Talking about depression: an analogue study of physician gender and communication style on patient disclosures

"How's your mood": Recorded physician mental health conversations with Chinese and Latino patients in routine primary care visits

OBJECTIVE

Patient-physician communication patterns may influence discussions around depressive symptoms and contribute to engagement in depression care among racial/ethnic minority adults. We examined patient-physician communication about depressive symptoms during routine primary care visits with Chinese and Latino patients with and without language barriers.

METHODS

We examined 17 audio-recorded conversations between primary care physicians and Chinese (N = 7) and Latino (N = 10) patients who discussed mental health during their visit and reported depressive symptoms on a post-visit survey. Conversations (in English, Cantonese, Mandarin, Hoisan-wa, Spanish) were transcribed and translated by bilingual/bicultural research assistants and analyzed using inductive and deductive thematic and discourse analysis.

RESULTS

Patients initiated mental health discussion in eleven visits. Physicians demonstrated care in word choice and sometimes avoided openly mentioning depression; this could contribute to miscommunication around symptoms and treatment goals. Interpreters had difficulty finding single words to convey terms used by either patients or physicians.

CONCLUSION

Patients and doctors appeared willing to discuss mental health; however, variability in terminology presented challenges in mental health discussions in this culturally and linguistically diverse sample.

PRACTICE IMPLICATIONS

Further understanding patient preferred terminology about mental health symptoms and interpreter training in these terms could improve patient-physician communication about depressive symptoms and treatment preferences.

The impact of gender patient-physician concordance on interpersonal processes of care and patients' outcomes in the diabetes care setting

OBJECTIVE

To investigate whether patient-physician gender concordance influences the patient's perceptions of interpersonal processes of care and patient outcomes in Muslim patients with diabetes.

METHODS

We conducted a cross-sectional telephone survey involving 4152 randomly selected patients using electronic diabetes records. Outcome measures included perceptions of interpersonal processes of care, adherence to medications, and HbA1c. Linear mixed regression models were used to explore the associations between the outcome variables and patient gender and gender concordance.

RESULTS

The best processes of care were observed consistently for female concordant dyads. In adjusted mixed models, lower Hurried Communication was associated with female concordant (-0.91, p < 0.001) and female physician-male patient dyads (-0.82, p = 0.007). Higher Elicited Concerns was associated with female concordant (0.65, p = 0.003) and female physician-male patient dyads (0.59, p = 0.013). Higher Explained Results and Compassionate/Respectful were associated with female concordant dyads (0.83, p < 0.001, and 0.55, p = 0.010 respectively). Lower HbA1c was independently linked with female concordant dyads (-0.84, p < 0.001).

CONCLUSION

This study highlights the importance of female gender concordance on perceptions of interpersonal processes of diabetes care and glycemic control.

PRACTICE IMPLICATIONS

Strengthening physicians' communication skills with female patients should be taken into consideration.

Equitability of Depression Screening After Implementation of General Adult Screening in Primary Care

IMPORTANCE

Depression is a debilitating and costly medical condition that is often undertreated. Men, racial and ethnic minority individuals, older adults, and those with language barriers are at increased risk for undertreatment of depression. Disparities in screening may contribute to undertreatment.

OBJECTIVE

To examine depression screening rates among populations at risk for undertreatment of depression during and after rollout of general screening.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study from September 1, 2017, to December 31, 2019, of electronic health record data from 52 944 adult patients at 6 University of California, San Francisco, primary care facilities assessed depression screening rates after implementation of a general screening policy. Patients were excluded if they had a baseline diagnosis of depression, bipolar disorder, schizophrenia, schizoaffective disorder, or dementia.

EXPOSURES

Screening year, including rollout (September 1, 2017, to December 31, 2017) and each subsequent calendar year (January 1 to December 31, 2018, and January 1 to December 31, 2019).

MAIN OUTCOMES AND MEASURES

Rates of depression screening performed by medical assistants using the Patient Health Questionnaire-2. Data collected included age, sex, race and ethnicity, and language preference (English vs non-English); to compare English and non-English language preference groups and also assess depression screening by race and ethnicity within the English-speaking group, a single language-race-ethnicity variable with non-English language preference and English language preference categories was created. In multivariable analyses, the likelihood of being screened was evaluated using annual logistic regression models for 2018 and 2019, examining sex, age, language-race-ethnicity, and comorbidities, with adjustment for primary care site.

RESULTS

There were 52 944 unique, eligible patients with 1 or more visits in one of the 6 primary care practices during the entire study period (59% female; mean [SD] age, 48.9 [17.6] years; 178 [0.3%] American Indian/Alaska Native, 13 241 [25.0%] English-speaking Asian, 3588 [6.8%] English-speaking Black/African American, 4744 [9.0%] English-speaking Latino/Latina/Latinx, 760 [1.4%] Pacific Islander, 22 689 [42.9%] English-speaking White, 4857 [9.0%] English-speaking other [including individuals who indicated race and ethnicity as other and individuals for whom race and ethnicity data were missing or unknown], and 2887 [5.5%] with language barriers [non-English language preference]). Depression screening increased from 40.5% at rollout (2017) to 88.8% (2019). In 2018, the likelihood of being screened decreased with increasing age (adusted odds ratio [aOR], 0.89 [95% CI, 0.82-0.98] for ages 45-54 and aOR, 0.75 [95% CI, 0.65-0.85] for ages 75 and older compared with ages 18-30); and, except for Spanish-speaking patients, patients with limited English proficiency were less likely to be screened for depression than English-speaking White patients (Chinese language preference: aOR, 0.59 [95% CI, 0.51-0.67]; other non-English language preference: aOR, 0.55 [95% CI, 0.47-0.64]). By 2019, depression screening had increased dramatically for all at-risk groups, and for most, disparities had disappeared; the odds of screening were only still significantly lower for men compared with women (aOR, 0.87 [95% CI, 0.81 to 0.93]).

CONCLUSIONS AND RELEVANCE

In this cohort study in a large academic health system, full implementation of depression screening was associated with a substantial increase in screening rates among groups at risk for undertreatment of depression. In addition, depression screening disparities narrowed over time for most groups, suggesting that routine depression screening in primary care may reduce screening disparities and improve recognition and appropriate treatment of depression for all patients.

The Relationship Between Provider Gender Preferences and Perceptions of Providers Among Veterans Who Experienced Military Sexual Trauma

Previous research has demonstrated that most veterans who have experienced military sexual trauma (MST) have provider gender preferences. Although provider gender mismatch, defined as not receiving a provider of the gender of one's preference, may deter veterans from disclosing MST or seeking MST-related care, there is little research that has examined this issue. The current study aimed to explore how provider gender mismatch is related to veterans' comfort with providers, perception of their providers' competency, and their endorsement of perceived provider barriers when communicating about MST. The current study was conducted as part of a larger national survey of veterans' barriers to accessing MST-related care. Participants in the study were identified using Veterans Health Administration (VHA) administrative data. Criteria for inclusion in the overall study were being enrolled in VHA health care, having screened positive for MST, and having received at least one VHA outpatient service. A subset of eligible veterans who had endorsed MST, reported a provider gender preference, and endorsed discussing MST with a VHA provider (N = 1,591) were included in the current study. Results demonstrated that provider gender preference mismatch was associated with greater endorsement of perceived provider barriers, less comfort with providers, and lower perceived provider competency in women; and greater perceived provider barriers and less comfort with providers among men. The study demonstrates that provider gender preferences may affect care for veterans who have experienced MST, and that the impact may differ for men and women. These findings may be used to improve patient-centered care and inform future research regarding veterans' provider gender preferences.

Is Patient-Physician Gender Concordance Related to the Quality of Patient Care Experiences?

BACKGROUND

There is great interest in identifying factors that are related to positive patient experiences such as physician communication style. Documented gender-specific physician communication and patient behavior differences raise the question of whether gender concordant relationships (i.e., both the provider and patient share the same gender) might affect patient experiences.

OBJECTIVE

Assess whether patient experiences are more positive in gender concordant primary care relationships.

DESIGN

Statewide telephone surveys. Linear mixed regression models to estimate the association of CAHPS scores with patient gender and gender concordance.

SUBJECTS

Two probability samples of primary care Medicaid patients in Connecticut in 2017 (5/17-7/17) and 2019 (7/19-10/19).

MAIN MEASURES

Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey augmented with questions about aspects of care most salient to PCMH-designated organizations and two questions to assess access to mental health services.

KEY RESULTS

There were no significant effects of gender concordance and differences in experiences by patient gender were modest.

CONCLUSIONS

This study did not support the suggestion that patient and physician gender and gender concordance have an important effect on patient experiences.

Primary Care Physician Recognition and Documentation of Depressive Symptoms Among Chinese and Latinx Patients During Routine Visits: A Cross-Sectional Study

Purpose: Asian and Latinx individuals have a high burden of untreated depression. Under-recognition of depressive symptoms may contribute to existing disparities in depression treatment. The objective of this cross-sectional study was to determine whether physicians recognize and treat depressive symptoms for Chinese and Latinx patients during routine primary care visits. Methods: We analyzed data from 1171 Chinese and Latinx patients who were interviewed within 1 week after a primary care visit in a large academic practice, which had not yet implemented universal depression screening. We included participants with depressive symptoms (defined as a Patient Health Questionaire-2 score ≥3) and no prior history of depression (N=118). We investigated whether patients perceived having a mental health need in the prior year and conducted chart reviews to assess provider recognition of depressive symptoms, defined as documentation of symptoms, antidepressant initiation, or mental health referral within 30 days of the visit. We further examined differences by race/ethnicity and language preference. Results: Among the 118 patients with depressive symptoms and no prior depression diagnosis (mean age 68), 71 (61%) reported a mental health need in the prior 12 months; however, providers recognized depressive symptoms in only 8/118 patients (7%). The number of patients with recognized symptoms was small across race/ethnicity and language preference groups and we found no significant differences. Conclusion: Physicians recognized and documented depressive symptoms for 1 in 10 Chinese and Latinx patients during routine primary care visits. Targeted efforts are needed to address under-recognition of symptoms and improve depression care for these populations.

Measurement-based care as a practice improvement tool: Clinical and organizational applications in youth mental health

Measurement-based care (MBC) is systematic, ongoing assessment to monitor treatment progress and inform clinical decision-making. MBC is considered an evidence-based practice, with extensive research support in adult clinical populations and emerging evidence in youth populations. This paper describes both clinical (e.g., enhancing therapy alliance, informing case conceptualization) and organizational (e.g., informing quality improvement efforts) applications of MBC, and illustrates the clinical applications through two case examples from publicly-funded mental health agency settings. The paper concludes by detailing future research needed to enhance the clinical and organizational utility of MBC.

Gender differences in the expression and cognition of empathy among nursing students: An educational assessment study

BACKGROUND

In the medical context, previous studies found that female care providers present more empathy with patients than their male counterparts. Yet, the explanatory mechanisms for such a difference are not fully explored.

PURPOSE

Guided by the message design logics, this study looked to assess the differences in the expression of empathy by male and female nursing students.

METHODS

The data included transcripts of conversations between 343 undergraduate nursing students and a virtual patient.

RESULTS

Study hypothesis, which was supported, predicted that when presented with opportunities to express empathy female students will use such opportunities more frequently than male students. RQ1 assessed the level of empathic responses and showed no differences between male and female students. RQ2 focused on the cognitive models of empathy and showed that female students had more complex maps that included a larger number and levels of empathy-related concepts.

CLINICAL RELEVANCE

While both male and female students could benefit from education and support in effective expression of empathy, tailored education could promote the recognition of opportunities to be empathic among male students. Clinical communication skill training programs should consider gender-sensitive interventions to support and promote male nurse empathy skills.

Study protocol for investigating physician communication behaviours that link physician implicit racial bias and patient outcomes in Black patients with type 2 diabetes using an exploratory sequential mixed methods design

INTRODUCTION

Patient-physician racial discordance is associated with Black patient reports of dissatisfaction and mistrust, which in turn are associated with poor adherence to treatment recommendations and underutilisation of healthcare. Research further has shown that patient dissatisfaction and mistrust are magnified particularly when physicians hold high levels of implicit racial bias. This suggests that physician implicit racial bias manifests in their communication behaviours during medical interactions. The overall goal of this research is to identify physician communication behaviours that link physician implicit racial bias and Black patient immediate (patient-reported satisfaction and trust) and long-term outcomes (eg, medication adherence, self-management and healthcare utilisation) as well as clinical indicators of diabetes control (eg, blood pressure, HbA1c and history of diabetes complication).

METHODS AND ANALYSIS

Using an exploratory sequential mixed methods research design, we will collect data from approximately 30 family medicine physicians and 300 Black patients with type 2 diabetes mellitus. The data sources will include one physician survey, three patient surveys, medical interaction videos, video elicitation interviews and medical chart reviews. Physician implicit racial bias will be assessed with the physician survey, and patient outcomes will be assessed with the patient surveys and medical chart reviews. In video elicitation interviews, a subset of patients (approximately 20-40) will watch their own interactions while being monitored physiologically to identify evocative physician behaviours. Information from the interview will determine which physician communication behaviours will be coded from medical interactions videos. Coding will be done independently by two trained coders. A series of statistical analyses (zero-order correlations, partial correlations, regressions) will be conducted to identify physician behaviours that are associated significantly with both physician implicit racial bias and patient outcomes.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Virginia Commonwealth University IRB. Study results will be disseminated through publications in peer-reviewed journals and presentations at conferences. A novel Medical Interaction involving Black Patients Coding System from this project will be made publicly available.

African American women perceptions of physician trustworthiness: A factorial survey analysis of physician race, gender and age

BACKGROUND/OBJECTIVE

Physical concordance between physicians and patients is advocated as a solution to improve trust and health outcomes for racial/ethnic minorities, but the empirical evidence is mixed. We assessed women's perceptions of physician trustworthiness based on physician physical characteristics and context of medical visit.

METHODS

A factorial survey design was used in which a community-based sample of 313 African American (AA) women aged 45+ years responded to vignettes of contrived medical visits (routine versus serious medical concern visit) where the physician's race/ethnicity, gender, and age were randomly manipulated. Eight physician profiles were generated. General linear mixed modeling was used to assess separately and as an index, trust items of fidelity, honesty, competence, confidentiality, and global trust. Trust scores were based on a scale of 1 to 5, with higher scores indicating higher trust. Mean scores and effect sizes (ES) were used to assess magnitude of trust ratings.

RESULTS

No significant differences were observed on the index of trust by physician profile characteristics or by medical visit context. However, the white-older-male was rated higher than the AA-older-female on fidelity (4.23 vs. 4.02; ES = 0.215, 95% CI: 0.001-0.431), competence (4.23 vs. 3.95; ES = 0.278, 95% CI: 0.062-0.494) and honesty (4.39 vs. 4.19, ES = 0.215, 95% CI: 0.001-0.431). The AA-older male was rated higher than the AA-older-female on competence (4.20 vs. 3.95; ES = 0.243, 95% CI: 0.022-0.464) and honesty (4.44 vs. 4.19; ES = 0.243, 95% CI: 0.022-0.464). The AA-young male was rated higher than AA-older-female on competence (4.16 vs. 3.95; ES = 0.205, 95% CI: 0.013-0.423).

CONCLUSIONS

Concordance may hold no salience for some groups of older AA women with regards to perceived trustworthiness of a physician. Policies and programs that promote diversity in the healthcare workforce in order to reduce racial/ethnic disparities should emphasize cultural competency training for all physicians, which is important in understanding patients and to improving health outcomes.

Informed and patient-centered decision-making in the primary care visits of African Americans with depression

OBJECTIVE

We examined the prevalence and extent of informed decision-making (IDM) and patient-centered decision-making (PCDM) in primary care visits of African Americans with depression.

METHODS

We performed a cross-sectional analysis of audiotaped clinical encounters and post-visit surveys of 76 patients and their clinicians. We used RIAS to characterize patient-centeredness of visit dialogue. IDM entailed discussion of 3 components: the nature of the decision, alternatives, and pros/cons. PCDM entailed discussion of: lifestyle/coping strategies, knowledge/beliefs, or treatment concerns. We examined the association of IDM and PCDM with visit duration, overall patient-centeredness, and patient/clinician interpersonal ratings.

RESULTS

Approximately one-quarter of medication and counseling decisions included essential IDM elements and 40% included at least one PCDM element. In high patient-centered visits, IDM was associated with patients feeling respected in counseling and liking clinicians in medication decisions. IDM was not related to clinician ratings. In low patient-centered visits, PCDM in counseling decisions was positively associated with patients feeling respected and clinicians respecting patients.

CONCLUSIONS

The associations between IDM and PCDM with interpersonal ratings was moderated by overall patient-centeredness of the visit, which may be indicative of broader cross-cultural communication issues.

PRACTICE IMPLICATIONS

Strengthening partnerships between depressed African Americans and their clinicians may improve patient-engaged decision-making.

Acceptability and design of video-based research on healthcare communication: Evidence and recommendations

OBJECTIVES

To contribute to understandings about acceptability and risks entailed in video-based research on healthcare communication. To generate recommendations for non-covert video-based research on healthcare communication - with a focus on maximising its acceptability to participants, and managing and reducing its risks.

METHODS

A literature review and synthesis of (a) empirical research on participant acceptability and risks of video recording; (b) regulations of professional and governmental bodies; (c) reviews and commentaries; (d) guidance and recommendations. These were gathered across several academic and professional fields (including medical, educational, and social scientific).

RESULTS

36 publications were included in the review and synthesis (7 regulatory documents, 7 empirical, 4 reviews/commentaries, 18 guidance/recommendations). In the context of research aiming in some way to improve healthcare communication:

CONCLUSION AND PRACTICE IMPLICATIONS

The recommendations are designed to support deliberations and decisions about individual studies and to support ethical scrutiny of proposed research studies. Whilst preliminary, it is nevertheless the most comprehensive and detailed currently available.

Communication training improves patient-centered provider behavior and screening for soldiers' mental health concerns

OBJECTIVE

To evaluate the effectiveness of patient-centered communication training for military providers who conduct post-deployment health screening. The half-day interactive workshop included simulated Soldier patients using video technology.

METHODS

Using a quasi-experimental design, all health care providers at four military treatment facilities were recruited for data collection during a four- to nine-day site visit (23 trained providers, 28 providers in the control group, and one provider declined to participate). All Soldiers were eligible to participate and were blinded to provider training status. Immediately after screening encounters, providers reported on their identification of mental health concerns and Soldiers reported on provider communication behaviors resulting in 1,400 matched pairs. Electronic health records were also available for 26,005 Soldiers.

RESULTS

The workshop was found to increase (1) providers' patient-centered communication behaviors as evaluated by Soldiers; (2) provider identification of Soldier mental health concerns; and (3), related health outcomes including provision of education and referral to a confidential counseling resource.

CONCLUSION

Results are promising, but with small effect sizes and study limitations, further research is warranted.

PRACTICE IMPLICATIONS

A brief intensive workshop on patient-centered communication tailored to the military screening context is feasible and may improve key outcomes.

Assessment of immigrant certified nursing assistants' communication when responding to standardized care challenges

OBJECTIVE

Certified nursing assistants (CNAs) provide 80% of the hands-on care in US nursing homes; a significant portion of this work is performed by immigrants with limited English fluency. This study is designed to assess immigrant CNA's communication behavior in response to a series of virtual simulated care challenges.

METHODS

A convenience sample of 31 immigrant CNAs verbally responded to 9 care challenges embedded in an interactive computer platform. The responses were coded with the Roter Interaction Analysis System (RIAS), CNA instructors rated response quality and spoken English was rated.

RESULTS

CNA communication behaviors varied across care challenges and a broad repertoire of communication was used; 69% of response content was characterized as psychosocial. Communication elements (both instrumental and psychosocial) were significant predictors of response quality for 5 of 9 scenarios. Overall these variables explained between 13% and 36% of the adjusted variance in quality ratings.

CONCLUSION

Immigrant CNAs responded to common care challenges using a variety of communication strategies despite fluency deficits.

PRACTICE IMPLICATIONS

Virtual simulation-based observation is a feasible, acceptable and low cost method of communication assessment with implications for supervision, training and evaluation of a para-professional workforce.

How doctors' communication style and race concordance influence African-Caribbean patients when disclosing depression

OBJECTIVE

To determine the impact of doctors' communication style and doctor-patient race concordance on UK African-Caribbeans' comfort in disclosing depression.

METHODS

160 African-Caribbean and 160 white British subjects, stratified by gender and history of depression, participated in simulated depression consultations with video-recorded doctors. Doctors were stratified by black or white race, gender and a high (HPC) or low patient-centred (LPC) communication style, giving a full 2×2×2 factorial design. Afterwards, participants rated aspects of doctors' communication style, their comfort in disclosing depression and treatment preferences

RESULTS

Race concordance had no impact on African-Caribbeans' comfort in disclosing depression. However a HPC versus LPC communication style made them significantly more positive about their interactions with doctors (p=0.000), their overall comfort (p=0.003), their comfort in disclosing their emotional state (p=0.001), and about considering talking therapy (p=0.01); but less positive about considering antidepressant medication (p=0.01).

CONCLUSION

Doctors' communication style was shown to be more important than patient race or race concordance in influencing African Caribbeans' depression consultation experiences. Changing doctors' communication style may help reduce disparities in depression care.

PRACTICE IMPLICATIONS

Practitioners should cultivate a HPC style to make African-Caribbeans more comfortable when disclosing depression, so that it is less likely to be missed.

[Patients' need for consultation after a geriatric assessment in family practice : Survey]

BACKGROUND

During a doctor-patient consultation patients usually seek information by disclosing their reasons for requesting the encounter. Geriatric assessment allows a proactive examination of patients' overall health and function and provides an opportunity to broach issues beyond the initial purposes of the consultation.

OBJECTIVES

The study aimed at investigating older patients' information seeking behavior following a geriatric assessment and the kind of topics they wished to discuss, taking a variety of patient and health-related factors into account.

MATERIAL AND METHODS

A total of 317 patients (≥ 70 years) underwent a geriatric assessment in 40 general practices. Subsequently they obtained a list of the problems uncovered and rated the relevance and information needs for each problem. Analyses consisted of determining the prevalence of information need for each health topic and identifying predictors in a mixed model (multilevel regression analysis).

RESULTS

The 317 patients presented with a median of 11 health problems (interquartile range, IQR 8-14) and 80 % of the patients had information needs concerning only a few of the problems. High information needs were present for physical complaints and for vaccination issues. Little information seeking behavior was evident for unhealthy lifestyles, falls, limitations in daily activities and psychosocial problems. In the mixed model the personal relevance and the type of health problem both had a significant and independent effect on information seeking behavior.

CONCLUSION

A geriatric assessment generates a moderate need for information. It provides physicians with an opportunity to focus on those health problems that are important to older patients but not usually addressed in normal consultations. This particularly applies to limitations in daily activities and psychosocial problems.