Emotional Communication in HIV Care: An Observational Study of Patients' Expressed Emotions and Clinician Response

Patients' emotional expressions and clinicians' responses in oncology - From recognition to exploration of concerns

Objectives

The objective of this study was to analyze patient's emotional expressions during the consultations and the responses of their oncologists to these expressions.

Methods

The study employed a mixed-method, observational, descriptive, and explanatory design. A total of 31 adult patients at different clinical stages, undergoing cancer treatment and 8 oncologists were included. Thirty-one routine outpatient oncology consultations were analyzed, after being transcribed and coded, using the Portuguese version of the Verona Coding Definitions of Emotional Sequences (VR-CoDES).

Results

The oncologists elicited and recognized patients' emotional concerns but they did not explore them in a way that encouraged patients to continue verbalizing their feelings. Oncologists provided more directive and guidance-oriented responses, focusing on cues related to physical pain and symptoms. Multilevel logistic regression analysis modeled the probability of oncologists' responses showing reduction of space in relation to patients' emotional cues/concerns, controlling for clustering and patients' clinical and socio-demographic variables. The type of cue and treatment influenced the oncologists' responses.

Conclusions

Communication skills training focused on the ability to better explore patients' emotions may help oncologists to provide more explicit and empathetic responses that validate the emotional content expressed during consultations. Practice Implications: Oncologists do not use the same responses as a standard with patients, thus adjusting them individually.

Role of the Surgeon in De-Escalating Emotion During a Breast Cancer Surgery Consultation: A Qualitative Study of Patients' Experiences in Alliance A231701CD

BACKGROUND

Patient engagement in decision making can improve satisfaction with care. Studies demonstrate that patients' emotional states can be significant barriers to engaging in shared decision making.

OBJECTIVE

We sought to examine how emotion associated with a breast cancer diagnosis impacts patient experiences during the surgical consultation, and explore opportunities for surgeons to mitigate the impact of emotion.

METHODS

We conducted 30 semi-structured interviews with patients who participated in the decision aid arm of Alliance A231701CD, had low engagement, and experienced barriers to engagement. We used qualitative content analysis to analyze the interview data and organize it into overarching themes.

RESULTS

Participants recalled strong emotions with their diagnosis, describing it as devastating and shocking. Although several participants said that their emotional reaction to the diagnosis lessened over time, others expressed still feeling very anxious. Participants described ways in which their surgeon helped to de-escalate their emotional state, beginning with the establishment of rapport and continuing through treatment planning. Participants valued surgeons who they perceived to be personable and compassionate, treated them as an individual, provided reassuring and matter-of-fact information about their cancer, and efficiently communicated plans for next steps.

CONCLUSIONS

Patients with breast cancer are often emotionally overwhelmed during their surgical consults, which impedes their ability to listen and participate in decision making. However, surgeon behaviors can help de-escalate emotions. Addressing emotion is critical to support patients in reaching a decision for breast cancer surgery and is likely to improve patient satisfaction with the decision process.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier: NCT03766009.

Which clinician responses to emotion are associated with more positive patient experiences of communication?

OBJECTIVES

To identify communication strategies that may improve clinician-patient interactions, we assessed the association between clinician response to emotion and patient ratings of communication.

METHODS

From a cohort of 1817 clinician-patient encounters, we designed a retrospective case-control study by identifying 69 patients who rated their interpersonal care as low-quality and 69 patients who rated their care as high-quality. We used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to identify patient emotional expressions and clinician responses. Using mixed-effects logistic regression, we evaluated the association between clinician responses to patients' emotions and patient ratings of their interpersonal care.

RESULTS

In adjusted analyses, explicit responses that reduced space for further emotional communication were associated with high ratings of care (OR 1.94, 95% CI 1.25, 2.99); non-explicit responses providing additional space were associated with low ratings (OR 0.54, 95% CI 0.36-0.82). In terms of specific response types, neutral/passive responses were associated with low ratings (OR 0.59, 95% CI 0.39-0.90), whereas giving information/advice was associated with high ratings (OR, 95% 1.91 CI 1.17-3.1).

CONCLUSIONS

Patients may prefer responses to their expressed emotions that demonstrate clinician engagement, with or without expressions of empathy.

PRACTICE IMPLICATIONS

These findings may inform educational interventions to improve clinician-patient communication.

Taxonomy and effectiveness of clinician agenda-setting questions in routine ambulatory encounters: A mixed method study

OBJECTIVES

Despite decades of communication training, studies repeatedly demonstrate that clinicians fail to elicit patients' agendas. Our goal was to provide clinicians with actionable guidance about the effectiveness of agenda-soliciting questions.

METHODS

We coded clinician agenda-soliciting questions and patient responses in audio-recorded ambulatory encounters at an urban academic hospital. To evaluate the association between question type and odds of the patient raising a concern, we performed mixed-effects logistic regression.

RESULTS

We identified 346 agenda-soliciting questions within 138 visits (mean 2.51/visit; range 0-9). Agenda-soliciting questions were categorized as personal state inquiries (37%, "How are you?"), feeling-focused (5% "How're you feeling?"), problem-focused (12%; "Are you having any problems"), direct solicitations (3%; "Anything you want to discuss today?"), "what else" (3%), "anything else" (14%), leading (16%; "Nothing else today?"), and space-reducing (11% "Anything else? Smoking?"). Patients raised a concern in response to 107 clinician questions (27%). Patients were more likely to raise a concern to direct solicitation (OR 22.95, 95% CI 2.62-200.70) or "what else" (OR 4.68, 95% CI 1.05-20.77) questions.

CONCLUSIONS

The most effective agenda-soliciting questions are used least frequently by clinicians.

PRACTICE IMPLICATIONS

Clinicians should elicit patient agendas by using direct language, and solicit additional concerns using "what else" vs. "anything else" questions.

Diversity of Parent Emotions and Physician Responses During End-of-Life Conversations

BACKGROUND AND OBJECTIVES

To provide support to parents of critically ill children, it is important that physicians adequately respond to parents' emotions. In this study, we investigated emotions expressed by parents, physicians' responses to these expressions, and parents' emotions after the physicians' responses in conversations in which crucial decisions regarding the child's life-sustaining treatment had to be made.

METHODS

Forty-nine audio-recorded conversations between parents of 12 critically ill children and physicians working in the neonatal and pediatric intensive care units of 3 Dutch university medical centers were coded and analyzed by using a qualitative inductive approach.

RESULTS

Forty-six physicians and 22 parents of 12 children participated. In all 49 conversations, parents expressed a broad range of emotions, often intertwining, including anxiety, anger, devotion, grief, relief, hope, and guilt. Both implicit and explicit expressions of anxiety were prevalent. Physicians predominantly responded to parental emotions with cognition-oriented approaches, thereby limiting opportunities for parents. This appeared to intensify parents' expressions of anger and protectiveness, although their anxiety remained under the surface. In response to more tangible emotional expressions, for instance, grief when the child's death was imminent, physicians provided parents helpful support in both affect- and cognition-oriented ways.

CONCLUSIONS

Our findings illustrate the diversity of emotions expressed by parents during end-of-life conversations. Moreover, they offer insight into the more and less helpful ways in which physicians may respond to these emotions. More training is needed to help physicians in recognizing parents' emotions, particularly implicit expressions of anxiety, and to choose helpful combinations of responses.

A Principal Investigator as a PrEP-Using Peer Change Agent for HIV Prevention among Black Gay and Bisexual Men: An Autoethnography

HIV pre-exposure prophylaxis (PrEP) use remains suboptimal among Black gay and bisexual men (GBM). Multilevel factors such as medication costs, intersectional stigma, patient-clinician communication, medical mistrust, side effect concerns, and low perceived HIV risk (PHR) are well-established PrEP initiation barriers for this group. Peer change agents (PCAs) are culturally congruent interventionists who can circumvent multilevel PrEP barriers among Black GBM. I led an intervention as a PrEP-using PCA to improve PHR and PrEP willingness among 69 Black GBM from 2019-2022 and conducted an autoethnography to better understand multilevel barriers and identify the personal/professional challenges of being an in-group HIV interventionist serving Black SMM. Findings provide novel perspectives regarding PrEP barriers, the role of cultural homophily in behavior change interventions, and how interpersonal dynamics can impact staff fatigue, protocol fidelity, and research participation. Recommendations to prepare and support culturally congruent research staff are also provided.

Psychometric Properties of an Emotional Communication Questionnaire for Education and Healthcare Professionals

Educational and healthcare professionals need to develop emotional communication with schoolchildren and patients, respectively. This study aims to analyse the psychometric properties of an instrument that evaluates emotional communication among these professionals. A total of 406 professionals and students of education and health sciences took part in the study. They were administered a questionnaire using a Google Form that collected different elements of emotional communication. An exploratory factor analysis was carried out from which three factors were extracted: Communicative Proactivity, Openness and Authenticity, and Listening. These were supported by confirmatory factor analysis. The internal consistency of the scale is also adequate, ranging from 0.69 to 0.82. This instrument is valid, and, in a self-reported, straightforward and time-efficient manner, can assess the emotional communication of professionals and students of education and health sciences.

Parental Expression of Emotions and Surgeon Responses During Consultations for Obstructive Sleep-Disordered Breathing in Children

Importance

Little is known about emotional communication between parents and surgeons. Understanding the patterns and correlates of emotional communication may foster collaboration during surgical consultations.

Objective

To describe the emotional expressions by parents when bringing their child for evaluation of obstructive sleep-disordered breathing (SDB) as well as surgeon responses to these emotional expressions and to evaluate the association between parental demographic characteristics and surgeon response types.

Design, Setting, and Participants

This cross-sectional study analyzed the audio-recorded consultations between otolaryngologists and parents of children who underwent their initial otolaryngological examination for obstructive SDB at 1 of 3 outpatient clinical sites in Maryland from April 1, 2016, to May 31, 2017. Data analysis was performed from November 1 to December 31, 2019.

Main Outcomes and Measures

Emotional expressions by parents and surgeon responses were audio recorded, transcribed, and coded using the Verona Coding Definitions of Emotional Sequences.

Results

A total of 59 consultations, of which 40 (67.8%) contained at least 1 emotional expression, were included. Participants included 59 parents (53 women [89.8%]; mean [SD] age, 33.4 [6.4] years) and 7 surgeons (4 men [57.1%]; mean [SD] age, 42.8 [7.9] years). Parents made 123 distinct emotional expressions (mean [SD], 3.08 [2.29] expressions per visit), which were often expressed as subtle cues (n = 103 of 123 [83.7%]) vs explicit concerns (n = 20 [16.3%]). Most expressions (n = 98 [79.7%]) were related to medical issues experienced by the child (eg, symptoms and surgical risks). Most surgeon responses provided parents space for elaboration of emotional expressions (n = 86 [69.9%]) and were nonexplicit (n = 55 [44.7%]). Surgeons were less likely to explore the emotions of parents from racial and ethnic minority groups compared with White parents (OR, 0.47; 95% CI, 0.18-0.98).

Conclusions and Relevance

This cross-sectional study found that emotional communication occurs between surgeons and parents of pediatric patients with obstructive SDB. However, surgeon responses varied according to parental race and ethnicity, suggesting the existence of implicit biases in surgeon-patient communication and calling for further research to inform efforts to promote family-centered, culturally competent communication in surgery.

Clinician Response to Patient Emotion: Impact on Subsequent Communication and Visit Length

PURPOSE

It is widely cited-based on limited evidence-that attending to a patient's emotions results in shorter visits because patients are less likely to repeat themselves if they feel understood. We evaluated the association of clinician responses to patient emotions with subsequent communication and visit length.

METHODS

We audio-recorded 41 clinicians with 342 unique patients and used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to time stamp patient emotional expressions and categorize clinician responses. We used random-intercept multilevel-regression models to evaluate the associations of clinician responses with timing of the expressed emotion, patient repetition, and subsequent length of visit.

RESULTS

The mean visit length was 30.4 minutes, with 1,028 emotional expressions total. The majority of clinician responses provided space for the patient to elaborate on the emotion (81%) and were nonexplicit (56%). As each minute passed, clinicians had lower odds of providing space (odds ratio [OR] = 0.96; 95% CI, 0.95-0.98) and higher odds of being explicit (OR = 1.02; 95% CI, 1.00-1.03). Emotions were more likely to be repeated when clinicians provided space (OR = 2.33; 95% CI, 1.66-3.27), and less likely to be repeated when clinicians were explicit (OR = 0.61; 95% CI, 0.47-0.80). Visits were shorter (β = -0.98 minutes; 95% CI, -2.19 to 0.23) when clinicians' responses explicitly focused on patient affect.

CONCLUSION

If saving time is a goal, clinicians should consider responses that explicitly address a patient's emotion. Arguments for providing space for patients to discuss emotional issues should focus on other benefits, including patients' well-being.

Are clinicians' self-reported empathic concern and perspective-taking traits associated with their response to patient emotions?: Communication Studies

OBJECTIVE

To understand whether clinicians' empathic concern and perspective-taking traits are associated with their response to patient emotions.

METHODS

We audio-recorded 41 HIV clinician interactions with 342 patients at two academic medical centers. We assessed clinicians' self-reported empathic concern and perspective-taking traits using the Interpersonal Reactivity Index and coded emotional communication using the Verona Coding Definitions of Emotional Sequences. We used random effects models to assess associations between clinician traits and clinician responses to patients' negative emotions, accounting for clustering of emotions within encounters and patients within clinicians.

RESULTS

Clinicians with more self-reported empathic concern received fewer emotional expressions from their patients (β -0.06; 95% CI -0.10, -0.01) and had greater odds of responding to emotions by giving information/advice (OR 1.10; 95% CI 1.01, 1.20). There were no associations between empathic concern or perspective-taking and any other clinician responses.

CONCLUSION

Clinicians with higher levels of empathic concern respond to patient emotions by giving information and advice, a response traditionally thought of as a missed empathic opportunity, not by exploring emotions or providing empathy. Whether this is helpful to patients is unknown.

PRACTICE IMPLICATIONS

Clinicians should be aware of their tendency to give information to patients with emotional distress, and consider whether this response is helpful to patients.

Racial disparities in clinician responses to patient emotions

OBJECTIVE

In a previous study of patients newly enrolled in HIV care, we observed that clinicians were less likely to address emotional issues expressed by African-American patients compared to whites. We sought to verify and expand these findings in a larger group of patients established in HIV care.

METHODS

We used VR-CoDES to analyze transcripts from 342 audio-recorded medical visits in the United States. We used random intercept multilevel logistic regression to assess associations between patient and clinician characteristics and patterns of emotional talk.

RESULTS

African-American patients were less likely than others to spontaneously express emotions (OR 0.50; 95 % CI 0.29-0.85). Clinicians, who were predominantly white, were more likely to respond to emotional expressions by African-American patients explicitly (OR 1.56; 95 % CI 1.11-2.20) but less likely to offer neutral/passive responses that provide space for emotional conversation (OR 0.56; 95 % CI 0.37-0.84) and more likely to block discussion of the emotional issue (OR 2.20; 95 % CI 1.05-4.63). Emotional talk did not vary by patient age or gender.

CONCLUSION

These results confirm our prior findings, demonstrating less open emotional communication between African-American patients and their providers.

PRACTICE IMPLICATIONS

Addressing racial differences in communicating about emotions may reduce disparities in patient-clinician relationships.

"I'm Not Feeling Like I'm Part of the Conversation" Patients' Perspectives on Communicating in Clinical Video Telehealth Visits

BACKGROUND

Clinical video telehealth (CVT) offers the opportunity to improve access to healthcare providers in medically underserved areas. However, because CVT encounters are mediated through technology, they may result in unintended consequences related to the patient-provider interaction.

METHODS

Twenty-seven patients with type 2 diabetes mellitus enrolled in Veteran Affairs Health Care and at least one previous telehealth visit experience were interviewed regarding their perspectives on facilitators and barriers to communication with their provider during their CVT visit. The semi-structured telephone interviews were approximately 30 min and were audio-recorded and transcribed. We conducted a thematic content analysis of the interview transcripts. Codes from the transcripts were grouped into thematic categories using the constant comparison method and each theme is represented with illustrative quotes.

RESULTS

We identified several themes related to patients' perspectives on CVT. In general, patients expressed satisfaction with CVT visits including better access to appointments, shorter travel time, and less time in the waiting room. Yet, patients also identified several challenges and concerns about CVT visits compared with in-person visits, including concerns about errors in their care because of perceived difficulty completing the physical exam, perceptions that providers paid less attention to them, barriers to speaking up and asking questions, and difficulty establishing a provider-patient relationship. Patients reported feeling less involved during the visit, difficulty finding opportunities to speak, and feeling rushed by the provider.

CONCLUSIONS

Patients believed that CVT can improve their access to care, but could hinder communication with their provider, and some were concerned about the completeness and accuracy of the physical exam.