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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.
ABSTRACT
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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.
INTRODUCTION
PRIMARY CARE is thought to create an atmosphere in which sensitive concerns
are more readily raised.1-2 Studies
in both pediatric and adult settings support this view—detection of
distress is increased when physicians and patients (or parents) believe they
have an ongoing relationship.3-5
Guidelines for pediatric primary care,6 supported
by studies in child development,7 underline
the importance of detecting problems with parental mental health, especially
in the first years of a child's life. Studies looking at practices at a single
point in time, however, have found low rates of identification of parental
distress by resident and faculty pediatricians.3, 8
To our knowledge, no studies in pediatrics, and only a few in other specialties,9-12 have
examined care over time to see if it leads to improved identification of mental
health problems, or if there are specific primary care provider skills important
to identification of distress in longitudinal settings.
Our goal was to examine the identification of parental distress in the
course of longitudinal care in a pediatric residents' continuity clinic. Our
specific aims were to (1) determine if the frequency of discussion, disclosure,
and detection of parents' social and emotional concerns changed in the course
of longitudinal care, and (2) describe physicians' communication behaviors
that might be responsible. We focused on 2 physician communication behaviors.
First, several studies have demonstrated that a cluster of behaviors, collectively
known as patient-centeredness (ie, giving information, showing empathy, listening
attentively, and asking questions about social and emotional issues) are associated
with increased patient willingness to share concerns.13-15
Second, studies have found that physicians sometimes seem to ignore or underrespond
to patients' tentative disclosures of distress.16-20
We hypothesized that patient-centeredness would be associated with increased
rates of discussion and detection of parental distress and that avoidant responses
would be associated with decreased discussion and detection.
PARTICIPANTS AND METHODS
SETTING
The study was conducted in the pediatric primary care clinic of an urban
teaching hospital. Children have assigned primary care providers whom they
see for health maintenance and, when possible, acute care.
STUDY DESIGN
The study design was descriptive, using a prospective longitudinal design.
Data were collected as part of a clinical trial (the SAFE Home Project) designed
to test the effect of anticipatory guidance on parents' injury prevention
practices. Physicians participating in the SAFE Home Project were randomized
to be trained in injury counseling (two 2 -hour sessions with role
playing and demonstrations) or to receive a single 1-hour seminar on injury
prevention.21
POPULATION
Forty-four first- and second-year residents were eligible to participate
in the SAFE Home Project; 31 residents (4 Asians and 27 whites) (70%) agreed
to participate. Twenty-three (74%) were women and 15 (48%) were in their first-year
of residency. Parents (or other guardians) were eligible if their child was
6 months of age or younger and cared for by a study-enrolled physician. Parents
were ineligible if they did not speak English or did not live with their child.
Research assistants systematically approached 224 eligible parents over an
8-month period; 196 (88%) agreed to participate; 25 (11%) declined, and 3
were ineligible. Of the 196 enrolled, 190 (85% of those approached) had at
least 1 recorded visit and were included in our analysis. Parents and primary
care providers gave informed, written consent for participation. The study
was approved by the Joint Committee on Clinical Investigation of Johns Hopkins
Hospital, Baltimore, Md.
One hundred eighty-three parents (96%) were the child's biological mother;
3 were female guardians, and 2 were fathers. Parents' average age was 24 years
(median age, 22 years; age range, 15-64 years) and infants were, on average,
2 months old at the time of enrollment (median age, 2 months; age
range, 3 days to 6 months). Ninety percent of the parents were African American,
8% were white. One was Hispanic and 2 were Native American. Fifty-one percent
graduated from high school and 14% had taken some college courses.
CONTINUITY
We calculated Bice and Boxerman's22 Continuity
of Care (COC) index using data from the outpatient appointment system.23 The COC index differs from a simple percentage of
visits with one's physician in that it is also sensitive to the total number
of physicians seen. Values range from 0 to 1, where 1 indicates all care provided
by a single physician. From birth to the end of the study, enrolled infants
and parents made 1538 visits to the primary care clinic, 94 to the emergency
department, and 276 to other hospital clinics. On average, infants saw their
assigned physician for 92% of the primary care visits (range, 22%-100%) and
71% of all visits at the medical center (range, 6%-100%). The COC index averaged
0.72 (range, 0-1) and was not significantly related to the physician's sex
(male, 0.71; female, 0.73; P = .78).
TALK DURING VISITS
Research assistants attempted to audiotape consecutive visits between
enrolled parents and physicians. Six hundred ninety-two visits were recorded,
a median of 4 per parent-physician pair (range, 1-9) and 21 per physician
(range, 4-48). For individual parents, recorded visits spanned an average
of 27 weeks from first to last visit (range, a single visit to 57 weeks).
Of first-recorded visits, 50% were of the parent's actual first or second
visit with the physician, while the remainder of first-recorded visits ranged
from the 3rd to the 17th actual visit. Most (82%) of the recorded visits were
for well-child care. Visits lasted an average of 25 minutes (median, 25 minutes;
range, 2-91 minutes).
Parent-physician talk was coded using the Roter Interactional Analysis
System (RIAS).15 The Roter Interactional Analysis
System coders listen to audiotapes and classify each speaker's utterances
into one of several categories including information giving, question asking,
empathy, and partnership facilitation. Reliability is monitored by duplicate
coding of a random 10% sample of audiotapes. Correlation coefficients for
individual Roter Interactional Analysis System categories ranged from 0.75
to 0.97. Physicians' patient-centeredness was calculated first as the sum
of physician talk in information giving (medical and psychosocial), asking
psychosocial questions, showing empathy, giving reassurance, and partnership
building.24 Some formulations of patient-centeredness
do not include medical information giving,25
so we calculated a second sum, partnership building omitting medical information
giving. The 2 measures were highly correlated (r
= 0.96). The Roter Interactional Analysis System coders also noted if visits
included 3 categories of social and emotional topics (parental mood, social
and family issues, and referrals for mental health care), and who initiated
the topic (parent or physician). Discussions of these topics were transcribed
and coded for the physician's method of initiation (neutral or positive-leading
tone) and response. Physician responses were classified using Hadjiisky and
colleagues'16 typology of avoidant or discouraging
clinician responses (Table 1).
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Table 1. Physician Avoidant Responses to Parents' Problems*
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PARENTAL DISTRESS
At each recorded visit, parents completed the 28-item General Health
Questionnaire (GHQ), a well-validated brief screen for adult emotional distress.8, 26-28 At
a cutoff score of greater than 4 (used in this study), sensitivity for psychiatric
disorder is more than 85% with a specificity of more than 75%. Forty-eight
(25%) of the 190 parents scored positive on the GHQ at 1 or more visits (n
= 68). Visits where the parent scored positive on the GHQ were distributed
evenly across the time span of parent-physician relationships. After each
visit, physicians rated the parents' emotional health on a scale of excellent,
good, fair, or poor.
STATISTICAL ANALYSIS
The multiple visits of each parent-physician pair, and the visits of
multiple parents with the same physician, are not statistically independent.
After exploratory analyses using standard tests ( 2 and t tests, ordinary linear and logistic regression), we computed
final results using generalized estimating equation–based procedures
in the statistical software Stata Version 6.0 (Stata Corp, College Station,
Tex). These procedures compute population-averaged statistics that consider
the nonindependence of observations, and also require few assumptions about
the distributions of the variables explored.29
A second problem involves missing observations. Overall, we had recordings
for 692 (68%) of 1015 visits between parents and their infant's primary care
physician from the time they enrolled in the study to their last recorded
visit. The generalized estimating equation–based methods described above
provide good estimates when data are "missing at random," that is, when whatever
mechanism accounts for the pattern of missing data does not depend on the
outcome being studied.29 To test if our data
met this condition, we developed regression models to predict if the next
visit would be recorded, based on whether a parent or physician initiated
psychosocial discussion at the immediately prior visit. These models did not
yield statistically significant coefficients.
RESULTS
MENTIONS OF SOCIAL AND/OR EMOTIONAL TOPICS
Frequency
Social and/or emotional topics were mentioned during 231 (33%) of the
692 recorded visits (Table 2).
Social and family issues were the most frequent (30% of visits). Parent's
sleep habits or mood was mentioned in 8% of the visits, and mental health
referrals or treatment were mentioned in 3%. More visits contained physician-initiated
topics (27%) than parent-initiated topics (8%).
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Table 2. Percentage of Visits With Mention of a Social and/or Emotional
Topic by Topic and by Initiator
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Physician Sex and Patient-Centeredness
Visits with female physicians had higher patient-centeredness scores
(average, 259 utterances per visit for female vs 198 for male; mean difference,
60.6; 95% confidence limits [CLs] for difference, 38.5%, 82.6%; P<.001). Assignment to the SAFE Home Project intervention group
was associated with a significant increase in patient-centeredness for female
but not male physicians' visits (average increase for female physicians, 31.7%;
95% CLs, 10.6%, 52.7%; P = .003; average increase
for male physicians, 18.2; 95% CLs, -17.4%, 53.8%; P = .31).
Topic Mentions and Patient-Centeredness
Patient-centeredness scores were significantly higher in visits where
social or emotional issues were mentioned, compared with visits where parents
did not initiate these discussions (Table
3). In visits in which parents initiated discussion of social or
family topics, physicians made on average 100 more patient-centered utterances
(95% CLs, 65.7%, 133.9%, about a 40% increase).
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Table 3. Differences in Physician's Patient-Centeredness Associated
With Parent-Initiated and Physician-Initiated Discussion of Psychosocial Topics*
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Topic Mentions and Parental Distress
Parental distress increased the odds that parents, but not physicians,
would initiate discussion of psychosocial topics. Visits where a parent was
distressed were more likely to contain a parent-raised social or emotional
topic (odds ratio, 2.4; 95% CLs, 1.1%, 5.1%; P =
.03, adjusted for patient-centeredness, visit number, COC index, physician's
sex, and intervention group) (Table 4).
Visits with distressed parents were not more likely to contain discussion
of a physician-raised topic (odds ratio, 1.3; 95% CLs, 0.73%, 2.2%; P = .42).
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Table 4. Mention of Social and/or Emotional Issues as a Function of
the Number of Visits, Parental GHQ Score, and Physician Patient-Centeredness*
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CHANGE IN MENTIONS OF SOCIAL AND EMOTIONAL TOPICS WITH VISIT NUMBER
Parents
The odds that parents would initiate discussion of social or emotional
topics did not change significantly over the course of time (Table 4). The odds that a parent-initiated topic would be discussed
at visits 6 or more vs during visits 1 through 5 was 0.84, with a 95% confidence
interval of 0.44 to 1.6. Similarly, distressed (GHQ-positive) parents were
no more likely to initiate discussions at visits 6 or more compared with visits
1 through 5.
Physicians
Time tended to decrease the odds that physicians would raise social
or emotional issues, even after adjustment for patient-centeredness that,
as noted earlier, is positively associated with the physicians' initiation
of these topics. The odds of physicians raising topics at visits 6 or more,
vs visits 1 through 5, were 0.46 (95% CLs, 0.31%, 0.67%). The COC index was
not associated with an increased odds of physician-initiated discussions.
Physicians' Detection of Parental Distress
Among 587 visits where both parent GHQ and physician ratings were available,
physicians' sensitivity was 14% (9/63) and specificity 90% (472/524). Accuracy
(correctly rating the parent as distressed or not distressed) was unrelated
to patient-centeredness, sex, intervention group, continuity, or the number
of visits (Table 5).
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Table 5. Predictors of Physicians' Accurate Labeling of Parental Emotional
Distress*
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Physicians' Initiation of and Response to Social and/or Emotional Discussions
Leading Positive Questions and Statements.
Of 141 social and/or emotional discussions initiated by physicians in
transcribed segments, 37 (26%) began with a leading positive question or statement.
For example:
Physician: Sounds like you really enjoy being with her.
Mother: Mm.
Physician: You look so
happy when you're with her.
Mother: (Laughs) She's a good baby.
Compared with more neutral statements or questions ("What has it been
like having a new baby?"), positive openings were less likely to be followed
by parents' disclosure of a problem. Of 37 discussions initiated with a positive
question or statement from the physician, 7 (19%) resulted in disclosure of
a problem compared with 52 (50%) of 104 episodes (odds of disclosure given
positive opening, 0.23; 95%CL, 0.08%, 0.62%; P =
.002).
Physicians' Response to Parents' Problems.
In 116 (53%) of 220 transcribed social and/or emotional discussions,
parents indicated a possible or definite problem, or asked for help. In 47
discussions (41%), physicians followed up in ways that seemed to avoid or
discourage further talk (Table 1).
Confused or powerless responses were the most common (15/116 [31%]), followed
by ignoring or changing the subject (15/116 [13%]), overly authoritative responses
(12/116 [10%]), and nonhelpful reframing (5/116 [4%]). These responses were
associated with a decreased likelihood of parents disclosing a problem in
a subsequent discussion in the same visit or during the next recorded visit.
To perform this analysis, we first identified all discussions of psychosocial
problems (n = 45) for which there was either a second psychosocial discussion
in the same visit or for which there was at least one subsequent recorded
visit. Of 25 problem discussions with avoidant responses, 6 (24%) were followed
by disclosure of a problem. Of 20 problem discussions without an avoidant
response, 11 (55%) were followed by disclosure of a problem (odds ratio, 0.26;
95% CLs, 0.07%, 0.90%; P = .03).
COMMENT
In this pediatric residents' clinic, only 15% of visits by distressed
parents included a parent-initiated discussion of social or emotional topics.
There was no increase over time in the odds that psychosocial topics would
be raised by parents or physicians (regardless of parental distress), and
time did not improve the odds that physicians would accurately identify a
parent's emotional state. These observations are consistent with the few longitudinal
descriptions of psychosocial discussions in adult primary care.9-12
Patient-centeredness, avoidant responses, and positive leading questions
partly explain these time-related trends. Physicians' patient-centered talk
was a strong predictor of both physician- and parent-initiated discussions
of social and/or emotional topics, and it tends to decrease over time.30 Physicians' avoidant responses—made in response
to about 40% of parent problem statements—were associated with a decreased
probability of disclosure. Levinson et al20
found that community-based internists and family physicians responded positively
to only about 20% of clues to emotional distress offered by their patients.
Other studies in pediatrics have found similar low rates of response and low
levels of empathy.17-18,31
We also found that questions asked with a positive bias resulted in fewer
disclosures of social and/or emotional problems. It is possible that residents
may have felt that these young, relatively disadvantaged mothers needed extra
encouragement, or that being overly enthusiastic reflected compensation for
so frequently feeling unable to help in other ways.
To our knowledge, this is the first large-scale analysis of the evolution
of communication in primary care. Although our findings are consistent with
observations from other adult and pediatric studies, several aspects of the
population that we studied might limit generalizability. We studied residents,
but studies of community physicians caring for adults have shown similar trends,9-11 and a study of 10
private practice pediatricians reported that only 62% of the parents felt
the physician had listened to their ideas.32
Residents may also have different attitudes toward involvement with patients,
knowing that there is a time limit on the length of their relationship. However,
the level of continuity achieved in the clinic we studied (overall COC index
of 0.72) is comparable to figures reported from 2 private pediatric practices
and higher than figures from another teaching hospital's resident clinic.33 Finally, we studied pediatricians' discussions of
parental rather than child problems. Pediatric health supervision guidelines
place a heavy emphasis on elicitation and discussion of parental mood, stress,
and family dynamics,6 but we do not know how
those guidelines are regarded by pediatricians in general or by the residents
we studied in particular.
Another limit to generalizability involves the study's parents, who
were largely young African Americans and from low-income neighborhoods. In
a diverse group of US practices, depressed African American adults were less
likely than whites to have their condition detected.34
Another study in adult primary care found that African American patients perceived
white physicians as having a less participatory interactional style compared
with African American physicians.35 There were
no African American physicians in our study. Detection may also have been
reduced because parents were not sufficiently distressed. Greater severity
of distress increases the odds of physicians detecting adult emotional distress.3, 19, 34 In our study, among
parents who screened positive on the GHQ, the average score was 8.6 (range,
5-21), in a low-moderate range.36 However,
our residents' sensitivity to distress (14%) is similar to that reported for
residents by Heneghan et al3(11%).
Another limitation is that 74% of the physicians in our study were women,
somewhat higher than the proportion of women in categorical pediatric residencies
in the United States, which has been slowly increasing among first-year resident
classes from 60% in 1991 to 66% in 2000.37
Female physicians tend to have longer visits with their patients and engage
in more counseling, partnership building, and listening.38
One explanation advanced for these differences is that women may believe more
than men in the healing power of relationships, show less tolerance of detachment,
and are less willing to trade intimacy for achievement.39
In our study, female physicians were more patient-centered, and when trained
in injury counseling had a greater increase in patient-centeredness, but were
no more likely than male physicians to correctly identify parents' emotional
states.
We also had to account for difficulties with data collection. We compensated
by analyzing data according to each visit's real position in the parent-physician
sequence, and by using statistical techniques designed to accommodate missing
data when calculating average trends over time. We were able to satisfy ourselves
that visits were missing randomly with respect to our main outcome measures,
but it is still possible that our analysis of avoidant responses missed key
visits at which important topics were discussed.
CONCLUSIONS
Our results suggest that creating opportunities for longitudinal relationships
does not itself lead to increased discussion and detection of parental psychosocial
issues. The results do not imply that longitudinal or high-continuity care
is no better than episodic or low-continuity care; we did not make comparisons
with parents whose children lacked a designated primary care provider. We
do propose possible explanations for why mental health detection rates remain
low, even in continuity settings.3, 34, 36, 40-41
Three core sets of skills—actively maintaining a patient-centered orientation,
learning how to respond to concerns, and being encouraging but neutral when
asking questions—have the potential to improve disclosure of distress
during longitudinal care. These skills can be taught to physicians at various
stages in their careers.42-44
These skills, however, may be necessary but insufficient to improve mental
health outcomes in primary care. Patient-centeredness was associated with
more psychosocial discussion but not increased detection. Residents likely
also need training in how mental health problems present and their treatment.45-46
| What This Study Adds
Longitudinality and continuity are believed to facilitate disclosure
of emotional distress and other sensitive issues. Studies in both adult and
child primary care, however, find low detection rates for distress, and reports
that physicians frequently ignore or respond minimally to patient concerns.
No studies to date have examined sequences of primary care visits to determine
mechanisms that might promote or discourage detection of distress.
This study found that in a pediatric residents' continuity clinic, neither
longitudinality nor continuity appeared to promote discussion or detection
of parental distress. Three core sets of communication skills—actively
maintaining a patient-centered orientation, response to concerns, and the
manner of asking questions—were associated with changes in the odds
of parents' discussion of distress. Simply providing continuity experiences
may not be sufficient to train residents in primary care; attention may also
be needed to specific interpersonal skills needed to promote relationships
over time.
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AUTHOR INFORMATION
Accepted for publication March 29, 2002.
This study of the analysis of longitudinal care was supported by grant
MH-57782 from the National Institute of Mental Health, Bethesda, Md. The SAFE
Home Project study was supported by grant MCJ-240638 from the Maternal and
Child Health Bureau, Health Resources and Services Administration, Rockville,
Md.
This study was presented in part at the National Institute of Mental
Health conference, Challenges for the 21st Century: Mental Health Services
Research, Washington, DC, July 19, 2000, and at the International Conference
on Communication and Health, Barcelona, Spain, September 21, 2000.
Corresponding author and reprints: Lawrence S. Wissow, MD, MPH, Bloomberg
School of Public Health, Johns Hopkins University, 624 N Broadway, 749 Hampton
House, Baltimore, MD 21205 (e-mail: Lwissow{at}jhsph.edu).
From the Bloomberg School of Public Health, Johns Hopkins University,
Baltimore, Md.
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