Abstract
BACKGROUND
Previous work suggests that exploration and validation of patients’ concerns is associated with greater patient trust, lower health care costs, improved counseling, and more guideline-concordant care.
OBJECTIVE
To describe physicians’ responses to patients’ worries, how their responses varied according to clinical context (straightforward versus medically unexplained symptoms [MUS]) and associations between their responses and patients’ ratings of interpersonal aspects of care.
DESIGN
Multimethod study. For each physician, we surveyed 50 current patients and covertly audiorecorded 2 unannounced standardized patient (SP) visits. SPs expressed worry about “something serious” in 2 scenarios: straightforward gastroesophageal reflux or poorly characterized chest pain with MUS.
PARTICIPANTS
One hundred primary care physicians and 4,746 patients.
MEASUREMENTS
Patient surveys measuring interpersonal aspects of care (trust, physician knowledge of the patient, satisfaction, and patient activation). Qualitative coding of 189 transcripts followed by descriptive, multivariate, and lag-sequential analyses.
RESULTS
Physicians offered a mean of 3.1 responses to each of 613 SP prompts. Biomedical inquiry and explanations, action, nonspecific acknowledgment, and reassurance were common, whereas empathy, expressions of uncertainty, and exploration of psychosocial factors and emotions were uncommon. Empathy expressed during SP visits was associated with higher patient ratings of interpersonal aspects of care. After adjusting for demographics and comorbidities, the association was only statistically significant for the MUS role. Empathy was most likely to occur if expressed at the beginning of the conversational sequence.
CONCLUSIONS
Empathy is associated with higher patient ratings of interpersonal care, especially when expressed in situations involving ambiguity. Empathy should be expressed early after patient expressions of worry.
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References
Lang F, Floyd MR, Beine KL. Clues to patients’ explanations and concerns about their illnesses. A call for active listening. Arch Fam Med. 2000;9:222–7.
Lang F, Floyd MR, Beine KL, Buck P. Sequenced questioning to elicit the patient’s perspective on illness: effects on information disclosure, patient satisfaction, and time expenditure. Fam Med. 2002;34:325–30.
Ring A, Dowrick C, Humphris G, Salmon P. Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study. BMJ. 2004;328:1057.
Salmon P, Dowrick CF, Ring A, Humphris GM. Voiced but unheard agendas: qualitative analysis of the psychosocial cues that patients with unexplained symptoms present to general practitioners. Br J Gen Pract. 2004;54:171–6.
Dowrick CF, Ring A, Humphris GM, Salmon P. Normalisation of unexplained symptoms by general practitioners: a functional typology. Br J Gen Pract. 2004;54:165–70.
Salmon P, Peters S, Stanley I. Patients’ perceptions of medical explanations for somatisation disorders: qualitative analysis. BMJ. 1999;318:372–6.
Seaburn DB, Morse D, McDaniel SH, Beckman H, Silberman J, Epstein RM. Physician responses to ambiguous patient symptoms. J Gen Intern Med. 2005;20:525–30.
McWhinney IR, Epstein RM, Freeman TR. Rethinking somatization. Ann Intern Med. 1997;126:747–50.
Epstein RM, Quill TE, McWhinney IR. Somatization reconsidered: incorporating the patient’s experience of illness. Arch Intern Med. 1999;159:215–22.
Barsky AJ, Borus JF. Somatization and medicalization in the era of managed care. JAMA. 1995;274:1931–4.
Epstein RM, Franks P, Shields CG, et al. Patient-centered communication and diagnostic testing. Ann Fam Med. 2005;3:415–21.
Epstein RM, Shields CG, Franks P, Meldrum SC, Feldman M, Kravitz RL. Exploring and validating patient concerns: relation to prescribing for depression. Ann Fam Med. 2007;5:21–8.
Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA. 1997;277:678–82.
Fiscella K, Meldrum S, Franks P, et al. Patient trust: is it related to patient-centered behavior of primary care physicians? Med Care. 2004;42:1049–55.
Epstein RM, Morse DS, Frankel RM, Frarey L, Anderson K, Beckman HB. Awkward moments in patient–physician communication about HIV risk. Ann Intern Med. 1998;128:435–42.
Floyd MR, Lang F, McCord RS, Keener M. Patients with worry: presentation of concerns and expectations for response. Patient Educ Couns. 2005;57:211–6.
Epstein RM, Shields CG, Meldrum SC, et al. Physicians’ responses to patients’ medically unexplained symptoms. Psychosom Med. 2006;68:269–76.
Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA. 2000;284:1021–7.
Safran DG, Montgomery JE, Chang H, Murphy J, Rogers WH. Switching doctors: predictors of voluntary disenrollment from a primary physician’s practice. J Fam Pract. 2001;50:130–6.
Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213–20.
Williams GC, Freedman ZR, Deci EL. Supporting autonomy to motivate patients with diabetes for glucose control. Diabetes Care. 1998;21:1644–51.
Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: have we improved? JAMA. 1999;281:283–7.
McLeod PJ, Tamblyn RM, Gayton D, et al. Use of standardized patients to assess between-physician variations in resource utilization. JAMA. 1997;278:1164–8.
Tamblyn RM. Use of standardized patients in the assessment of medical practice. CMAJ. 1998;158:205–7.
Kravitz RL, Epstein RM, Feldman MD, et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 2005;293:1995–2002.
Epstein RM, Franks P, Fiscella K, et al. Measuring patient-centered communication in patient–physician consultations: theoretical and practical issues. Soc Sci Med. 2005;61:1516–28.
Glassman PA, Luck J, O’Gara EM, Peabody JW. Using standardized patients to measure quality: evidence from the literature and a prospective study. Jt Comm J Qual Improv. 2000;26:644–53.
Franz CE, Epstein RM, Miller KN, et al. Caught in the act? Prevalence, predictors, and consequences of physician detection of unannounced standardized patients. Health Serv Res. 2006;41:2290–302.
Ware JE, Snyder MK, Wright WR, Davies AR. Defining and measuring patient satisfaction with medical care. Eval Program Plann. 1984;6:247–63.
Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care. 1998;36:728–39.
Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213–20.
Williams GC, Rodin GC, Ryan RM, Grolnick WS, Deci EL. Autonomous regulation and long-term medication adherence in adult outpatients. Health Psychol. 1998;17:269–76.
Franks P, Fiscella K, Shields CG, et al. Are patients’ ratings of their physicians related to health outcomes? Ann Fam Med. 2005;3:229–34.
Bakeman R, Gottman JM. Observing Interaction: An Introduction to Sequential Analysis. 2nd ed. Cambridge: Cambridge University Press; 1997.
Eide H, Quera V, Graugaard P, Finset A. Physician–patient dialogue surrounding patients’ expression of concern: applying sequence analysis to RIAS. Soc Sci Med. 2004;59:145–55.
Beach MC, Inui T, Relationship-Centered Care research Network. Relationship-centered care. A constructive reframing. J Gen Intern Med. 2006;21(Suppl 1):S3–8.
Bellet PS, Maloney MJ. The importance of empathy as an interviewing skill in medicine. JAMA. 1991;266:1831–2.
Charon R. The patient–physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001;286:1897–902.
Jordan JV. Relational development through mutual empathy. In: Bohart AC, Greenberg LS, eds. Empathy Reconsidered: New Directions in Psychotherapy. Washington, DC: American Psychological Association; 1995:343–51.
Larson EB, Yao X. Clinical empathy as emotional labor in the patient–physician relationship. JAMA. 2005;293:1100–6.
Platt FW. Empathy: can it be taught? Ann Intern Med. 1992;117:700.
Spiro H. What is empathy and can it be taught? Ann Intern Med. 1992;116:843–6.
Zachariae R, Pedersen CG, Jensen AB, Ehrnrooth E, Rossen PB, von der MH. Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease. Br J Cancer. 2003;88:658–65.
Zinn W. The empathic physician. Arch Intern Med. 1993;153:306–12.
Havens L. Making Contact. Cambridge, MA: Harvard University Press; 1986.
McDonald IG, Daly J, Jelinek VM, Panetta F, Gutman JM. Opening Pandora’s box: the unpredictability of reassurance by a normal test result. BMJ. 1996;313:329–32.
Stark D, Kiely M, Smith A, Morley S, Selby P, House A. Reassurance and the anxious cancer patient. Br J Cancer. 2004;91:893–9.
Gerrity M, White K. Physicians’ reactions to uncertainty: refining the constructs and scales. Motiv Emot. 1995;19:175–91.
Epstein RM. Mindful practice. JAMA. 1999;282:833–9.
Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician: personal awareness and effective patient care. JAMA. 1997;278:502–9.
Johnson CG, Levenkron JC, Suchman AL, Manchester R. Does physician uncertainty affect patient satisfaction? J Gen Intern Med. 1988;3:144–9.
Ogden J, Fuks K, Gardner M, et al. Doctors expressions of uncertainty and patient confidence. Patient Educ Couns. 2002;48:171–6.
Acknowledgements
We would like to express thanks to David Seaburn Ph.D. who helped with the initial conceptualization of this project. Vi Luong provided graphic design support, and Sue Palmiero and Mary Haddad provided secretarial and administrative support. Some of the results reported in this article were presented at the International Conference on Communication in Healthcare, Basel, Switzerland, September 7, 2006. This study was funded by Patient Centered Care and Health Care Costs, AHRQ R01-HS1610-01A1, Ronald M. Epstein, Principal Investigator.
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Epstein, R.M., Hadee, T., Carroll, J. et al. “Could this Be Something Serious?”. J GEN INTERN MED 22, 1731–1739 (2007). https://doi.org/10.1007/s11606-007-0416-9
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DOI: https://doi.org/10.1007/s11606-007-0416-9