Exploring and Validating Patient Concerns: Relation to Prescribing for Depression

“By far the most frequently used drug in general practice is the doctor ….No pharmacology of this important drug exists. No guidance is contained in any textbook as to the dosage the doctor should prescribe, in what form, how frequently, what their curative and maintenance doses should be and so on. Still more disquieting is the lack of any literature on the possible hazards…or on the undesirable side effects of this drug.” Michael Balint1

In their remarkable study, Epstein and colleagues2 have made an invaluable contribution to our understanding of this “important drug,” as they have demonstrated how a physician’s communication can significantly impact the quality of care. As they correctly conclude, “this is the first published study to link particular physician communication behaviors with appropriateness of prescribing” (p.27).2

They have given us a peek into the underbelly of our primary care visits, particularly initial ones. Recalling Balint again, the diagnostic process involves the patient’s offering of information, the “unorganized illness,” and the doctor’s important job of organizing it.1 In general, this is a complicated process, and in the current study, the researchers wisely chose conditions which bring additional complexity to the diagnostic and decision making process. As we know, no simple blood tests or imaging studies exist to help diagnose depression or adjustment disorder. Patients must explain their experience, while physicians try to gather the right information to make an assessment. Physicians must determine whether the patients' self report and their own clinical observation accurately represent what occurs outside the exam room. Of course, both of these methods are vulnerable to assumptions, biases and differences in interpretation.3 The fact that, in 87% of the encounters in this study, physicians were unable to recognize that they were treating standardized patients reveals how susceptible we can be to misinterpretation. Epstein and colleagues have designed an elegant methodology that gives us a glimpse of how the patient-physician interaction helps shape both the focus of the diagnosis and the decision making regarding treatment. We can begin to see more clearly how the movement from the “unorganized” to the “organized” is a communication- sensitive process.

Their study begins to highlight the synergy of the interaction, which many of us experience but rarely have seen demonstrated in research. This work shows that the medical encounter is not simply two people engaged in a problem solving discussion. Patients entered the exam room, suffering and requesting help; they were accompanied by their explanatory models and influences from popular advertising. Physicians entered with their expertise and desire to help, as well as their own values and beliefs (e.g., what constitutes depression and adjustment disorders, how these illnesses should be treated (pharmacologically, psychotherapy, by themselves, or by someone else), how much a physician should give the patient what they want).4 What emerged in the course of their interaction was a rich, complex dance in which both parties mutually influenced the other.

To help manage the complexity of this “mutuality of influence” and improve prescribing behaviors, Epstein and colleagues advocate for physicians to become mindful of their own perspectives and tendencies, as well as take an active role in exploring and validating patients’ concerns (e.g., symptoms, ideas, expectations, functioning, feelings). In addition, their research suggests that participatory patient communication will have a beneficial effect on clinical care if it is met by physician openness, validation, empathy and a genuine desire for greater partnership.

This “mutuality of influence” is particularly poignant when we consider disparities in health status and health care. At the close of their article, Epstein and colleagues rightly charge us with examining how their findings might relate to the care of underserved populations (e.g., racial/ethnic minorities, economically disadvantaged,low literacy) and whether attention to the patient-physician communication can help us reduce disparities in mental health care and outcomes. Increasingly, research is mounting to suggest that disparities are related both to health care system delivery and to discrimination. Cooper and colleagues have steadily documented that communication between physicians and racial and ethnic minorities are vulnerable to both of these factors With underserved populations, communication is often less patient-centered and occurs with less participatory decision making. 5,6,7 Physician bias, the power differential between physicians and patients, and differences in class, language and education can all affect the communication and subsequently the quality of the care. The methodology that Epstein and colleagues have presented may help us better understand how such communication factors operate; they are not always so obvious. For example, research on shared decision making with an underserved, economically disadvantaged and racially/ethnically diverse population has shown that physicians and patients frequently could be observed “going through the motions” of a participatory process, and yet not feel they were collaborating. In stimulated recall sessions, patients revealed that they often felt mistrustful, disrespected and fearful to disclose; while physicians revealed that they often felt frustrated or annoyed. Nonetheless, observing the interaction suggested that both parties were sharing and eliciting information, beliefs and feelings and coming to a mutually acceptable decision.8

The “mutuality of influence” also raises important issues for training. Clearly we should train physicians to adopt the attitudes, skills and self-reflection needed to offer high quality of care. And, we should work with patients to help them realize the importance of a participatory approach to their care and enable them to do so. Both of these groups can be trained separately, but more may be needed. I believe that to improve the communication in primary care relationships we need to think creatively about how to train the “relationship” for more competent communication. For example, we may need to reconsider the context of the 15 minute, one-to-one medical encounter. We may need to increase the time to allow for clarity of communication and "closing the loop." We may want to involve other health professionals into the visit who can help broker the communication, perhaps addressing language, literacy and cultural competency. We may also need to have mechanisms of self reflection built in for both the physician and patient, when poor clinical outcomes persist.

We may not have all the answers about the dose, frequency, therapeutic benefits or adverse side effects of physicians’ communications, but we can no longer pretend that they are inconsequential. I thank and applaud Epstein and colleagues for doing the extremely hard work, doing it right, and challenging us to examine the therapeutic nature of our relationships.

References

1. Balint M. The doctor, his patient and the illness, revised 2nd ed, 1957, London: Pitman Paperbacks, 1968. 2. 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;5:21-28. 3. Mokros HB Communication and psychiatric diagnosis: tales of depressive moods from two contexts. Human communication research.1993;5:113-127. 4. Saba G. What family physicians believe and value in their work. JABFP, 1999;12(3):206-213. 5. Beach MC, Gary TL, Price EG, Robinson K, Gozu A, Palacio A, Smarth C, Jenckes M, Feuerstein C, Bass EB, Powe N, Cooper LA. Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions. BMC Public Health 2006;6:1-11. 6. Cooper LA, Beach MC, Johnson RL, Inui TS. Delving below the surface: understanding how race and ethnicity influence relationships in health care. J Gen Intern Med 2006;21:S21-27. 7. Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health 2004;94:2084-2090. 8. Saba G, Wong S, Schillinger D, Fernandez A, Somkin C, Wilson, C, Grumbach K. Shared decision making and the experience of partnership in primary care. Annals of Family Medicine 2006;4:54-62.

Competing interests:   None declared