How psychiatric disorders are missed during medical consultations

Psychosocial needs of inpatient women with gestational diabetes mellitus: a qualitative study

BACKGROUND

Gestational diabetes mellitus (GDM) is one of the most common medical complications associated with pregnancy. Its treatment requires multidisciplinary cooperation, and identifying the psychosocial needs of patients is important in the management of their condition.

OBJECTIVE

This study investigates the psychosocial needs of inpatient mothers with GDM from the joint perspectives of future mothers and healthcare providers.

METHODS

This qualitative study used a content analysis approach. Semi-structured individual interviews focusing on the psychosocial needs of women with GDM were conducted with twelve women suffering from GDM and eight medical staff. Sampling continued until data saturation.

RESULTS

According to the findings of this study, the psychosocial needs of these mothers were classified into the following categories: Support for worries related to the consequences of the disease, Interpersonal support, Infrastructural support, educational support.

CONCLUSION

The psychosocial needs of inpatient mothers with GDM were identified in this study. Attention to these needs can help enhance the mother's satisfaction and treatment adherence, and reduce worries and anxiety during hospitalisation.

ABBREVIATIONS

GDM: Gestational Diabetes Mellitus; hPGH: human placental growth hormone; COREQ: Consolidated criteria for reporting qualitative research; WHO: World Health Organization; HCP: healthcare provider.

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.

"How Much Time Do I Have?": Communicating Prognosis in the Era of Exceptional Responders

Prognostication is the science by which clinicians estimate a patient's expected outcome. A robust literature shows that many patients with advanced cancer have inaccurate perceptions of their prognosis, thus raising questions about whether patients are truly making informed decisions. Clinicians' ability to communicate prognostic information is further complicated today by the availability of novel, efficacious immunotherapies and genome-guided treatments. Currently, clinicians lack tools to predict which patients with advanced disease will achieve an exceptional response to these new therapies. This increased prognostic uncertainty on the part of clinicians further complicates prognostic communication with patients. Evidence also suggests that many oncologists avoid or rarely engage in prognosis-related communication and/or lack skills in this area. Although communication skills training interventions can have a positive impact on complex communication skills for some clinicians, there is no one-size-fits-all approach to improving patient-clinician communication about prognosis. Yet improving patient understanding of prognosis is critical, because patient understanding of prognosis is linked with end-of-life care outcomes. Solutions to this problem will likely require a combination of interventions beyond communication skills training programs, including enhanced use of other cancer clinicians, such as oncology nurses and social workers, increased use of palliative care specialists, and organizational support to facilitate advance care planning.

Do doctors' attachment styles and emotional intelligence influence patients' emotional expressions in primary care consultations? An exploratory study using multilevel analysis

OBJECTIVE

To investigate whether and how doctors' attachment styles and emotional intelligence (EI) might influence patients' emotional expressions in general practice consultations.

METHODS

Video recordings of 26 junior doctors consulting with 173 patients were coded using the Verona Coding Definition of Emotional Sequences (VR-CoDES). Doctors' attachment style was scored across two dimensions, avoidance and anxiety, using the Experiences in Close Relationships: Short Form questionnaire. EI was assessed with the Mayer-Salovey-Caruso Emotional Intelligence Test. Multilevel Poisson regressions modelled the probability of patients' expressing emotional distress, considering doctors' attachment styles and EI and demographic and contextual factors.

RESULTS

Both attachment styles and EI were significantly associated with frequency of patients' cues, with patient- and doctor-level explanatory variables accounting for 42% of the variance in patients' cues. The relative contribution of attachment styles and EI varied depending on whether patients' presenting complaints were physical or psychosocial in nature.

CONCLUSION

Doctors' attachment styles and levels of EI are associated with patients' emotional expressions in primary care consultations. Further research is needed to investigate how these two variables interact and influence provider responses and patient outcomes.

PRACTICE IMPLICATIONS

Understanding how doctors' psychological characteristics influence PPC may help to optimise undergraduate and postgraduate medical education.

Do patients' faces influence General Practitioners' cancer suspicions? A test of automatic processing of sociodemographic information

BACKGROUND

Delayed cancer diagnosis leads to poorer patient outcomes. During short consultations, General Practitioners (GPs) make quick decisions about likelihood of cancer. Patients' facial cues are processed rapidly and may influence diagnosis.

AIM

To investigate whether patients' facial characteristics influence immediate perception of cancer risk by GPs.

DESIGN AND SETTING

Web-based binary forced choice experiment with GPs from Northeast Scotland.

METHOD

GPs were presented with a series of pairs of face prototypes and asked to quickly select the patient more likely to have cancer. Faces were modified with respect to age, gender, and ethnicity. Choices were analysed using Chi-squared goodness-of-fit statistics with Bonferroni corrections.

RESULTS

Eighty-two GPs participated. GPs were significantly more likely to suspect cancer in older patients. Gender influenced GP cancer suspicion, but this was modified by age: the male face was chosen as more likely to have cancer than the female face for young (72% of GPs;95% CI 61.0-87.0) and middle-aged faces (65.9%; 95% CI 54.7-75.5); but 63.4% (95% CI 52.2-73.3) decided the older female was more likely to have cancer than the older male (p = 0.015). GPs were significantly more likely to suspect cancer in the young Caucasian male (65.9% (95% CI 54.7, 75.5)) compared to the young Asian male (p = 0.004).

CONCLUSION

GPs' first impressions about cancer risk are influenced by patient age, gender, and ethnicity. Tackling GP cognitive biases could be a promising way of reducing cancer diagnostic delays, particularly for younger patients.

Seeking help for first-episode psychosis: a family narrative

AIM

Delayed help-seeking can have serious consequences for young people with first-episode psychosis (FEP), in terms of treatment response and outcome. Young people's narratives about help-seeking are important to understand why delays occur; however, as the majority of help-seeking is initiated by family members, through a general practitioner (GP), family narratives are also of interest. The aim of this study was to explore help-seeking for FEP, including first contact with a GP.

METHOD

A semistructured interview was developed using a topic guide. Framework analysis was used to analyse data and a deductive qualitative method for applied research. The study was set in Birmingham, UK. Participants were interviewed separately by researchers. Joint coding and identification of 14 complete family dyads was then explored for emerging patterns within the family context.

RESULTS

Family responses to FEP that had an impact on help-seeking behaviour included withdrawal, normalization, stigma, fear and guilt; poor knowledge of availability, and means of access to mental health services was also important. Help-seeking was usually instigated by a family member through a GP, although this was not the case for two of our families, and while contact with GP was generally described as a positive experience for several families, it was hindered by poor communication and lack of engagement.

CONCLUSION

Families play a key role in facilitating help-seeking for FEP, but attempts are often derailed by complex family responses to illness. Public mental health interventions should focus on increasing community awareness of psychosis and improving access and alternative routes to mental health services. However, improvements will have little impact unless primary care and other help-seeking sources engage in open and easy dialogue with the families and young people trying to access their specialist services.

Emotions in primary care: Are there cultural differences in the expression of cues and concerns?

OBJECTIVE

This study compared native-Dutch and Turkish-Dutch patients' expressions of emotional cues/concerns and GPs' responses to these cues/concerns. Relations between patient's cues/concerns and GPs' perceptions of the patient's health complaint were examined too.

METHODS

82 audiotaped encounters with native-Dutch and 38 with Turkish-Dutch GP patients were coded using the VR-CoDES and VR-CoDES-P. Patients filled out a survey before each consultation to assess their cultural identification, Dutch language proficiency and health-related variables. GPs filled out a survey after each consultation to assess their perceptions of the patient's health complaint.

RESULTS

Turkish-Dutch patients expressed more cues than native-Dutch patients, which was explained by higher worries about their health and worse perceived general health. GPs responded more often with space-providing responses to Turkish-Dutch patients compared to native-Dutch patients. Turkish-Dutch patients' cue expression strongly influenced GPs' perceptions about the presence of psychosocial problems.

CONCLUSION

Migrant patient-related factors influence the amount of emotional cue expression in primary care. GPs perceive these cues as indicating the presence of psychosocial problems and provide space for patients to elaborate on their emotional distress.

PRACTICE IMPLICATIONS

GPs should be trained in using more affective communication techniques to enhance elicitation of the underlying reasons for migrant patients' enhanced emotional cue expression.

All eyes on the patient: the influence of oncologists' nonverbal communication on breast cancer patients' trust

Trust in the oncologist is crucial for breast cancer patients. It reduces worry, enhances decision making, and stimulates adherence. Optimal nonverbal communication by the oncologist, particularly eye contact, body posture, and smiling, presumably benefits patients’ trust. We were the first to experimentally examine (1) how the oncologist’s nonverbal behavior influences trust, and (2) individual differences in breast cancer patients’ trust. Analogue patients (APs) viewed one out of eight versions of a video vignette displaying a consultation about chemotherapy treatment. All eight versions varied only in the oncologist’s amount of eye contact (consistent vs. inconsistent), body posture (forward leaning vs. varying), and smiling (occasional smiling vs. no smiling). Primary outcome was trust in the observed oncologist (Trust in Oncologist Scale). 214 APs participated. Consistent eye contact led to stronger trust (β = −.13, p = .04). This effect was largely explained by lower educated patients, for whom the effect of consistent eye contact was stronger than for higher educated patients (β = .18, p = .01). A forward leaning body posture did not influence trust, nor did smiling. However, if the oncologist smiled more, he was perceived as more friendly (r_s = .31, p < .001) and caring (r_s = .18, p = .01). Older (β = .17, p = .01) and lower educated APs (β = −.25, p < .001) were more trusting. Trust was weaker for more avoidantly attached APs (β = −.16, p = .03). We experimentally demonstrated the importance of maintaining consistent eye contact for breast cancer patients’ trust, especially among lower educated patients. These findings need to be translated into training for oncologists in how to optimize their nonverbal communication with breast cancer patients while simultaneously managing increased time pressure and computer use during the consultation.

Patient expression of emotions and neurologist responses in first multiple sclerosis consultations

BACKGROUND

Anxiety and depression are common in people with multiple sclerosis (MS), but data on emotional communication during MS consultations are lacking. We assessed patient expressions of emotion and neurologist responses during first-ever MS consultations using the Verona Coding Definitions of Emotional Sequences (VR-CoDES).

METHODS

We applied VR-CoDES to recordings/transcripts of 88 outpatient consultations (10 neurologists, four MS Italian centers). Before consultation, patients completed the Hospital Anxiety and Depression Scale (HADS). Multilevel sequential analysis was performed on the number of cues/concerns expressed by patients, and the proportion of reduce space responses by neurologists.

RESULTS

Patients expressed 492 cues and 45 concerns (median 4 cues and 1 concern per consultation). The commonest cues were verbal hints of hidden worries (cue type b, 41%) and references to stressful life events (type d, 26%). Variables independently associated with number of cues/concerns were: anxiety (HADS-Anxiety score >8) (incidence risk ratio, IRR 1.08, 95% CI 1.06-1.09; p<0.001); patient age (IRR 0.98, 95% CI 0.98-0.99; p<0.001); neurologist age (IRR 0.94, 95% CI 0.92-0.96; p=0.03); and second opinion consultation (IRR 0.72, 95% CI 0.60-0.86; p=0.007). Neurologists reacted to patient emotions by reducing space (changing subject, taking no notice, giving medical advice) for 58% of cues and 76% of concerns. Anxiety was the only variable significantly associated with 'reduce space' responses (odds ratio 2.17, 95% CI 1.32-3.57; p=0.003).

CONCLUSIONS

Patient emotional expressions varied widely, but VR-CoDES cues b and d were expressed most often. Patient anxiety was directly associated with emotional expressions; older age of patients and neurologists, and second opinion consultations were inversely associated with patient emotional expression. In over 50% of instances, neurologists responded to these expressions by reducing space, more so in anxious patients. These findings suggest that neurologists need to improve their skills in dealing with patient emotions.

The correlation of phrases and feelings with disability

BACKGROUND

Patient expressions reflect disability and psychological factors. The aim of this study was to list common phrases and feelings in hand surgery practice and to prospectively study the correlation of these phrases and to correlate them with possible associated feelings and disability.

METHODS

Eighty-three patients completed the short version of the disabilities of arm, shoulder and hand (QuickDASH) questionnaire to measure disability, the pain self-efficacy questionnaire (PSEQ) to study coping, and a pain scale. The patients also completed the phrases and feelings questionnaire, which list verbal expressions patients often use. Pearson's correlation was used to test the correlation of continuous variables, and independent t test and one-way ANOVA were used for categorical variables. All variables with p < 0.08 were inserted in a multivariable regression.

RESULTS

There was a large correlation between the individual phrases and feelings questions with PSEQ and QuickDASH. The best model for the combined phrases questionnaire included pain, PSEQ, smoking, and other pain conditions. The best model for the combination of all the feelings questions included PSEQ, pain, and marital status. The best model for QuickDASH included phrases, PSEQ, prior treatment, and working status, with phrases being the strongest factor.

CONCLUSIONS

Patients use specific phrases that indicate the magnitude of their disability and the effectiveness of their coping strategies. Providers should respond to these phrases by empathetically acknowledging these aspects of the human illness experience.

Talking about feelings and worries in cancer consultations: the effects of an interactive tailored symptom assessment on source, explicitness, and timing of emotional cues and concerns

BACKGROUND

Patients are experts of their own symptoms and worries, but tend not to express their concerns spontaneously in the consultation. Even when emotions are brought up, they are discussed briefly.

OBJECTIVE

The objective of this study was to examine the impact of an interactive tailored patient assessment (Choice) on communication of emotional cues and concerns expressed by cancer patients in terms of source of initiation of cues/concern, explicitness, timing during the consultation, and consultation type (inpatient/outpatient).

METHODS

We audiotaped and coded consultations between cancer patients and nurses or physicians in 1 control group (n = 99) with standard consultations and 1 intervention group (n = 97) where patients used Choice prior to the consultation. Direct and interaction effects were tested using multilevel analyses.

RESULTS

In the Choice intervention group, there were significantly more frequent and more explicit expressions of cues and concerns; more clinician-initiated concerns occurred during the first 10 minutes; and it was more likely for any cue or concern to be succeeded by a subsequent one. In consultations with many cues/concerns, these were on average more emotionally descriptive or explicit and occurred somewhat earlier in the consultation in the Choice group. Furthermore, more cues/concerns were expressed in inpatient consultations with nurses than in outpatient consultations with physicians.

CONCLUSION

Cancer patients' expressions of cues and concerns do not occur at random. More cues/concerns are expressed early in the consultation, in consultations with nurses, and in the Choice intervention group.

IMPLICATION FOR PRACTICE

Choice may be a useful clinical tool. Use of Choice might aid cancer patients in handling their emotions.

Patterns in clinicians' responses to patient emotion in cancer care

OBJECTIVE

To investigate how patient, clinician and relationship characteristics may predict how oncologists and nurses respond to patients' emotional expressions.

METHODS

Observational study of audiotapes of 196 consultations in cancer care. The consultations were coded according to Verona Coding Definitions of Emotional Sequences (VR-CoDES). Associations were tested in multi-level analyzes.

RESULTS

There were 471 cues and 109 concerns with a mean number of 3.0 (SD=3.2) cues and concerns per consultation. Nurses in admittance interviews were five times more likely to provide space for further disclosure of cues and concerns (according to VR-CoDES definitions) than oncologists in out-patient follow-up consultations. Oncologists gave more room for disclosure to the first cue or concern in the consultation, to more explicit and doctor initiated cues/concerns and when the doctor and/or patient was female. Nurses gave room for further disclosure to explicit and nurse initiated cues/concerns, but the effects were smaller than for oncologists.

CONCLUSION

Responses of clinicians which provide room for further disclosure do not occur at random and are systematically dependent on the source, explicitness and timing of the cue or concern.

PRACTICE IMPLICATIONS

Knowledge on which factors influence responses to cues and concerns may be useful in communication skills training.

Patients' negative emotional cues and concerns in hospital consultations: a video-based observational study

OBJECTIVE

Little is known about the frequency and occurrence of patients' negative emotional cues and concerns (NECC) across specialties in hospital departments.

METHODS

Ninety-six consultations were videotaped in a general hospital. The VR-CoDES (Verona Coding Definitions of Emotional Sequences) were used to code the patients' NECC. Cohen's kappa was used to establish reliability between coders.

RESULTS

Cohen's kappa was above 0.60. NECC were observed in more than half of the consultations. The number of NECC in the consultations was 163, with 109 negative emotional cues and 54 concerns. The mean number of NECC in the consultations was 1.69, with a median of 1. The first NECC in consultations were stated after a median duration of 5min 21s. We could not find significant differences related to the gender and age of the patient or the physician, or the specialty of the physician.

CONCLUSIONS

More than half of the concerns were not preceded by a negative emotional cue. Few consultations contained more than 3 NECC, and NECC tended to be expressed relatively early.

PRACTICE IMPLICATIONS

Patients' expressions of emotional issues are few, and most of them are subtle. Physicians should be thoroughly trained to identify and respond to them.

Application of the verona coding definitions of emotional sequences (VR-CoDES) on a pediatric data set

OBJECTIVE

Adult patients present concerns as defined in the Verona Coding Definitions of Emotional Sequences (VR-CoDES), but we do not know how children express their concerns during medical consultations. This study aimed to evaluate the applicability of VR-CoDES to pediatric oncology consultations.

METHODS

Twenty-eight pediatric consultations were coded with the Verona Coding Definitions of Emotional Sequences (VR-CoDES), and the material was also qualitatively analyzed for descriptive purposes. Five consultations were randomly selected for reliability testing and descriptive statistics were computed.

RESULTS

Perfect inter-rater reliability for concerns and moderate reliability for cues were obtained. Cues and/or concerns were present in over half of the consultations. Cues were more frequent than concerns, with the majority of cues being verbal hints to hidden concerns or non-verbal cues. Intensity of expressions, limitations in vocabulary, commonality of statements, and complexity of the setting complicated the use of VR-CoDES. Child-specific cues; use of the imperative, cues about past experiences, and use of onomatopoeia were observed.

CONCLUSION

Children with cancer express concerns during medical consultations. VR-CoDES is a reliable tool for coding concerns in pediatric data sets.

PRACTICE IMPLICATIONS

For future applications in pediatric settings an appendix should be developed to incorporate the child-specific traits.

The medical consultation viewed as a value chain: a neurobehavioral approach to emotion regulation in doctor-patient interaction

OBJECTIVE

To present a model of the medical consultation as a value chain, and to apply a neurobehavioral perspective to analyze each element in the chain with relevance for emotion regulation.

METHODS

Current knowledge on four elements in medical consultations and neuroscientific evidence on corresponding basic processes are selectively reviewed.

RESULTS

The four elements of communication behaviours presented as steps in a value chain model are: (1) establishing rapport, (2) patient disclosure of emotional cues and concerns, (3) the doctor's expression of empathy, and (4) positive reappraisal of concerns.

CONCLUSION

The metaphor of the value chain, with emphasis on goal orientation, helps to understand the impact of each communicative element on the outcome of the consultation. Added value at each step is proposed in terms of effects on outcome indicators; in this case patients affect regulation. Neurobehavioral mechanisms are suggested to explain the association between communication behaviour and affect regulation outcome.

PRACTICE IMPLICATIONS

The value chain metaphor and the emphasis on behaviour-outcome-mechanisms associations may be of interest as conceptualizations for communications skills training.

Cancer patient ethnicity and associations with emotional distress--the 6th vital sign: a new look at defining patient ethnicity in a multicultural context

Variations in access to care, utilization of available resources and treatment outcomes in the context of ethnicity have been recognized, but very little research of this nature exists in the oncology context. The present paper is an in-depth analysis of data on a large representative sample of Canadian cancer patients with a focus on the role of 'ethnicity', its association to psychological distress, and its impact on the cancer experience. Because of a heterogeneous representation of ethnic self-identifications which were not easily grouped or classified, English as a second language was considered as a surrogate marker to ethnicity. People who self-reported to be from an English-speaking country were grouped together and compared to those hailing from countries which do not have English as a primary language. In a hierarchical logistic regression model (n = 2,402) the demographic and cancer-related variables associated with significant clinical distress in the first block were gender (male, except those with prostate cancer), age less that 68 years, less than a year since diagnosis, diagnosis of lung cancer, and recurrent disease. In the second block, after controlling for the influence of these factors, patient-reported ethnicity (being originally from a non-English speaking country) added significantly to the prediction of patient distress. Though compelling, there is a need to understand the relationship between the ethnic features and language (English versus non-English language). A hypothesis is presented as an attempt to understand an individual's 'ethnicity' within the framework of a multicultural society.

Factors influencing physicians' detection of cancer patients' and relatives' distress: can a communication skills training program improve physicians' detection?

PURPOSE

This study aimed to assess the impact on physicians' detection of patients' and relatives' distress of six 3-h consolidation workshops (CW) following a 2.5-day communication skills basic training (BT) program and to investigate factors associated with detection of distress.

METHODS

Physicians, after BT, were randomized to CW or to a waiting list. Physicians' detection of patients' and relatives' distress was measured through differences between physicians' ratings of patients' and relatives' distress (VAS) and patients' and relatives' self-reported distress (HADS). Communication skills were analysed according to the CRCWEM.

RESULTS

Mixed-effects modelling of physicians' detection of patients' distress showed a positive group by time effect in favour of physicians in the CW group. Detection of patients' distress was associated negatively with patients' distress, positively with physicians' concurrent use of psychological assessment and supportive skills, and negatively with general assessment skills. Mixed-effects modelling of physicians' detection of relatives' distress showed no significant group by time effect. Detection of relatives' distress was associated negatively with relatives' distress and with general assessment skills.

CONCLUSION

CW following a 2.5-day BT are needed to improve physicians' detection of patients' distress in three-person interviews. Results indicate the need to further improve physicians' detection of relatives' distress.

Sequence analysis in multilevel models. A study on different sources of patient cues in medical consultations

The aims of the study were to explore the importance of macro (patient, physician, consultation) and micro (doctor-patient speech sequences) variables in promoting patient cues (unsolicited new information or expressions of feelings), and to describe the methodological implications related to the study of speech sequences. Patient characteristics, a consultation index of partnership and doctor-patient speech sequences were recorded for 246 primary care consultations in six primary care surgeries in Verona, Italy. Homogeneity and stationarity conditions of speech sequences allowed the creation of a hierarchy of multilevel logit models including micro and macro level variables, with the presence/absence of cues as the dependent variable. We found that emotional distress of the patient increased cues and that cues appeared among other patient expressions and were preceded by physicians' facilitations and handling of emotion. Partnership, in terms of open-ended inquiry, active listening skills and handling of emotion by the physician and active participation by the patient throughout the consultation, reduced cue frequency.

"What concerns me is..." Expression of emotion by advanced cancer patients during outpatient visits

OBJECTIVE

Cancer patients have high levels of distress, yet oncologists often do not recognize patients' concerns. We sought to describe how patients with advanced cancer verbally express negative emotion to their oncologists.

MATERIALS AND METHODS

As part of the Studying Communication in Oncologist-Patient Encounters Trial, we audio-recorded 415 visits that 281 patients with advanced cancer made to their oncologists at three US cancer centers. Using qualitative methodology, we coded for verbal expressions of negative emotion, identified words patients used to express emotion, and categorized emotions by type and content.

RESULTS

Patients verbally expressed negative emotion in 17% of the visits. The most commonly used words were: "concern," "scared," "worried," "depressed," and "nervous." Types of emotion expressed were: anxiety (46%), fear (25%), depression (12%), anger (9%), and other (8%). Topics about which emotion was expressed were: symptoms and functional concerns (66%), medical diagnoses and treatments (54%), social issues (14%), and the health care system (9%). Although all patients had terminal cancer, they expressed negative emotion overtly related to death and dying only 2% of the time.

CONCLUSIONS

Patients infrequently expressed negative emotion to their oncologists. When they did, they typically expressed anxiety and fear, indicating concern about the future. When patients use emotionally expressive words such as those we described, oncologists should respond empathically, allowing patients to express their distress and concerns more fully.

Tailoring communication in cancer genetic counseling through individual video-supported feedback: a controlled pretest-posttest design

OBJECTIVES

To assess the influence of a 1-day individual video-feedback training for cancer genetic counselors on the interaction during initial visits. Feedback was intended to help counselors make counselees' needs more explicit and increase counselors' sensitivity to these.

METHODS

In total 158 counselees, mainly referred for breast or colon cancer and visiting 1 of 10 counselors, received a pre- and post-visit questionnaire assessing needs (fulfillment). Visits were videotaped, counselor eye gaze was assessed, and verbal communication was analyzed by Roter Interaction Analysis System (RIAS) adapted to the genetic setting. Halfway the study, five counselors were trained.

RESULTS

Trained counselors provided more psychosocial information, and with trained counselors emotional consequences of DNA-testing was more often discussed. Counselees seen by a trained counselor considered their need for explanations on (emotional) consequences of counseling as better fulfilled. Unexpectedly, counselees' contribution to the interaction was smaller with trained counselors.

CONCLUSION

Feedback appeared to result in greater emphasis on psychosocial issues, without lengthening the visit. However, counselors did not become more verbally supportive in other ways than by providing information.

PRACTICE IMPLICATIONS

A 1 day individual training appears effective to some extend; increased opportunities for watching and practicing behavioral alternatives and arranging consolidating sessions may improve training results.

The importance of somatic symptoms in depression in primary care

OBJECTIVE

Patients with depression present with psychological and somatic symptoms, including general aches and pains. In primary care, somatic symptoms often dominate. A review of the literature was conducted to ascertain the importance of somatic symptoms in depression in primary care.

DATA SOURCES AND EXTRACTION

MEDLINE, EMBASE, and PsychLIT/PsychINFO databases (1985-January 2004) were searched for the terms depression, depressive, depressed AND physical, somatic, unexplained symptoms, complaints, problems; somatised, somatized symptoms; somatisation, somatization, somatoform, psychosomatic; pain; recognition, under-recognition; diagnosis, underdiagnosis; acknowledgment, under-acknowledgment; treatment, undertreatment AND primary care, ambulatory care; primary physician; office; general practice; attribution, re-attribution; and normalising, normalizing. Only English-language publications and abstracts were considered.

STUDY SELECTION

More than 80 papers related to somatic symptoms in depression were identified using the content of their titles and abstracts.

DATA SYNTHESIS

Approximately two thirds of patients with depression in primary care present with somatic symptoms. These patients are difficult to diagnose, feel an increased burden of disease, rely heavily on health care services, and are harder to treat. Patient and physician factors that prevent discussion of psychological symptoms during consultations must be overcome.

CONCLUSIONS

Educational initiatives that raise awareness of somatic symptoms in depression and help patients to re-attribute these symptoms should help to improve the recognition of depression in primary care.

Factors that influence physicians' detection of distress in patients with cancer: can a communication skills training program improve physicians' detection?

BACKGROUND

No study to date has assessed the impact of skills acquisition after a communication skills training program on physicians' ability to detect distress in patients with cancer.

METHODS

First, the authors used a randomized design to assess the impact, on physicians' ability to detect patients' distress, of a 1-hour theoretical information course followed by 2 communication skills training programs: a 2.5-day basic training program and the same training program consolidated by 6 3-hour consolidation workshops. Then, contextual, patient, and communication variables or factors associated with physicians' detection of patients' distress were investigated. After they attended the basic communication skills training program, physicians were assigned randomly to consolidation workshops or to a waiting list. Interviews with a cancer patient were recorded before training, after consolidation workshops for the group that attended consolidation workshops, and approximately 5 months after basic training for the group that attended basic training without the consolidation workshops. Patient distress was recorded with the Hospital Anxiety and Depression Scale before the interviews. Physicians rated their patients' distress on a visual analog scale after the interviews. Physicians' ability to detect patients' distress was measured through computing differences between physicians' ratings of patients' distress and patients' self-reported distress. Communication skills were analyzed according to the Cancer Research Campaign Workshop Evaluation Manual.

RESULTS

Fifty-eight physicians were evaluable. Repeated-measures analysis of variance showed no statistically significant changes over time and between groups in physicians' ability to assess patient distress. Mixed-effects modeling showed that physicians' detection of patients' distress was associated negatively with patients' educational level (P = 0.042) and with patients' self-reported distress (P < 0.000). Mixed-effects modeling also showed that physicians' detection of patient distress was associated positively with physicians breaking bad news (P = 0.022) and using assessment skills (P = 0.015) and supportive skills (P = 0.045).

CONCLUSIONS

Contrary to what was expected, no change was observed in physicians' ability to detect distress in patients with cancer after a communication skills training programs, regardless of whether physicians attended the basic training program or the basic training program followed by the consolidation workshops. The results indicated a need for further improvements in physicians' detection skills through specific training modules, including theoretical information about factors that interfere with physicians' detection and through role-playing exercises that focus on assessment and supportive skills that facilitate detection.

The English version of the Verona medical interview classification system (VR-MICS). An assessment of its reliability and a comparative cross-cultural test of its validity

OBJECTIVE

This study aimed to assess the inter-rater and intra-rater reliability of the English translation of the original Italian version of the VR-MICS and to evaluate its sensitivity by comparing the coding of English and Italian general practice consultations with emotionally distressed and non-distressed patients, as defined by the 12-item General Health Questionnaire (GHQ-12).

METHOD

Six male GPs from Manchester (UK) and six from Verona (Italy) each contributed five consultations, which were coded using the VR-MICS. Intra-rater and inter-rater reliability were assessed both for the division of interviews into speech units and the speech unit coding. Interaction and main effects of GHQ-12 status and nationality on patient and GP expressions were assessed by two-way ANOVA.

RESULTS

Agreement indices for the division of speech units varied between 88-96 and 87-93% for GP and patient speech, respectively; those for coding categories between 88-91 and 82-86%, with Cohen's Kappa values between 0.86-0.91 and 0.80-0.85 for GP and patient speech, respectively. Cross-cultural comparisons of patient and GP speech showed no interaction effects between GHQ-12 status and nationality. The Italian GPs were more 'doctor-centred', while the UK GPs tended to use a more 'sharing' consulting style. Independent of nationality, distressed patients talked more, gave more psychosocial cues and increased amounts of positive talk compared to non-distressed patients. GPs in both settings, when interviewing distressed patients, reduced social conversation and increased psychosocial information-giving, checking questions and reassurance.

CONCLUSION

The English translation of the VR-MICS showed satisfactory reliability indices and similar sensitivity to patients' verbal behaviours in relation to their emotional state in the two settings.

PRACTICE IMPLICATIONS

The VR-MICS may be an useful coding instrument to support collaborative research on doctor-patient communication between the two countries.

How to recognize and manage psychological distress in cancer patients

Psychological distress is common in cancer patients, however, it is often unrecognized and untreated. We aimed to identify barriers to cancer patients expressing their psychological concerns, and to recommend strategies to assist oncologists to elicit, recognize, and manage psychological distress in their patients. Medline, Psychlit, and the Cochrane databases were searched for articles relating to the detection of emotional distress in patients. Patients can provide verbal and non-verbal information about their emotional state. However, many patients may not reveal emotional issues as they believe it is not a doctor's role to help with their emotional concerns. Moreover, patients may normalize or somatize their feelings. Anxiety and depression can mimic physical symptoms of cancer or treatments, and consequently emotional distress may not be detected. Techniques such as active listening, using open questions and emotional words, responding appropriately to patients' emotional cues, and a patient-centred consulting style can assist in detection. Screening tools for psychological distress and patient question prompt sheets administered prior to the consultation can also be useful. In conclusion, the application of basic communication techniques enhances detection of patients' emotional concerns. Training oncologists in these techniques should improve the psychosocial care of cancer patients.

Improving psychiatric interview skills of established GPs: evaluation of a group training course in Italy

BACKGROUND

A number of studies have shown that the communication style of GPs has a significant impact on their ability to recognize and manage psychiatric disorders. Italian training programmes do exist, but none have been evaluated for effectiveness.

METHODS

Nine established GPs participated in a training programme consisting of twelve 3-h education sessions. Each session consisted of group discussion of videotaped patient interviews selected by GPs. Case discussion followed Lesser's "problem-based approach" criteria. Efficacy of training was assessed by measuring the pre-post change in accuracy in detecting psychiatric illness and changes in the interview skills of the GPs.

RESULTS

Accuracy in detection of psychiatric illness increased significantly after training. Changes were seen in the interview style after training, such as use of open-ended questions and appropriate counselling in relation to problems presented by the patient. Physicians also improved their management skills by using a more negotiatory style and providing patients with supportive feedback. The way in which physicians gave advice and information to the patients improved significantly despite the fact that GPs were not instructed about how to give information to their patients.

CONCLUSIONS

Group training in problem-based interviewing utilizing video feedback is a robust, culturally transferrable model for improving the skills of established physicians. Our results suggest that training produces indirect effects that are the result of the teaching method rather than of explicit instructions. Further research is required to assess how to optimize the effect of educational interventions to ensure sustainability and maximal impact on measurable outcomes of care.

A patient-centred approach to defining and assessing interviewing competency

The inclusion of communication skills as a core competency in health care curricula, has led to the need to define adequacy in this area. Developments in the field of interview analysis have meant that robust and objective ways of assessing interview behaviours are now available; however, these systems in themselves do not provide a model for assessing competency. As adequacy in interviewing is contextually driven, this paper discusses the potential of using patient centeredness to address the issue. It suggests two ways in which patient centeredness may be operationally defined, permitting data available from current rating systems, and from a new system shortly to be available, to be used to assess interviewing competency.

Patient cues and medical interviewing in general practice: examples of the application of sequential analysis

AIMS

To illustrate how sequence analysis may be applied to the medical interview to: 1. explore how physicians without formal training in communication skills elicit and respond to patient cues and expression of expectations and opinions; and 2. test the hypothesis that physicians' closed ended questions determine the use of subsequent closed ended questions.

METHODS

238 consultations in primary care, coded with the Verona Medical Interview Classification System, were analysed. Lag 1 analysis was applied to study which physician behaviour precedes and follows patient cues. Pattern recognition analysis for five lag sequences was performed to test the occurrence of predefined specific code chains, where a closed and an open ended question were followed either by two closed-ended questions or by two patient facilitating interventions

RESULTS

Patients' cue offers were most likely after facilitative interventions, but not after open-ended questions; physicians were most likely to respond to these expressions with facilitation. Physicians' tendency to use closed ended questions increased after previous closed questions and decreased after an open-ended question.

CONCLUSIONS

Lag sequential analysis and pattern recognition analysis are useful methods to study exploratory and theory driven hypotheses and allow an initial approach to validate the supposed appropriateness of specific physician interventions.

The patient-computer interview: a neglected tool that can aid the clinician

In this article, I (1) review the process of interviewing patients by computer, (2) summarize computer-interviewing work done in 1968, (3) address the weaknesses of collecting information with the traditional history-taking methods or paper questionnaires, (4) discuss commercial software designed for computer interviewing, and (5) focus on the strengths and weaknesses of interviewing patients with a computer. The strengths of this process compared with traditional interviewing are that computer interviewing allows the physician to gather more data; gives the patient more time to complete an interview; uncovers more sensitive information; provides more adaptability to non-English-speaking patients, patients with hearing impairment, or patients who are illiterate; and provides structured information for research. The weaknesses of computer interviewing are that it generates false-positive responses, is not accepted by a minority of patients, is unable to detect nonverbal behavior, and requires changes in work flow. With the advent of an electronic medical record and the financial rewards for comprehensive history recording, the gathering of history and documentation from patients is increasingly important and favors adaptation to computer interviewing.

The good news about giving bad news to patients

BACKGROUND

There are few data available on how physicians inform patients about bad news. We surveyed internists about how they convey this information.

METHODS

We surveyed internists about their activities in giving bad news to patients. One set of questions was about activities for the emotional support of the patient (11 items), and the other was about activities for creating a supportive environment for delivering bad news (9 items). The impact of demographic factors on the performance of emotionally supportive items, environmentally supportive items, and on the number of minutes reportedly spent delivering news was analyzed by analysis of variance and multiple regression analysis.

RESULTS

More than half of the internists reported that they always or frequently performed 10 of the 11 emotionally supportive items and 6 of the 9 environmentally supportive items while giving bad news to patients. The average time reportedly spent in giving bad news was 27 minutes. Although training in giving bad news had a significant impact on the number of emotionally supportive items reported (P <.05), only 25% of respondents had any previous training in this area. Being older, a woman, unmarried, and having a history of major illness were also associated with reporting a greater number of emotionally supportive activities.

CONCLUSIONS

Internists report that they inform patients of bad news appropriately. Some deficiencies exist, specifically in discussing prognosis and referral of patients to support groups. Physician educational efforts should include discussion of prognosis with patients as well as the availability of support groups.

Inter and intra individual variations in physicians' verbal behaviour during primary care consultations

It is well established that most medical interviews in primary care are characterised by a scarcity of patient-centred interventions and a predominance of doctor-centred behaviours. Less information is available on the intra- and inter-individual variability between the physicians' use of these categories. The study aimed to examine the impact of physician, physician's attribution of emotional distress, patients' GHQ-12 status and gender on the frequency of doctor and patient-centred verbal behaviours. A matched pair design involved six General Practitioners (GPs) and 238 patients. GPs'speech was classified using nine main categories derived from the Verona medical interview classification system (VR-MICS/D). Frequencies of the behaviours were calculated as percentages of total utterances per interview. Parametric and non-parametric ANOVAs were performed with GHQ-12 score, GP attribution of psychological distress, gender, and the six GPs as main factors. GPs varied in their use of the various interviewing behaviours. GHQ-12 status had no impact on GPs' interview behaviour, while GPs' distress attribution was associated with an increase of closed psychosocial questions and a decrease of closed medical questions. Within comparisons showed that each GP tended to change very little and only as a function of attribution: four out of six GPs increased closed psychosocial questions with patients they thought to be distressed. Patients' gender did not significantly alter GPs' interviewing behaviour. The variability in the use of specific verbal behaviours among GPs indicates a highly individualised approach and the lack of a common interview strategy. The fact that GPs' interviewing styles did not change according to patient characteristics, such as emotional distress, but only according to attribution further indicates that GPs untrained in communication techniques tend to use a predominant doctor-centred approach to the medical interview.

Insights from cancer patient communication research

Good communication skills are essential for all aspects of patient care in a palliative setting. A considerable body of evidence has accrued in the general oncology literature concerning doctor-patient and doctor-doctor communication. Many of the models and methods explored in the oncology setting may be applied usefully to palliative care; however palliative care is unique in some aspects and has its own particular challenges. Further evidence is needed to guide palliative care and other health care professionals in communicating effectively and sensitively with palliative care patients while holding a balance between telling the truth and maintaining hope.

Oncologists' reactions to cancer patients' verbal cues

The diagnosis and treatment of cancer cause considerable psychological distress and morbidity. Consequently, cancer patients have high needs for informational and emotional support and doctors vary in their ability to recognise and address these needs. This study investigated patients' attempts to gain informational and emotional support through the use of verbal cues. The sample consisted of 298 patients with heterogeneous cancers, seeing one of five medical and four radiation oncologists for the first time. Sociodemographic variables and patient anxiety and satisfaction ratings were obtained. Transcripts of the audiotaped consultations were analysed and question-asking, use of indirect cues, cue type (informational or emotional), content categories in which questions and cues occurred and doctor response (responded to or not responded to), were recorded. Patients asked a median of 11 questions and gave two cues per consultation, usually during treatment discussions. Patients gave, and doctors responded to, more informational than emotional cues. Patients gave significantly more informational cues during longer consultations. Younger and female patients gave more cues for emotional support and asked questions. No demographic variables were associated with the doctors' response to emotional and informational cues; however, consultations in which more informational cues were responded to were shorter, even when controlling for the number of cues given. Satisfaction with the consultation and patient anxiety were unaffected by doctors' responses to cues. Overall, results showed that doctors effectively identify and respond to the majority of informational cues; however, they are less observant of and able to address cues for emotional support. Cues can be addressed without lengthening the consultation or increasing patient anxiety.

The Medical Interaction Process System (MIPS): an instrument for analysing interviews of oncologists and patients with cancer

The increase in communication skills training for doctors has led to the need for more effective means of evaluation. Analysis of video and audiotaped consultations using systems of interaction analysis can provide the trainee with in-depth feedback about their communication skills. Most interaction process systems were designed for use in primary care and recent research has questioned the applicability of these systems in medical specialties such as oncology. We describe the development of a new instrument, the Medical Interaction Process System (MIPS) for use in teaching communication skills and empirical research in medical encounters, particularly, between doctors and patients with cancer. A comparison of the MIPS and comparable behaviour categories of another widely used system (the Roter Interaction Analysis System) was made to test convergent validity. Pearson correlation coefficients suggested a good level of concurrence between the two systems. Intercoder reliability tests were carried out between two coders at two separate time periods. Both of these indicated good reliability for the majority of categories. The two major advantages of the MIPS over other coding systems are: (1) the system allows for sequential and parallel coding, thus avoiding major coding conflicts and (2) the design of the coding sheet results in a multidimensional view of the consultation without data loss. We believe that the MIPS yields useful information for teaching doctors communication skills and also provides an objective method for evaluating the effectiveness of communication skills courses.

Improving communication with cancer patients

If doctors and nurses involved in cancer care are to help patients and their families achieve an optimal level of quality of life and psychological adjustment they must be able to carry out key communication tasks successfully. Yet, objective scrutiny of their consultations confirms that deficiencies in their ability to conduct these tasks remain. The reasons for this are discussed before important innovations in training and their impact are described.

Improving communication with cancer patients

If doctors and nurses involved in cancer care are to help patients and their families achieve an optimal level of quality of life and psychological adjustment they must be able to carry out key communication tasks successfully. Yet, objective scrutiny of their consultations confirms that deficiencies in their ability to conduct these tasks remain. The reasons for this are discussed before important innovations in training and their impact are described.

[The Verona Medical Interview Classification System/Patient (VR-MICS/P): the tool and its reliability]

OBJECTIVE

To assess the reliability and to describe the categories and the procedure to apply the VR-MICS/P (Verona-Medical Interview Classification System/Patient).

SETTING

The interviews used for the reliability study were audiotaped. Five general practitioners (GPs) working in two general practices in South-Verona recorded their consultations.

SAMPLE

50 interviews selected randomly from 120, 10 for each GP. The selection criterion for the participating patients was a GHQ-12 score of 3 and the consultation for a new illness episode.

MAIN OUTCOME MEASURES

The VR-MICS/P classifies patients' verbal behaviours into 21 categories, 15 of them are defined by form (cue or statement) and content.

PROCEDURE

Two trained raters classified 50 interviews. Before applying the classification system each interview is divided into units which are numbered to define doctor's and patient's sequence of speech.

RESULTS

The reliability of VR-MICS/P was satisfactory (Kappa 0.85). Similarity Index (Dice, 1945) for categories varied between 0.71 and 0.94. Reliability for form and content classification was satisfactory too (Similarity Index between 0.81 and 0.89 and between 0.84 and 0.94, respectively).

CONCLUSIONS

The VR-MICS/P is a reliable measure for describing patients' verbal behaviours during medical interviews. It can be used together with the VR-MICS/D (Verona-Medical Interview Classification System/Doctor; Saltini et al., 1998) to describe the medical interview, the quality of doctor-patient interview and can be used as a measure of patient centredness.

[An instrument for evaluating th medical interview in general practice: VR-MICS/D (Verona-Medical Interview Classification System/Doctor)]

OBJECTIVE

To assess the reliability of the VR-MICS/D (Verona-Medical Interview Classification System/Doctor) and to identify the verbal behaviour by general practitioners in interviews conducted with primary care attenders with medical complaints and emotional distress.

SETTING

Two general practices in South-Verona.

SAMPLE

100 primary care patients attending for a new illness episode with a GHQ-12 score > or = 3. The five participating GPs contributed each with 20 audiotaped interviews of 10 patients judged by GP as emotionally distressed and of 10 judged without emotional distress.

MAIN OUTCOME MEASURES

The VR-MICS/D classifies GPs' verbal behaviour during the medical interview into 16 categories in terms of form (question or statement) and content and allows to assess their interview skills.

PROCEDURE

Two raters classified 30 interviews (15 with patients judged by their GP as emotionally distressed and 15 with patients judged without emotional distress). Having established satisfactory reliability, the overall verbal performance, based on 100 interviews, was assessed and GPs' verbal behaviours with patients judged as emotionally distressed was compared with that adopted with patients judged without emotional distress.

RESULTS

The reliability was satisfactory (Kappa 0.93). Percentage agreements for categories varied between 78.2% and 96.4%. The most frequent verbal behaviours were closed ended questions and information giving (58% of a total of 5522 classified verbal units). Interviews with patients judged as emotional distressed contained a greater number of psychological and psychosocial contents, facilitating comments and clarifications. These differences, however, were small, despite their statistical significance.

CONCLUSIONS

The VR-MICS/D is a reliable measure for describing GPs' verbal behaviour during the interview with emotional distressed patients. The interview style of the GPs in this study was similar to that reported in the literature for GPs without formal training in communication skills and was characterised by a prevalently doctor-centred approach. This approach, particularly with emotional distressed patients, has severe limitations and underlines the necessity of the introduction of communication skills training.

[Physician-patient interactions: a comparison of analysis systems]

OBJECTIVE

The medical interview has important diagnostic and therapeutic functions and requires the integration of doctor-centred and patient-centred interviewing techniques to collect accurate and complete biopsychosocial data from the patient. Analysis of the interaction between patient and doctors which occur during the medical interview allow to evaluate physicians' interview techniques and to eventually improve them.

OBJECTIVE

1. To review different Interaction Analysis Systems (IAS) used to describe doctor-patient communication in terms of clinical relevance, observational strategy, reliability and behavioural and verbal contents. 2. To critically evaluate these IASs on the basis of their relevant research outcomes.

METHOD

Previous reviews on interaction and keywords for Medline research (HealthGate) listed above were utilised to collect the relevant literature.

RESULTS

Seventeen classification systems were identified and ten were discussed in a chronological order. Starting from a general sociological or psycholinguistic approach, the IASs over the years have became more specific and detailed, focusing more on the medical interview and on specific topics, such as cancer or hospital medical consultations.

CONCLUSIONS

When studying interactions in general practice medicine, it is important to define the significant units of interaction which allow to identify a "patient-centred approach", since this is relevant not only for obtaining reliable and complete medical and social data, but also for the recognition of patients with emotional disorders and their correct diagnosis. Listening to the patient and facilitating the expression of emotions is an important aspect of patient education too, as patients learn that talking about psychological problems to their physician is appropriate and may be therapeutic.

Determining the effect that consultation-liaison psychiatry in primary care has on family physicians' psychiatric knowledge and practice

The impact of a community-based consultation-liaison (C-L) psychiatry service on family physicians' levels of psychiatric knowledge, diagnostic and treatment confidence, and patterns of referral to mental health care agencies was evaluated over a 12-month period. The physicians with long-term access to the C-L service had higher levels of psychiatric knowledge than those with short-term or no access. However, there was no evidence that the C-L service produced changes in the physicians' levels of clinical confidence, referral likelihood, or psychiatric knowledge during the evaluation period. Significant predictors of psychiatric knowledge were age (younger) and gender (women). The participating physicians were highly satisfied with the service and preferred it over other possible referral agencies. However, community C-L services in family practice appear to have a limited role in the provision of psychiatric care and are not an efficient way for improving family physicians' levels of psychiatric knowledge or altering their practices. The appropriate role of community C-L psychiatry may be as one component of a comprehensive service-delivery strategy integrated within ongoing, formal family-physician educational programs.

Major depression in primary medical care practice. Research trends and future priorities

This paper reviews recent developments in assessing and treating major depression in primary care practice and proposes needed research directions for the coming years. Topics warranting attention include the predictive validity of psychiatric nomenclatures specific to general medical settings; the impact of patient, clinician, and system factors on the physician's assessment of major depression; the relationship between diagnostic and treatment decisions; and the course of this disorder when treated in primary care facilities by generalists or specialists.