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

Engagement with emotional concerns in general practice: a thematic analysis of GP consultations

BACKGROUND

Emotional concerns (defined as any expression of low mood, anxiety, or psychosocial stress) are an important part of the biopsychosocial care model used in modern medical practice. Previous work has demonstrated variable engagement with emotional concerns and that improved communication has been associated with reductions in emotional distress.

AIM

To examine how emotional concerns are engaged with during routine GP consultations.

DESIGN & SETTING

Secondary study using the Harnessing Resources from the Internet (HaRI) database. The available dataset contains 231 recordings from 10 GPs across eight urban and suburban practices recorded in 2017 and 2018.

METHOD

The dataset was reviewed to identify any consultations containing emotional concerns (as defined as any expression of low mood, anxiety, or psychosocial stress) before being imported into NVivo (version 12) to facilitate thematic analysis and coding. Reflexive inductive thematic analysis resulted in two major themes.

RESULTS

The two main themes were as follows: engagement with emotional concerns as dynamic throughout consultations; and GPs engage with emotional concerns both diagnostically and therapeutically. In theme 1, this dynamism relates to competing areas of focus, immediate versus delayed engagement and reiteration of concerns throughout consultations. Emotional concerns can be engaged with in a similar way to physical concerns (theme 2) using a diagnostic and treatment-based approach; however, in addition to this, therapeutic listening and conversation is utilised.

CONCLUSION

Awareness of the dynamic nature of emotional concerns within consultations and encouraging engagement with concerns in a flexible and patient-oriented manner may help improve doctor-patient communication. In addition, investigating how GPs and patients build shared understanding around emotional concerns may identify methods to reduce patients' emotional distress.

Do I care for you more when you really need help? An experimental test of the effect of clinical urgency on compassion in health care

OBJECTIVES

To experimentally investigate whether more urgent patient presentations elicit greater compassion from health care professionals than less urgent, facilitating future research and thinking to address systemic barriers to compassion in health care.

DESIGN

This is a pre-registered online study with an experimental, within-subjects repeated-measure study design. Two clinical vignettes that systematically varied the urgency of patient presentation were utilized. Both vignettes depicted a patient with difficult behaviours typically associated with lower compassion.

METHODS

Health care professionals (doctors, nurses and allied health practitioners) recruited from all 20 District Health Boards across Aotearoa/New Zealand completed two vignettes in a counterbalanced order. Paired-sample t-tests were used to test the effect of the presentation urgency on indices of compassion.

RESULTS

A total of 939 participants completed the vignettes (20% doctors, 47%, nurses and 33% allied health professionals). As expected, participants reported greater care and motivation to help the more urgent patient. However, the more urgent patient was also perceived as less difficult, and exploratory analyses showed that perceived patient difficulty was associated with lower caring and motivation to help, particularly in the less urgent patient.

CONCLUSIONS

This is the first work to experimentally test the relationship between the urgency of patient presentation and compassion in health care. Although the association between urgency and difficulty is complex, our findings are consonant with evolutionary views in which urgent distress elicits greater compassion. A system-wide orientation towards efficiency and urgency may exacerbate this 'bias' which must be addressed to ensure more equitable compassion in health care.

Working in value-discrepant environments inhibits clinicians' ability to provide compassion and reduces well-being: A cross-sectional study

BACKGROUND

The practice of compassion in healthcare leads to better patient and clinician outcomes. However, compassion in healthcare is increasingly lacking, and the rates of professional burnout are high. Most research to date has focused on individual-level predictors of compassion and burnout. Little is known regarding how organizational factors might impact clinicians' ability to express compassion and well-being. The main study objective was to describe the association between personal and organizational value discrepancies and compassion ability, burnout, job satisfaction, absenteeism and consideration of early retirement among healthcare professionals.

METHODS

More than 1000 practising healthcare professionals (doctors, nurses and allied health professionals) were recruited in Aotearoa/New Zealand. The study was conducted via an online cross-sectional survey and was preregistered on AsPredicted (75407). The main outcome measures were compassionate ability and competence, burnout, job satisfaction and measures of absenteeism and consideration of early retirement.

RESULTS

Perceived discrepancies between personal and organizational values predicted lower compassion ability (B = -0.006, 95% CI [-0.01, -0.00], p < 0.001 and f ²  = 0.05) but not competence (p = 0.24), lower job satisfaction (B = -0.20, 95% CI [-0.23, -0.17], p < 0.001 and f ²  = 0.14), higher burnout (B = 0.02, 95% CI [0.01, 0.03], p < 0.001 and f ²  = 0.06), absenteeism (B = 0.004, 95% CI [0.00, 0.01], p = 0.01 and f ²  = 0.01) and greater consideration of early retirement (B = 0.02, 95% CI [0.00, 0.03], p = 0.04 and f ²  = 0.004).

CONCLUSIONS

Working in value-discrepant environments predicts a range of poorer outcomes among healthcare professionals, including hindering the ability to be compassionate. Scalable organizational and systems-level interventions that address operational processes and practices that lead to the experience of value discrepancies are recommended to improve clinician performance and well-being outcomes.

Predictors of Physician Compassion, Empathy, and Related Constructs: a Systematic Review

BACKGROUND

Compassion in healthcare provides measurable benefits to patients, physicians, and healthcare systems. However, data regarding the factors that predict care (and a lack of care) are scattered. This study systematically reviews biomedical literature within the Transactional Model of Physician Compassion and synthesizes evidence regarding the predictors of physician empathy, compassion, and related constructs (ECRC).

METHODS

A systematic literature search was conducted in CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, OvidJournals, ProQuest, Web of Science, and Scopus using search terms relating to ECRC and its predictors. Eligible studies included physicians as participants. Methodological quality was assessed based on the Cochrane Handbook, using ROBINS-I risk of bias tool for quantitative and CASP for qualitative studies. Confidence in findings was evaluated according to GRADE-CERQual approach.

RESULTS

One hundred fifty-two included studies (74,866 physicians) highlighted the diversity of influences on compassion in healthcare (54 unique predictors). Physician-related predictors (88%) were gender, experience, values, emotions and coping strategies, quality of life, and burnout. Environmental predictors (38%) were organizational structure, resources, culture, and clinical environment and processes. Patient-related predictors (24%) were communication ease, and physicians' perceptions of patients' motives; compassion was also less forthcoming with lower SES and minority patients. Evidence related to clinical predictors (15%) was scarce; high acuity presentations predicted greater ECRC.

DISCUSSION

The growth of evidence in the recent years reflects ECRC's ongoing importance. However, evidence remains scattered, concentrates on physicians' factors that may not be amenable to interventions, lacks designs permitting causal commentary, and is limited by self-reported outcomes. Inconsistent findings in the direction of the predictors' effects indicate the need to study the relationships among predictors to better understand the mechanisms of ECRCs. The current review can guide future research and interventions.

General practitioner responses to concerns in chronic care consultations for patients with a history of cancer

We investigated general practitioners' (GPs') responses to patients' concerns in chronic care consultations. Video recordings of 14 consultations were analyzed with conversation analysis. We found two categories of responses: exiting and exploring the patient's concerns. Most GPs exited the concern by interrupting the patient, acknowledging the concern but then referring back to the progression of the consultation, or affiliating with the concern without exploring it. Only a few raised concerns were explored, and then most often the somatic rather than the emotional aspects of them. The findings point to the risk of missing patients' voiced concerns in consultations with a fixed agenda.

The Patients' Practises Disclosing Subjective Experiences in the Psychiatric Intake Interview

In psychiatric diagnostic interviews, a clinician's question designed to elicit a specific symptom description is sometimes met with the patient's self-disclosure of their subjective experience. In shifting the topical focus to their subjective experiences, the patients do something more or something other than just answering the question. Using conversation analysis, we examined such sequences in diagnostic interviews in an outpatient clinic in Finland. From 10 audio-recorded diagnostic interviews, we found 45 segments where medical questions were met with patients' self-disclosures. We show four sequential trajectories that enable this shift of topic and action. There are four possible trajectories: (1) the patient first answers the medical question and the clinician acknowledges this answer, whereupon the patient shifts to a self-disclosure of their subjective experience; (2) the patient first gives the medical answer but shifts to self-disclosure without the clinician's acknowledgement of that answer; (3) the patient produces an extensive answer to the medical question and, in the course of producing this, shifts into the self-disclosure; (4) the patient does not offer a medical answer but designs the self-disclosure as if it were the answer to the medical question. We argue that in the shifts to the self-disclosure of their subjective negative experience, the patients take local control of the interaction. These shifts also embody a clash between the interactional projects of the participants. At the end of the paper, we discuss the clinical relevance of our results regarding the patient's agency and the goals of the psychiatric assessment.

Furthering patient-centered counseling: Exploring new aspects around pharmacists' experiences in pharmacy encounters through video-stimulated recall interviewing

BACKGROUND

Studies on pharmacy communication have illustrated problems with patient-centeredness. Exploring pharmacists' experiences of pharmacy counseling in depth is essential to understand what hinders patient-centeredness. Existing studies, based primarily on surveys and qualitative interviews, tap into perceptions of pharmacy counseling that are informed by general conceptualizations rather than what participants actually experience during the encounters. Thus, important aspects of the dynamics of pharmacy encounters might be missed.

OBJECTIVES

To explore the potential of the method video-stimulated recall interview (VSRI)( Wolters et al., 2017) 1 in a pharmacy setting to gain new insights into pharmacists' experiences of patient encounters. This includes: 1) to investigate the potential of VSRI to reveal accurate and immediate perceptions of pharmacy encounters, and 2) to identify specific perceptions that pharmacists report in VSRIs.

METHODS

Seven VSRIs conducted in 2 different community pharmacies in Denmark were analyzed. Videos of at-the-counter meetings were recorded (interaction1), and then selected for replay in a VSRI between a researcher and the pharmacist featured in the video (interaction2). Descriptive categories that characterized pharmacists' experiences with the encounter were inferred from interview statements.

RESULTS

New barriers to patient-centeredness were identified: pharmacists' experiences revealed that they were affected by patients' moods and that they found it inappropriate when patients disclosed personal perspectives. Also, pharmacists seemed to disregard that active listening requires responsiveness and should be seen as a process that pharmacists co-construct together with the patient.

CONCLUSION

The method of VSRI proved useful in revealing new dynamics of pharmacy interaction and pinpointing shortcomings in how pharmacists communicate with patients. Based on the findings, suggestions for how to establish better patient-centered communication are provided.

Nurses' instruction of patients in the use of INR-monitors for self-management of cardio-vascular conditions: Missed instructional opportunities

OBJECTIVE

To explore the effectiveness of a patient education programme for chronic disease self-management in terms of whether (a) patients are taught to perform the medical procedure and (b) nurses have evidence of patients' proficiency when they start self-management.

METHODS

Patients were followed through an education programme for oral anticoagulation therapy, involving the use of INR-monitors. Training sessions were video-recorded and analyzed using Conversation Analysis. 55 instructional opportunities were identified, and the relationship between instructional response and patients' subsequent (un)successful demonstration of the procedure traced.

RESULTS

Patient errors provide the most frequent type of instructional opportunity, but not all are addressed; a significant number is allowed to pass uncorrected. Consequently, patients are not given the opportunity to learn. In the majority of cases where instructional opportunities are missed, patients subsequently do not demonstrate a correct understanding of the procedure.

CONCLUSION

Patients are allowed to start self-management although nurses do not have evidence that they are capable of performing all aspects of the medical procedure correctly.

PRACTICE IMPLICATIONS

Effective practice suggests that nurses take measures to minimize the amount of missed instructional opportunities that arise and ensure that errors are pursued until patients demonstrate proficiency in all aspects of the procedure.

Do multimorbidity and deprivation influence patients' emotional expressions and doctors' responses in primary care consultations?--An exploratory study using multilevel analysis

OBJECTIVE

To explore whether and how patient multimorbidity and socioeconomic deprivation might influence patients' emotional expression and doctors' responses in the general practice (GP) consultations.

METHODS

Video recordings of 107 consultations (eight GPs) were coded with the Verona Coding Definitions of Emotional Sequences (VR-CoDES). Multilevel logistic regressions modelled the probability of GP providing space response, considering patient multimorbidity, deprivation conditions and other contextual factors. Further multinomial regressions explored the possible impact of multimorbidity and deprivation on expression of and specific responses to patients' emotional distress.

RESULTS

It was less likely for GPs to provide space as the consultation proceeded, controlling for multimorbidity and deprivation variables. Patients with multimorbidity were less likely to express emotional distress in an explicit form. GPs were more likely to provide acknowledgement to emotions expressed by patients from more deprived areas.

CONCLUSION

Multimorbidity and deprivation may influence the dynamics of the GP consultations in specific ways. Rigorous methodologies using larger samples are required to explore further how these two variables relate to each other and influence cue expression, provider response and subsequent patient outcomes.

PRACTICE IMPLICATIONS

Understanding how multimorbidity and deprivation impact on GP consultations may help inform future service improvement programmes.