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Mechanisms Behind the Failure of Residents' Longitudinal Primary Care to Promote Disclosure and Discussion of Psychosocial Issues
Lawrence S. Wissow, MD, MPH;
Debra Roter, DrPH;
Susan M. Larson, MS;
Mei-Cheng Wang, PhD;
Wei-Ting Hwang, PhD;
Rachel Johnson;
Xianghua Luo
Arch Pediatr Adolesc Med. 2002;156:685-692.
Context Longitudinality (care by a single physician over time) and continuity
(receipt of most care from a single physician) are believed to enhance patient-physician
relationships and facilitate disclosure of emotional distress, but some studies
suggest this potential goes unrealized.
Objectives To determine whether care in a pediatric residents' continuity clinic
promotes, over time, increased discussion, disclosure, and detection of parents'
social and emotional distress and to understand physicians' communication
behaviors underlying changes with time.
Design Longitudinal, observational study of parent-physician interaction over
the course of 1 year.
Participants One hundred ninety parents (90% African American) and their infants'
primary care physicians (31 [4 Asians and 27 whites] first- and second-year
pediatric residents).
Main Outcome Measures Frequency with which parents and physicians raised topics related to
parental mood and family or social functioning; proportion of distressed parents
discussing mood or functioning; and physicians' detection of parent distress.
Results Physician initiation of psychosocial topics fell in the course of longitudinal
relationships (odds of initiation in visits  6 vs odds of initiation in
visits 1-5 = 0.46 [95% confidence limits, 0.31%, 0.67%]); parent initiation
did not change over time nor was it increased by greater levels of continuity.
Length of relationship was not associated with increased physician detection
of parental distress or with increased rates of disclosure by distressed parents.
Physicians' positively framed leading questions, and their avoidant responses
to prior parental disclosures were significantly associated with decreased
odds of problem disclosure. In contrast, visits in which parents or physicians
raised psychosocial topics were characterized, on average, by 40% higher levels
of physicians' "patient-centeredness" (increases of about 100 utterances per
visit [95% confidence limits, 65.7%, 133.9%]).
Conclusions Longitudinal relationships between residents and patients may not be
sufficient to promote the discussion, disclosure, and detection of psychosocial
issues. Training in communication skills may help residents achieve the potential
and goals of longitudinal care.
From the Bloomberg School of Public Health, Johns Hopkins University,
Baltimore, Md.
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