Decisional strategies for the attribution of emotional distress in primary care.

BACKGROUND: In primary care the General Health Questionnaire (GHQ) is used to provide an independent assessment of probable caseness of psychological disorder against which to test the ability of the general practitioner (GP) to recognize patients with current emotional problems. METHOD: The aim of the present study was to identify those clinical and psychosocial data on patients that increase the likelihood of GPs' attribution of emotional distress (GP model) and those that predict patients' emotional distress as defined by the GHQ-12 (GHQ model). The associations were explored using a classification tree technique (CHAID) and compared using bivariate logistic regression. Six GPs and 444 primary care patients took part. RESULTS: The accuracy indices of the hierarchical GP and GHQ models were 72% and 69% respectively. The availability of information on patients' psychopharmacological and psychiatric/psychological treatment in the last year was the most important predictor of attribution. Occupational, financial and housing problems and life events of loss were the most important predictors of the GHQ-12 case definition. The overall accuracy of the bivariate model was 73%. Compared with the GHQ-12, GPs gave significantly more importance to psychiatric treatment, psychopharmacological drug use and chronic illness. CONCLUSIONS: The findings suggest that to improve the detection of current emotional distress in primary care patients GPs should pay foremost and systematic attention to social problems and recent life events of loss. These problems are important clues for the possible presence of emotional distress, whereas critical patient data, in particular psychiatric history and psychopharmacological treatment, increase the probability of attribution errors.

Differences in verbal behaviours of patients with and without emotional distress during primary care consultations.

BACKGROUND: In primary care consultations patients with emotional distress tend to give verbal cues or symptom reports with psychological or psychiatric contents. This study examined the cue behaviour defined not only by psychological, but also by medical, social and life episodes related contents in patients with and without emotional distress, recognized and not by their GP. The GP's verbal behaviour in relation to patients' cue emission was also investigated. METHOD: For the six participating GPs two groups of matched pairs of patients (N = 238) were created. The two groups comprised either patients considered by GPs as being without emotional distress or patients considered as emotionally distressed. Within each pair, one patient was a case (GHQ-12 score > 2) and the other was the matched control (GHQ-12 score < 3). The medical interviews with these patients were transcribed and classified according to the Verona Medical Interview Classification System (VR-MICS). RESULTS: GHQ positive patients of both groups gave more cues in terms of total proportion than their matched controls (GHQ negative patients). The proportion of cues given by patients was related also to GP's verbal behaviour, increasing with closed psychosocial questions and decreasing with the use of active interview techniques. Attribution of emotional distress was more frequent when patients were high attenders and had a past psychiatric history. The content of cues changed in relation to GP's attribution: recognized patients gave more cues and more often with psychological content, patients not recognized as distressed gave mainly cues related to their lifestyle and life episodes. CONCLUSIONS: To improve the recognition of those emotionally distressed patients most likely to be missed GPs should increase their attention to cues related to life style and life episodes.

[Patient-centered interviews in general practice]. / Il colloquio con il paziente in medicina generale.

Many studies have confirmed that the interview approach adopted by the physician influences the quality of the doctor-patient relationship as well as the accuracy and validity of information which is elicited during the medical interview. A correct interview approach is also the basis for diagnosis and treatment. This paper summarizes the main characteristics of the patient-centred interview approach which has to integrate the doctor centred approach in order to render the medical interview efficient in terms of data collection, doctor-patient relationship and time. The first part of the interview with the patient has always to be patient-centred. The patient is facilitated to report all the information regarding his symptoms and their psychosocial context and to express his ideas and expectations, after which the interview style becomes more directive and doctor-led. In this phase the doctor remaining however attentive to patient's cues. Some data are presented which describe the prevailing interview approach of general practitioners without any formal training in patient-centred interview techniques. The analysis of doctors' verbal behaviour during the consultation confirmed the necessity of educational interventions focalized on the improvement of doctors' interview skills.

[The Verona Medical Interview Classification System/Patient (VR-MICS/P): the tool and its reliability]. / Il Verona-Medical Interview Classification System/Patient (VR-MICS/P). Presentazione dello strumento e studio di attendibilità.

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.

Which patients talk about stressful life events and social problems to the general practitioner?

BACKGROUND: Life events and social problems are common in primary-care attenders and contribute to the high rate of emotional distress observed in this setting but are often not disclosed during the consultation. Physicians' characteristics associated with patients' disclosure of psychosocial problems are well documented, but less empirical evidence is available on the contribution of patients' variables. METHOD: Logistic regression analyses were performed on a set of clinical and psychosocial data from 319 primary-care attenders with stressful life events and/or social problems in the presence or absence of emotional distress, in order to identify the variables that predict disclosure of such problems during the consultation. RESULTS: Two-thirds of patients with stressful life events and social problems had mentioned them to their GP. In both sexes a positive attitude about confiding and emotional distress were the best predictors of confiding. In men they accounted for 76% of correct predictions and, in women, together with past confiding, long-lasting relationship with GP, and coexistence of life events and social problems, for 81%. A positive confiding attitude was related in males to age and severity of medical condition and in females to age and experience of past confiding. CONCLUSIONS: In view of the high prevalence of positive attitude towards confiding the efforts by GPs should focus on the reduction of disclosure thresholds. This would require increased abilities to elicit psychosocial information and show emphatic understanding of patients' life difficulties. By contrast there is a need to promote a positive attitude in confiding that concerns only a minority of primary-care patients. More data are needed for shaping more specific strategies for these patients.

[An instrument for evaluating th medical interview in general practice: VR-MICS/D (Verona-Medical Interview Classification System/Doctor)]. / Uno strumento per la valutazione dell'intervista medica nel contesto della medicina generale: il 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.

[The prescription of treatment and the problem of adherence to the care on the part of the patient]. / La prescrizione del trattamento ed il problema dell'adesione alla cura da parte del paziente.

Poor adherence to treatment contributes significantly to treatment failures in medical care. The extent of the problem and its impact are considerable, by affecting patients, society and the health care system. Studies examining contributing factors have focused on patients' sociodemographic characteristics, features of the treatment regimen and disease state. When viewed in isolation, these variables have little if any descriptive or predictive value. It is difficult to identify which factors contribute to non-adherence, in any particular patient, without carefully interviewing the patient, and the solutions to remove barriers to adherence and to facilitate prescription observations must be individually tailored. Patient's beliefs, expectancies and representations of illness and treatment play a central role in determining the degree of adherence and the level of resistance to educational interventions; for this reason, during the medical interview, the first task is pick-up the cues of patient's representation to identify their features. In this perspective, the appropriate style of interaction is the biopsychosocial approach.

[Communication of bad information: general indications and guidelines]. / La comunicazione di cattive notizie. Indicazioni generali e linee guida.

Breaking bad news to a patient requires from the physician specific communication skills and interpersonal abilities which, in the past, traditional medical curricula have tended to neglect. The authors present in this paper general guidelines for breaking bad news, illustrating how to structure the interview and how to evaluate patients' need for information before the communication of the diagnosis. A first step comprised the evaluation of how the patient perceives and interprets his illness and what type of information he wants to receive. The physician should establish the patient's actual knowledge of his illness which must be the starting point for the successive communication of the diagnosis. To facilitate patient's understanding of the news, the physician has to consider his perception of the illness, and to taylor the information he wants to convey accordingly. Patients' knowledge will be integrated gradually until the desired level of completeness is reached. It has to be considered that patients' need for information may change during the course of illness. Information giving is therefore part of a process. Physicians should be alert to possible changes and adjust the quantity and quality of information they give according to the changing needs of their patients.

[Communication of bad facts. To inform or not to inform the patient: a choice between 2 alternatives?]. / La comunicazione di cattive notizie. Informare o non informare il paziente: una scelta tra due alternative?

In the last thirty years physicians changed their attitudes regarding the communication of the diagnosis to their patients. The prevailing tendency in the past to protect patients against emotional distress thought to be caused by the breaking of bad news has been replaced by the acknowledgment of the patient's right to be informed about their condition. This acknowledgement has not been accompanied by a different cognitive approach to patients: the decision to inform or not inform the patient about his/her diagnosis still depends more on doctor than on patient characteristics. It has been demonstrated that patients are usually not well informed and known less about their illness than doctors suppose they do. Technical jargon and unclear communication contribute to the patients' difficulty in understanding correctly the information provided by their doctors. If patients perceive genuine interest and feel supported by their doctors, only very few prefer not "to know". To be informed about the illness does not seem to be associated with increased emotional distress on the long term but, on the contrary, facilitates patients' adjustment to illness.