emphasis on complaints and the attitude of clinical staff. Senior management had widely differing views on how the PALS should operate and the management of complaints is a much higher priority. Few PALS teams carried out any analysis of the data or shared data within their organisations.

CONCLUSIONS

PALS teams fulfil their core responsibilities by acting as point of contact for patients, providing information and resolving concerns. PALS staff also act as navigators of services, mediators between families and staff and, occasionally, patient advocates in supporting them to raise concerns. PALS has the potential to reduce complaints, increase patient satisfaction and provide rapid organisational feedback. Achieving this potential will require more awareness and support within organisations together with updated national policy guidance.

Evaluating relationships between lung cancer stigma, anxiety, and depressive symptoms and the absence of empathic opportunities presented during routine clinical consultations

OBJECTIVE

Empathic communication in clinical consultations is mutually constructed, with patients first presenting empathic opportunities (statements communicating emotions, challenges, or progress) to which clinicians can respond. We hypothesized that lung cancer patients who did not present empathic opportunities during routine consultations would report higher stigma, anxiety, and depressive symptoms than patients who presented at least one.

METHODS

Audio-recorded consultations between lung cancer patients (N = 56) and clinicians were analyzed to identify empathic opportunities. Participants completed questionnaires measuring sociodemographic and psychosocial characteristics.

RESULTS

Twenty-one consultations (38 %) did not contain empathic opportunities. Unexpectedly, there was a significant interaction between presenting empathic opportunities and patients' race on disclosure-related stigma (i.e., discomfort discussing one's cancer; F = 4.49, p = .041) and anxiety (F = 8.03, p = .007). Among racial minority patients (self-identifying as Black/African-American, Asian/Pacific Islander, or other race), those who did not present empathic opportunities reported higher stigma than those who presented at least one (t=-5.47, p = .038), but this difference was not observed among white patients (t = 0.38, p = .789). Additional statistically significant findings emerged for anxiety.

CONCLUSION

Disclosure-related stigma and anxiety may explain why some patients present empathic opportunities whereas others do not.

PRACTICE IMPLICATIONS

Clinicians should intentionally elicit empathic opportunities and encourage open communication with patients (particularly from diverse racial backgrounds).

How doctors recognise that their patients are worried: A qualitative study of patient cues

OBJECTIVES

Recognising patient cues indicating worry is essential for successful reassurance. To obtain more insight into the variety and nature of patient cues that may arise in practice, this study explores doctors' reflections on patient cues they recognise during consultations.

METHODS

We performed a qualitative study during which GPs participated in stimulated recall interviews, using their own video-recorded consultations to enhance reflection. First, we reanalysed an existing dataset of 15 interviews during which GPs elaborated on the doctor-patient interaction. Additionally, 12 GPs were interviewed specifically about recognising patients' cues.

RESULTS

GPs described four categories of patient cues that indicate worry. GPs recognised worry based on non-verbal cues such as visible bodily reactions, and verbal cues that can be further categorised by type of worry (e.g. about serious disease). Moreover, GPs described behavioural cues, e.g. the patient bringing a list of symptoms. Lastly, GPs recognise worry based on prior knowledge about the patient.

CONCLUSIONS

GPs reflections have given insight into a wide variety of non-verbal -, verbal -, behavioural- and foreknowledge-based cues.

PRACTICE IMPLICATIONS

The identified cues can guide other clinicians in recognising worries and inform medical communication training and future research on the effectiveness of recognising cues and patient reassurance.

Emotional communication with older people: A cross-sectional study of home care

The aim of this study was to explore the influence of characteristics of nurses and older people on emotional communication in home care settings. A generalized, linear, mixed model was used to analyze 188 audio-recorded home care visits coded with Verona Coding Definitions of Emotional Sequences. The results showed that most emotional distress was expressed by older females or with female nurses. The elicitation of an expression of emotional distress was influenced by the nurses' native language and profession. Older women aged 65-84 years were given the most space for emotional expression. We found that emotional communication was primarily influenced by sex for nurses and older people, with an impact on the frequency of expressions of and responses to emotional distress. Expressions of emotional distress by older males were less common and could risk being missed in communication. The results have implications for students' and health professionals' education in increasing their knowledge of and attentiveness to the impacts of their and others' characteristics and stereotypes on emotional communication with older people.

Nursing staff's responses to thematic content of patients' expressed worries: observing communication in home care visits

Background

The aim of the study was to explore the thematic content of older persons’ expressed worries in home care visits, and how nursing staff respond to different thematic contents.

Methods

The study had a descriptive, observational design, including 195 audio-recorded Norwegian home care visits with 33 nursing staff and 48 older persons. In all, 638 patient cues/concerns (worries) and subsequent nursing staff’s responses were identified using Verona Coding Definitions of Emotional Sequences. A novel thematic coding scheme was used to label the thematic content of the cues/concerns. The nursing staff’s responses were grouped based on communicative function as emotion-focused, content-focused or ignoring/blocking the cue/concern. Group difference was analysed using Pearson’s chi-squared test, Fisher’s exact test, and adjusted residuals.

Results

The theme of worries was associated with elicitation of the cue/concern, either elicited by the nursing staff or spontaneously expressed by the patient (Chi-square, p< 0.001). “Ageing and bodily impairment” was the most common theme (66%) and was equally elicited by patients and nursing staff. Worries about “Relationships with others” (9%), “Health care-related issues” (15%) and “Life narratives and value issues” (9%) were mainly elicited by nursing staff. The nursing staff response was associated with the theme of worries (p˂0.001). For the sub-themes of “Ageing and bodily impairment”, Coping with existential challenges received more frequently emotion-focused responses (adjusted residuals: 3.2) and Expression of pain felt in the moment were more frequently ignored/blocked (adjusted residuals: 4.0, Fisher’s exact test, p< 0.001). For the sub-themes of “Relationships with others”, Being a burden more frequently received a content-focused response (adjusted residuals: 2.8), while Losing social ties more frequently received an emotion-focused response (adjusted residuals: 3.1, Fisher’s exact test, p = 0.009).

Conclusion

“Ageing and bodily impairment” was the most common theme and more frequently elicited by the older persons than other themes. Emotionally focused nursing staff responses were most common when addressing existential challenges and fear of losing social ties. Whereas nursing staff showed a tendency to ignore patients’ spontaneous expressions of pain. Further research should explore the influence of nursing staff’s responses on quality of care and patient satisfaction.

Assessment of patient concerns: a review

BACKGROUND

Patient-centred communication is the mainstay of the medical consultation. It includes the assessment of patient concerns and is important in building the doctor-patient therapeutic relationship. Our aim was to perform a literature review to identify relevance of patient concern assessment, to identify what concerns are encountered in various clinical settings and to explore the different methodologies used to obtain them.

METHODS

A narrative review was performed.

RESULTS

Addressing patient concerns is associated with increased patient satisfaction. Unvoiced concerns are associated with unresolved health issues and poor doctor-patient relationships. Different specialities have focused on different aspects of concern assessment. Patient concern assessment studies are mostly qualitative in nature. Not all qualitative methods give similar results. Interviews are more reliable sources of information than questionnaires as no one questionnaire captures all patient concerns. The location where interviews take place is also relevant.

CONCLUSIONS

Assessing patient concerns is associated with positive outcomes. Patient concerns are handled differently by different clinical specialties. Various methodologies have been used for concern assessment. Interviews and questionnaires can often yield different results.

Verona Coding Definitions of Emotional Sequences (VR-CoDES): Conceptual framework and future directions

OBJECTIVE

To discuss the theoretical and empirical framework of VR-CoDES and potential future direction in research based on the coding system.

METHODS

The paper is based on selective review of papers relevant to the construction and application of VR-CoDES.

RESULTS

VR-CoDES system is rooted in patient-centered and biopsychosocial model of healthcare consultations and on a functional approach to emotion theory. According to the VR-CoDES, emotional interaction is studied in terms of sequences consisting of an eliciting event, an emotional expression by the patient and the immediate response by the clinician. The rationale for the emphasis on sequences, on detailed classification of cues and concerns, and on the choices of explicit vs. non-explicit responses and providing vs. reducing room for further disclosure, as basic categories of the clinician responses, is described.

CONCLUSIONS

Results from research on VR-CoDES may help raise awareness of emotional sequences. Future directions in applying VR-CoDES in research may include studies on predicting patient and clinician behavior within the consultation, qualitative analyses of longer sequences including several VR-CoDES triads, and studies of effects of emotional communication on health outcomes.

PRACTICE IMPLICATIONS

VR-CoDES may be applied to develop interventions to promote good handling of patients' emotions in healthcare encounters.

Applying the Verona coding definitions of emotional sequences (VR-CoDES) to code medical students' written responses to written case scenarios: Some methodological and practical considerations

OBJECTIVE

To investigate whether the Verona Coding Definitions of Emotional Sequences to code health providers' responses (VR-CoDES-P) can be used for assessment of medical students' responses to patients' cues and concerns provided in written case vignettes.

METHODS

Student responses in direct speech to patient cues and concerns were analysed in 21 different case scenarios using VR-CoDES-P.

RESULTS

A total of 977 student responses were available for coding, and 857 responses were codable with the VR-CoDES-P. In 74.6% of responses, the students used either a "reducing space" statement only or a "providing space" statement immediately followed by a "reducing space" statement. Overall, the most frequent response was explicit information advice (ERIa) followed by content exploring (EPCEx) and content acknowledgement (EPCAc).

DISCUSSION

VR-CoDES-P were applicable to written responses of medical students when they were phrased in direct speech. The application of VR-CoDES-P is reliable and feasible when using the differentiation of "providing" and "reducing space" responses. Communication strategies described by students in non-direct speech were difficult to code and produced many missings.

PRACTICE IMPLICATIONS

VR-CoDES-P are useful for analysis of medical students' written responses when focusing on emotional issues. Students need precise instructions for their response in the given test format.

Older persons' worries expressed during home care visits: Exploring the content of cues and concerns identified by the Verona coding definitions of emotional sequences

OBJECTIVE

Little is known about how older persons in home care express their concerns. Emotional cues and concerns can be identified by the Verona coding definitions of emotional sequences (VR-CoDES), but the method gives no insight into what causes the distress and the emotions involved. The aims of this study are to explore (1) older persons' worries and (2) the content of these expressions.

METHODS

An observational exploratory two-step approach was used to investigate audiotaped recordings from 38 Norwegian home care visits with older persons and nurse assistants. First, 206 cues and concerns were identified using VR-CoDES. Second, the content and context of these expressions were analysed inductively.

RESULTS

Four main categories emerged: worries about relationships with others, worries about health care-related issues, worries about aging and bodily impairment, and life narratives and value issues, with several subcategories showing the causes of worry and emotions involved.

CONCLUSION

The two-step approach provides an in-depth knowledge of older persons' worries, causes of worries, and their related emotions.

PRACTICE IMPLICATIONS

The subcategories described in a language close to the experience can be useful in practice development and communication training for students and health care providers.

Practice nurses mental health provide space to patients to discuss unpleasant emotions

WHAT IS KNOWN ON THE SUBJECT?: A core skill of practice nurses' mental health is to recognize and explore patients' unpleasant emotions. Patients rarely express their unpleasant emotions directly and spontaneously, but instead give indirect signs that something is worrying them. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Patients with mild psychosocial and psychological problems provide signs of worrying or express a clear unpleasant emotion in 94% of consultations with a practice nurse mental health. Nurses' responses to patients' signs of worrying or clear unpleasant emotions were mostly characterized by providing space for patients to talk about these emotions, by using minimal responses. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Practice nurses' mental health have passive listening skills, and to a lesser extent, use active listening techniques. Accurate emotion detection and the ability to pick out emotional signs during consultations must also be considered as an important skill for health providers to improve patient-centred communication.

AIM

Patients with physical problems are known to express their emotional concerns in an implicit way only. Whether the same counts for patients presenting mental health problems in primary care is unknown. This study aims to examine how patients with mild psychosocial and psychological complaints express their concerns during consultations with the practice nurse mental health and how practice nurses respond to these expressions.

METHOD

Fifteen practice nurses mental health working in Dutch general practices participated in the study. Their consultations with 116 patients with mild psychosocial or psychological complaints were video recorded. patients' explicitly expressed emotional concerns and more implicit expressions of underlying emotional problems (cues) as well as nurses' responses to these expressions were rated using the Verona Coding Definition of Emotional Sequences.

RESULTS

Almost all consultations contained at least one cue or concern (94%). Nurses' responses were mostly characterized by providing space for patients to talk about their cue or concern in a non-explicit way (62%), by using minimal responses (42%).

DISCUSSION

Practice nurses mental health have passive listening skills, and to a lesser extent, use active listening techniques. However, there are no strict rules which way of responding is the best and patients value responses differently.

Sequences of talk about emotional concerns in follow-up consultations with adolescent childhood cancer survivors

OBJECTIVE

To explore practices regarding communication about emotional concerns in follow-up consultations with adolescent cancer survivors and pediatrician.

METHOD

Seven video-taped follow-up consultations with adolescent survivors which contained many examples of emotional cues and concern were analyzed according to principles of conversation analysis.

RESULTS

During talk about emotional concerns, a task-focused asymmetric pattern of pediatrician questions and patient responses was most often upheld. In a number of cases a gradual build-up of emotional expression from a weak hint to a more explicit expression of emotional concern was observed, often facilitated by the pediatricians. Most often work-up was relatively brief, sometimes with a brief positive reappraisal, but more comprehensive elaboration was also seen. Topic shifts were often abrupt.

CONCLUSION

Pediatricians and patients used some of the same conventions as in everyday conversation during emotional talk in medical encounters. We observed shifts between informal talk and a typical task-focused mode. Conscious attention to such shifts and to the sequential nature of emotional talk could be helpful for doctors in designing their responses to patients' emotional concerns.

PRACTICE IMPLICATIONS

Our findings may contribute to insight in how clinicians respond to emotional concerns in follow-up consultations and have implications for communication skills training.

Accurate diagnosis of patients' distress levels: The effect of family physicians' ability to take the patient's perspective

OBJECTIVE

Previous research on diagnosis of distress among patients with physical ailments has focused on physicians who specialize in the treatment of chronic illness. This study explores family physicians' accuracy in diagnosing patients' emotional distress.

METHODS

Questionnaires were administered to family physicians (N=61) and their patients (N=496) immediately after a medical encounter. Patients reported their distress levels. Physicians evaluated patients' distress levels and filled out a questionnaire measuring perspective-taking, i.e., the tendency to perceive the point of view of others.

RESULTS

Mixed model analyses of nested data showed a moderate positive relationship between physicians' evaluations of patients' distress and patients' self-reported distress. Diagnosis of distress was more accurate among family physicians with a better ability to take the patient's perspective.

CONCLUSION

Family physicians' capacity to accurately diagnose patient distress is positively related to their ability to adopt patients' viewpoint.

PRACTICE IMPLICATIONS

Family physicians' training should include enhancement of physicians' ability to take the patient's perspective.

General practitioners' and psychiatrists' responses to emotional disclosures in patients with depression

OBJECTIVE

To investigate general practitioners' (GPs') and psychiatrists' responses to emotional disclosures in consultations with patients with depression.

METHODS

Thirteen patient consultations with GPs and 17 with psychiatrists were video-recorded and then analyzed using conversation analysis (CA).

RESULTS

Psychiatrists responded to patients' emotional disclosures by attempting to clarify symptoms, by rational argumentation, or by offering an interpretation of the emotions from their own perspectives. GPs responded by claiming to understand the emotions or by formulating the patients' statements, but without further exploring the emotions.

CONCLUSION

GPs displayed a greater engagement with patients' emotions than psychiatrists. Their approach could be described as empathic, corresponding to a mentalizing stance. The different approaches taken by psychiatrists could represent conceptual differences and might affect fruitful interdisciplinary work. Psychiatric nurses' responses to patients' emotions must also be studied to complete our knowledge from psychiatry.

PRACTICE IMPLICATIONS

Experiences from training in mentalization could be used to develop physicians' empathic or mentalizing approach. As most patients with depression are treated in primary care, developing GPs' mentalizing capacity instead of offering didactic training could have a substantial effect in the population.

Patient satisfaction with physician errors in detecting and identifying patient emotion cues

OBJECTIVE

Previous research has examined physicians' ability to respond to or identify the type of emotion cues. Yet in physician-patient interactions, identification and response are preceded by the ability to detect whether an emotion cue has occurred. This research assesses consequences of emotion detection errors for patient satisfaction.

METHODS

Participants responding to an online survey read one of six randomly assigned descriptions of a physician-patient interaction varying on: whether the patient presented an emotion cue; whether the physician detected an emotion cue; and whether the physician correctly identified the cue. Participants then rated satisfaction with the physician.

RESULTS

Satisfaction was highest when the physician correctly detected the patient's emotion cue and lowest when the physician failed to detect the patient's emotion. Failing to detect the emotion cue had lower satisfaction than other emotion processing errors, including falsely detecting an emotion cue that was not there or incorrectly identifying the type of emotion.

CONCLUSIONS

Emotion cue detection has implications for patient satisfaction distinct from emotion identification.

PRACTICE IMPLICATIONS

Results suggest it may be better for physicians to incorrectly identify than miss an emotion. Training for healthcare providers should consider incorporating emotion detection.

Emotional communication in medical consultations with native and non-native patients applying two different methodological approaches

OBJECTIVE

To explore the potential agreement between two different methods to investigate emotional communication of native and non-native patients in medical consultations.

METHODS

The data consisted of 12 videotaped hospital consultations with six native and six non-native patients. The consultations were coded according to coding rules of the Verona Coding definitions of Emotional Sequences (VR-CoDES) and afterwards analyzed by discourse analysis (DA) by two co-workers who were blind to the results from VR-CoDES.

RESULTS

The agreement between VR-CoDES and DA was high in consultations with many cues and concerns, both with native and non-native patients. In consultations with no (or one cue) according to VR-CoDES criteria the DA still indicated the presence of emotionally salient expressions and themes.

CONCLUSION

In some consultations cues to underlying emotions are communicated so vaguely or veiled by language barriers that standard VR-CoDES coding may miss subtle cues. Many of these sub-threshold cues could potentially be coded as cues according to VR-CoDES main coding categories, if criteria for coding vague or ambiguous cues had been better specified.

PRACTICE IMPLICATIONS

Combining different analytical frameworks on the same dataset provide us new insights on emotional communication.

Why should I talk about emotion? Communication patterns associated with physician discussion of patient expressions of negative emotion in hospital admission encounters

OBJECTIVE

To describe hospital-based physicians' responses to patients' verbal expressions of negative emotion and identify patterns of further communication associated with different responses.

METHODS

Qualitative analysis of physician-patient admission encounters audio-recorded between August 2008 and March 2009 at two hospitals within a university system. A codebook was iteratively developed to identify patients' verbal expressions of negative emotion. We categorized physicians' responses by their immediate effect on further discussion of emotion - focused away (away), focused neither toward nor away (neutral), and focused toward (toward) - and examined further communication patterns following each response type.

RESULTS

In 79 patients' encounters with 27 physicians, the median expression of negative emotion was 1, range 0-14. Physician responses were 25% away, 43% neutral, and 32% toward. Neutral and toward responses elicited patient perspectives, concerns, social and spiritual issues, and goals for care. Toward responses demonstrated physicians' support, contributing to physician-patient alignment and agreement about treatment.

CONCLUSION

Responding to expressions of negative emotion neutrally or with statements that focus toward emotion elicits clinically relevant information and is associated with positive physician-patient relationship and care outcomes.

PRACTICE IMPLICATIONS

Providers should respond to expressions of negative emotion with statements that allow for or explicitly encourage further discussion of emotion.

Physicians' responses to patients' expressions of negative emotions in hospital consultations: a video-based observational study

OBJECTIVE

Patients express their negative emotions in medical consultations either implicitly as cue to an underlying unpleasant emotion or explicitly as a clear, unambiguous concern. The health provider's response to such cues and concerns is important for the outcome of consultations. Yet, physicians often neglect patient's negative emotions. Most studies of this subject are from primary health care. We aimed to describe how physicians in a hospital respond to negative emotions in an outpatient setting.

METHODS

Ninety six consultations were videotaped in a general teaching hospital. The Verona Coding Definitions of Emotional Sequences was used to identify patients' expression of negative emotions in terms of cue and concern and to code physicians' subsequent responses. Cohen's kappa was used as interrater reliability measure. Acceptable kappa level was set to .60.

RESULTS

We observed 163 expressions of negative emotions. In general, the physician responses to patients' cues and concerns did not include follow up or exploration. Concerns more often than cues led to lack of emotional exploration.

CONCLUSIONS

When patients expressed negative emotions or cues to such, hospital physicians tended to move away from emotional communication, particularly if the emotion was expressed as an explicit concern.

PRACTICE IMPLICATIONS

Medical training should enable physicians' to explore the patients' emotions in situations where it will improve the medical treatment.