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Which medical interview skills are associated with patients’ verbal indications of undisclosed feelings of anxiety and depressive feelings?

Which medical interview skills are associated with patients’ verbal indications of undisclosed... Background: In medical practice, obtaining information regarding patients’ undisclosed “feelings of anxiety” or “depressive feelings” is important. The purpose of this study was to determine which interview skills are best suited for eliciting verbal indications of undisclosed feelings, for example anxiety or depressive feelings in patients. Methods: Our group videotaped 159 medical interviews at an outpatient department of the Department of Fam- ily Medicine, Mie University Hospital (Mie, Japan). Physicians’ medical interview skills were evaluated using a Medical Interview Evaluation System and Emotional Information Check Sheet for assessing indications of “feelings of anxiety” or “depressive feelings”. We analyzed the relationship between the interview skills and patients’ consequent emotional disclosure using generalized linear model (GLIM). Results: The usage of interview skills such as “open-ended questions” “asking the patient’s ideas about the meaning of illness” “reflection” and “legitimization” were positively associated with the number of anxiety disclosure, whereas “close-ended questions” and “focused question” were negatively associated. On the other hand, only “respect” was pos- itively associated with the number of depressive disclosures, whereas “surveying question” was negatively associated. Conclusions: The results revealed that there are several interview skills that are effective in eliciting verbal indication of undisclosed “feelings of anxiety” or “depressive feelings”. Keywords: Family medicine, Medical interview, Depression, Anxiety, Communication shorten the consultation time and reduce the extra stress Background of the physicians [6]. However, in many cases, patients One of the important functions of the medical interview are said to only send indirect signals with no explicit is to understand the mental status of patients. It is impor- emotional expressions [7] and show only an ambiguous tant that the physician checks the mental status of the response [8]. The cue expressed by the patient may be patient during the medical interview, because patients overlooked due to the physician’s low awareness [9, 10] or often do not come to see physicians suspecting that they might have mental disorder [1, 2]. Paying attention insufficient clinical skills due to the lack of training [ 11, to the patients’ emotions could not only contribute to 12]. Furthermore, even when they are encouraged by the early detection of psychiatric disease but is said to affect physicians, many patients would feel embarrassed, hesi- the patient’s satisfaction [3–5]. This approach will also tated or simply feel that they do not deserve to disclose emotions [13]. In recent years, many studies have been made on the *Correspondence: yousuke@clin.medic.mie-u.ac.jp relationship between the patients’ emotional response Department of Family Medicine, Mie University School of Medicine and Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, and the physicians’ interview skills to address these Japan needs. Many of them have discussed that physicians’ Full list of author information is available at the end of the article © 2016 Goto and Takemura. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons. org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Goto and Takemura Asia Pac Fam Med (2016) 15:2 Page 2 of 6 communication skills should be employed to help This scale was assessed for reliability. First, for each patients’ express their emotions [6, 8, 14, 15]. However, videotaped interview, an evaluator used the scale to eval- most of the reports on the patients’ emotional response uate the number of skills used by the physician. Second, are made in the context of cancer treatment. Suffi - the same evaluator did a second review a random selec- cient studies have not been made on the physicians’ tion of 25 interviews 2 months after the first review. The skills and the patients’ emotional response during the kappa value was calculated and found to be 0.93. common medical interviews like ones at primary care Interview length was considered as a confounder, facilities. because longer interview duration was presumed to posi- The aim of the present study is to explore the associa - tively influence our findings [18]. In addition, patients’ tion between physicians’ interview skills and patients’ sex, sex matching between patient and physician, and disclosure about anxiety or depression in the primary affiliation (student, resident and family physician) were care setting. also obtained as other possible confounders. Methods Statistical analyses Participants and procedures Demographic data were obtained first. Then, we used a One hundred and fifty nine different new patients (74 generalized linear model (GLM) to assess the relation- males and 85 females) participated in this observational, ship between a physician’s use of these interview skills cross-sectional study. They are patients at outpatient and verbal indications of feelings of anxiety or depres- department of the Department of Family Medicine of sion. Because our observation of physicians’ interview large-scale hospital, Japan. The patients came from both skills and patients’ emotional disclosures were recorded rural and urban areas and were from a wide range of soci- as count data, we modeled the relationship using the oeconomic classes. All of the patients were over 15 years Poisson distributions and log link function. After the of age, and most patients generally had common medical generalized linear model was estimated, we verified the problems such as hypertension, hypercholesterolemia, variance inflation factors of each independent variable and diabetes. First, we checked whether this was a first and the covariates (VIF). Finally, we evaluated goodness visit and asked if the prospective participant were willing of fit of the estimated model using Akaike Information to participate, and if he or she declined, no further effort Criteria (AIC). was made. Second, we gave them instructions about the Statistical significance was set as p < 0.05 for all meas - purpose and meaning of the study and told them that ures. We used R version 3.1.1 [19] for statistical analyses. they could decline from this study anytime when they Generalized linear model analyses were conducted using want to. Third, we obtained each participant’s signature. the “glm” function. There was no missing data. Parental permission was obtained for patients whose age is less than 20 years old. Results Each patient was interviewed by one of 26 family phy- Characteristics of patients and physicians are shown sicians, 98 family medicine residents, or 35 medical stu- in Table  3. Additionally, the table shows basic statistics dents having family medicine clinical clerkship. These including mean value, standard deviations, and quartile interviews were videotaped for evaluation. values of each interview skill and emotional disclosure. Informed consents were obtained from patients and The estimated model for disclosures of anxiety is physicians prior to any observation of the medical inter- shown in Table 4, and the estimated model about that of views. The research protocol of this study was approved depression is shown in Table  5. For the purposes of our by the Research Ethical Committee of the Mie University analyses, only modified models will be considered. School of Medicine. Patients’ disclosures of anxiety were positively asso- ciated with “open-ended questions” “legitimization” Outcome measurements “reflection” and “asking the patient’s idea about the The videotaped medical interview skills were reviewed by meaning of the illness (meaning of the illness)”. Con- trained researchers using the Takemura Medical Inter- versely, they were negatively associated with “close-ended view Rating Scale (TMIRS) (Table  1) [16]. Some systems questions” and “focused questions”. As none of the inter- of the Roter interaction analysis system were used to view-skills and covariates showed VIF above 10 (data not build this scale [17]. “Feelings of anxiety” and “depressive shown), multicollinearity which was found to be within feelings” were also operationally defined (Table  2). These acceptable norms [20–23]. items were all combined into a single sheet to allow us to Patients’ disclosures of depression were positively asso- count the skills that doctor’s used and patients’ emotional ciated with “respect for patients” and negatively asso- responses. ciated with “survey questions”. As with the result for Goto and Takemura Asia Pac Fam Med (2016) 15:2 Page 3 of 6 Table 1 Definition of each medical interview skill (Medical Interview Evaluation System) Medical inter skill Definition Open-ended questions An open-ended question invites the patient to use his or her own judgment in deciding what topics and problems to emphasize. These questions invite patients to describe their problems by using their own vocabulary and personal experience of their symp- toms Close-ended questions A question which can be answered by Yes/No or a single word Survey questions A question after summarization (the summary) to survey the problem, and whether the patient has other problems or not Focused questions The question for understanding clearly the contents which a patient is going to tell and not a close-ended question but in-between open-ended questions and close-ended questions. In other words, questions which slightly limited the range of the answer. For example, “Where is the pain?” Requests for feelings Direct requests for the patient’s own feelings Asking the patient’s ideas about the Directly asking the patient what he or she thinks could be causing the symptom meaning of the illness Asking the patient’s preferences about Directly asking the patient what kind of examination he or she would like to have or not the examination have Summarization Attempts on the physician’s part to summarize the information settled to some extent that he or she has just received from the patient Reflection The physician’s statement of an observed feeling or emotion in the patient Legitimization An intervention that specifically communicates acceptance and validation of the patient’s emotional experience Personal support Letting the patient know that the doctor is there for the patient and wants to help Partnership Letting the patient feel a sense of partnership Respect for patients Respectful communication strategies, such as addressing the patient by name or giving affirmative comments Table 2 Definition of feelings of anxiety and depressive feelings Feelings of anxiety The state of feeling nervous or worried that something bad is going to happen Linguistic expressions: scary, sleepless, anorexic, get scared, something wrong, apprehensive about, painful, concerned about, etc. Depressive feelings Unhappy, disappointed, or suicidal feelings Linguistic expressions: despair, feel like dying, boring, not fun, unhappy, not interesting in something, etc. disclosures of anxiety, multicollinearity was found to be “Open-ended questions” “meaning of the illness” within acceptable limits, with no VIF above than 10 (data “reflection” and “legitimization” had a positive associa - not shown). tion with indications of “feelings of anxiety”. We compared the respective association strengths of “Open-ended questions” were effective for eliciting the various independent variables. “Open-ended ques- patients’ feelings of anxiety, but “close-ended questions” tions” and “legitimization” were found to have the strong- or “focused questions” were not. A lot of previous studies est association with respect to indications of undisclosed recommended using the open-ended questions to solic- “feelings of anxiety”. “Close-ended questions” and iting patients’ information [24–26] and the result of this “focused question” were also significant; however, their study is in agreement with these investigations. respective association strengths were close to zero. As for Previous study showed that “reflection” and “legiti - depression, “survey questions” and “respect for patients” mization” were associated with patient satisfaction were the only notable associations. [16]. Another study also identified a significant posi - tive association between the amount of information Discussion elicited from patients and patient satisfaction [27]. There were differences in which skills were effective for Furthermore, an investigation also indicated that eliciting feelings of anxiety and depression clearly. patient satisfaction is associated with discussion of Goto and Takemura Asia Pac Fam Med (2016) 15:2 Page 4 of 6 Table 3 Basic statistics of emotional disclosures, interview skills and covariates Medical interview skill Mean SD Quartiles 0 (%) 25 (%) 50 (%) 75 (%) 100 (%) Demographic Sex of patients Male: 74; female: 85 Sex matching Matched: 83; not matched 76 Interview skills Open-ended questions 0.6 0.5 0 0 1 1 1 Close-ended questions 43.7 20.5 0 29 44 55 124 Focused questions 7.7 6.2 0 4 7 10 51 Survey questions 0.5 1.2 0 0 0 1 14 Request for feelings 0.1 0.4 0 0 0 0 3 Meaning of the illness 0.5 0.6 0 0 0 1 4 Preference 0.3 0.5 0 0 0 1 2 Summarization 0.4 0.5 0 0 0 1 2 Reflection 0.4 0.5 0 0 1 3 23 Legitimization 0.4 0.9 0 0 0 0 4 Personal support 0.1 0.5 0 0 0 0 4 Partnership 0.0 0.1 0 0 0 0 1 Respect for patients 2.2 2.1 0 1 2 3 13 Emotional disclosures Anxiety 3.4 4.6 0 1 2 5 41 Depression 0.3 0.9 0 0 0 0 32 Confounder Mean duration 1356.5 730.1 133 834 1205 1753 4062 of interview (sec) Table 4 Estimated model of physician’s interview style on number of disclosure about anxiety by patients b a Item Crude Modified Estimate SE z value p Estimate SE z value p Intercept 0.389 0.154 2.529 0.011 0.234 0.329 0.712 0.477 Open-ended questions 0.189 0.096 1.975 0.048 0.282 0.100 2.821 0.005 Close-ended questions 0.004 0.003 1.317 0.188 −0.008 0.004 −2.241 0.025 Focused questions −0.008 0.008 −0.973 0.331 −0.018 0.009 −2.053 0.040 Survey questions −0.044 0.031 −1.414 0.157 −0.041 0.032 −1.308 0.191 Requests for feelings 0.160 0.080 2.006 0.045 −0.004 0.080 −0.050 0.960 Meaning of the illness 0.207 0.069 2.995 0.003 0.157 0.070 2.256 0.024 Preference about examination −0.077 0.093 −0.828 0.408 −0.033 0.092 −0.361 0.718 Summarization −0.134 0.102 −1.317 0.188 −0.175 0.104 −1.683 0.092 Reflection 0.066 0.012 5.533 <0.001 0.066 0.013 5.195 <0.001 Legitimization 0.285 0.049 5.779 <0.001 0.205 0.051 4.014 <0.001 Personal support 0.009 0.092 0.093 0.926 −0.041 0.094 −0.435 0.663 Partnership −0.982 0.593 −1.654 0.098 −0.543 0.607 −0.895 0.371 Respect for patients 0.070 0.024 2.899 0.004 −0.002 0.028 −0.079 0.937 Model was estimated using generalized linear model. Dependent variable was number of disclosure about anxiety SE standard error Patient’s sex, physician’s title, sex matching between the patient and the physician, and duration of interview were modified as covariates. AIC was 768.85 Akaike information criteria (AIC) was 810.00. AIC is an index of goodness of fit for the estimated model by generalized linear model Intercept is the value of dependent variable when all the independent variables were zero Goto and Takemura Asia Pac Fam Med (2016) 15:2 Page 5 of 6 Table 5 Estimated model of physician’s interview style on number of disclosure about depression by patients b a Item Crude Modified Estimate SE z value p Estimate SE z value p Intercept −2.478 0.440 −5.630 <0.001 −4.596 0.992 −4.634 <0.001 Open-ended questions −0.458 0.231 −1.984 0.047 −0.379 0.258 −1.469 0.142 Close-ended questions 0.014 0.008 1.793 0.073 −0.008 0.009 −0.924 0.355 Focused questions 0.029 0.012 2.379 0.017 0.004 0.013 0.325 0.745 Survey questions −0.089 0.049 −1.825 0.068 −0.115 0.052 −2.192 0.028 Requests for feelings 0.622 0.156 3.978 <0.001 0.049 0.158 0.313 0.754 Meaning of the illness 0.129 0.174 0.742 0.458 −0.065 0.194 −0.334 0.738 Preference about examination −0.559 0.242 −2.308 0.021 −0.085 0.230 −0.367 0.713 Summarization −0.008 0.264 −0.031 0.975 −0.179 0.297 −0.605 0.545 Reflection −0.010 0.030 −0.338 0.736 0.009 0.035 0.267 0.789 Legitimization 0.350 0.142 2.462 0.014 0.007 0.173 0.039 0.969 Personal support 0.068 0.150 0.454 0.650 −0.218 0.164 −1.331 0.183 Partnership −15.362 828.283 −0.019 0.985 −15.020 982.600 −0.015 0.988 Respect for patients 0.344 0.053 6.523 <0.001 0.215 0.065 3.293 0.001 Model was estimated using generalized linear model. Dependent variable was number of disclosure about depression SE standard error Patient’s sex, physician’s title, sex matching between the patient and the physician, and duration of interview were modified as covariates. AIC was 286.96 Akaike information criteria (AIC) was 322.39. AIC is an index of goodness of fit for the estimated model by generalized linear model Intercept is the value of dependent variable when all the independent variables were zero emotional distress [3, 4, 28]. This study might provide Strength and limitations an explanation as to why “reflection” and “legitimiza - Strength of this study is the use of an objective method tion” have been shown to increase patient satisfaction, to assess medical interview skills and patients’ emotion. as enhanced disclosure has been shown to increase Conversely, there are several limitations. First, there may patients’ satisfaction. be other confounding factors not measured in this study; “Meaning of the illness” was effective for eliciting for example, other relevant patient background informa- patient’s feelings of anxiety, but “close-ended questions” tion, non-verbal communications, and so on. Second, it is and “focused questions” might conceal it. That results difficult to evaluate subjective information such as men - are in accordance with the previous investigation that tal feelings objectively. patients are more likely talk about psychosocial issues in the atmosphere created when a physician uses less Conclusions close-ended questions and less dominating [3, 4]. These This study reveals that several interview skills including results may show it is difficult for patients to express their “open-ended questions” “legitimization” would be effec - anxieties when the patients were asked to verbalize the tive in eliciting undisclosed “feelings of anxiety”. On the feeling directly by “close-ended questions” or “focused other hand, “respect for patients” was associated with questions”. undisclosed “depressive feelings”. In this study, “respect for patients” had positive asso- Authors’ contributions ciation with indications of feelings of depression. Previ- MG conceived of the study, analyzed and interpreted the videotaped data and ous research showing that patients were more willing to drafted the manuscript. Y T participated in the design of the study, revised it critically for important intellectual content, performed the statistical analysis divulge personal information; such as therapeutic, life- and drafted the manuscript. Both authors contributed to defining the research style, and psychosocial information to physicians who question, participated in the coordination of the study. Both authors read and show respect supports the result of this study [29]. Cape approved the final manuscript. and McCulloch also explored patients’ reasons for not Author details presenting emotional problems in medical interviews 1 Department of Education and Research in Family and Community Medi- and they found that 45 percent of reasons related to psy- cine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan. Department of Family Medicine, Mie University School chological embarrassment or hesitation to trouble the of Medicine and Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie general practitioner or family physician [13]. Their result 514-8507, Japan. shares similarity in our result. Goto and Takemura Asia Pac Fam Med (2016) 15:2 Page 6 of 6 Acknowledgements 12. Gask L, Goldberg D, Lesser AL, Millar T. Improving the psychiatric skills of We would especially like to thank all the patients who participated in this the general practice trainee: an evaluation of a group training course. study. We would also like to thank the physicians who made this study Med Educ. 1988;2:132–8. possible by inviting their patients to participate and allowing their work to 13. Cape J, McCulloch Y. Patients’ reasons for not presenting emotional prob- be recorded. We really appreciate Shuhei Ichikawa for his assistance with lems in general practice consultations. Br J Gen Pract. 1999;49:875–9. the statistics processes. We wish to express our gratitude to Alberto Gayle 14. Hsu I, Saha S, Korthuis PT, Sharp V, Cohn J, Moore RD, Beach MC. Provid- for his assistance regarding interpretation of the results and revision to the ing support to patients in emotional encounters: a new perspective on manuscript. We would also like to thanks the technical staff that helped record missed empathic opportunities. Patient Educ Couns. 2012;3:436–42. and collect the video data at Mie University.This work was supported by the 15. Adams K, Cimino JE, Arnold RM, Anderson WG. Why should I talk about Sciences Research Grant of the Ministry of Health, Labour and Welfare, Japan. emotion? Communication patterns associated with physician discus- (No.16211701). sion of patient expressions of negative emotion in hospital admission encounters. Patient Educ Couns. 2012;1:44–50. Competing interests 16. Takemura YC, Atsumi R, Tsuda T. Which medical interview behaviors are The authors declare that they have no competing interests. associated with patient satisfaction? Fam Med. 2008;40:253–8. 17. Roter DL. The Roter method of interaction process analysis. Baltimore: Received: 6 May 2015 Accepted: 15 February 2016 Johns Hopkins University; 1991. 18. Badger LW, deGruy FV, Hartman J, Plant MA, Leeper J, Ficken R, Maxwell A, Rand E, Anderson R, Templeton B. Psychosocial interest, medical inter- views, and the recognition of depression. Arch Fam Med. 1994;3:899–907. 19. R core team. R: a language and environment for statistical computing. R foundation for statistical computing. Vienna Austria. http://www.R- References project.org. Accessed 25 Aug 2014. 1. Robinson JW, Roter DL. Psychosocial problem disclosure by primary care 20. Marquardt DW. Generalized inverses, ridge regression, biased linear patients. Soc Sci Med. 1999;10:1353–62. estimation, and nonlinear estimation. Technometrics. 1970;12:591–612. 2. Ansseau M, Dierick M, Buntinkx F, Cnockaert P, De Smedt J, Van Den 21. Neter J, Wasserman W, Kutner MH. Applied linear regression models. Haute M, Vander MD. High prevalence of mental disorders in primary Maidenheach: McGraw-Hill Irwin; 1989. care. J Aec ff t Disord. 2004;1:49–55. 22. Kennedy P. A guide to econometrics. Oxford: Blackwell; 1992. 3. Bertakis KD, Roter D, Putnam SM. The relationship of physician medical 23. Hair JF Jr, Anderson RE, Tatham RL, Black WC. Multivariate Data Analysis. interview style to patient satisfaction. J Fam Pract. 1991;2:175–81. 3rd ed. New York: Macmillan; 1995. 4. Levinson W, Roter D. Physicians’ psychosocial beliefs correlate with their 24. Roter DL, Hall JA. Physicians’ interview styles and medical information patient communication skills. Gen Intern Med. 1995;7:375–9. obtained from patients. J Gen Intern Med. 1987;2(7):325–9. 5. Blanch-Hartigan D. Patient satisfaction with physician errors in detecting 25. Maguire P, Faulkner A, Booth K, Elliott C, Hillier V. Helping cancer patient’s and identifying patient emotion cues. Patient Educ Couns. 2013;1:56–62. disclose their concern. Eur J Cancer. 1996;32A:78–81. 6. Mjaaland TA, Finset A, Jensen BF, Gulbrandsen P. Physicians’ responses to 26. Cole SA, Bird J. The medical interview: the three-function approach. 2nd patients’ expressions of negative emotions in hospital consultations: a ed. Oxford: St Louis: Mosby; 2000. video-based observational study. Patient Educ Couns. 2011;84:332–7. 27. Takemura YC, Liu J, Atsumi R, Tsuda T. Development of questionnaire to 7. Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic evaluate patient satisfaction with medical encounters. Tohoku J Exp Med. communication in the medical interview. JAMA. 1997;277:678–82. 2006;210:373–81. 8. Del Piccolo L, Saltini A, Zimmermann C, Dunn G. Differences in verbal 28. Gross R, Brammli-Greenberg S, Tabenkin H, Benbassat J. Primary care behaviors of patients with and without emotional distress during primary physicians’ discussion of emotional distress and patient satisfaction. Int J care consultations. Psychol Med. 2000;30:629–43. Psychiatry Med. 2007;37:331–45. 9. Tiemens BG, Ormel J, Simon GE. Occurrence, recognition, and out- 29. Cape J, Geyer C, Barker C, Pistrang N, Buszewicz M, Dowrick C, Salmon come of psychological disorders in primary care. Am J Psychiatry. P. Facilitating understanding of mental health problems in GP consul- 1996;5:636–44. tations: a qualitative study using taped-assisted recall. Br J Gen Pract. 10. Kessler D, Lloyd K, Lewis G, Gray DP. Cross sectional study of symptom 2010;60:837–45. attribution and recognition of depression and anxiety in primary care. BMJ. 1999;7181:436–9. 11. Gask L, McGrath G, Goldberg D, Millar T. Improving the psychiatric skills of established general practitioners: evaluation of group teaching. Med Educ. 1987;4:362–8. Submit your next manuscript to BioMed Central and we will help you at every step: • We accept pre-submission inquiries • Our selector tool helps you to find the most relevant journal • We provide round the clock customer support • Convenient online submission • Thorough peer review • Inclusion in PubMed and all major indexing services • Maximum visibility for your research Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Which medical interview skills are associated with patients’ verbal indications of undisclosed feelings of anxiety and depressive feelings?

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Springer Journals
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Copyright © 2016 by Goto and Takemura.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: In medical practice, obtaining information regarding patients’ undisclosed “feelings of anxiety” or “depressive feelings” is important. The purpose of this study was to determine which interview skills are best suited for eliciting verbal indications of undisclosed feelings, for example anxiety or depressive feelings in patients. Methods: Our group videotaped 159 medical interviews at an outpatient department of the Department of Fam- ily Medicine, Mie University Hospital (Mie, Japan). Physicians’ medical interview skills were evaluated using a Medical Interview Evaluation System and Emotional Information Check Sheet for assessing indications of “feelings of anxiety” or “depressive feelings”. We analyzed the relationship between the interview skills and patients’ consequent emotional disclosure using generalized linear model (GLIM). Results: The usage of interview skills such as “open-ended questions” “asking the patient’s ideas about the meaning of illness” “reflection” and “legitimization” were positively associated with the number of anxiety disclosure, whereas “close-ended questions” and “focused question” were negatively associated. On the other hand, only “respect” was pos- itively associated with the number of depressive disclosures, whereas “surveying question” was negatively associated. Conclusions: The results revealed that there are several interview skills that are effective in eliciting verbal indication of undisclosed “feelings of anxiety” or “depressive feelings”. Keywords: Family medicine, Medical interview, Depression, Anxiety, Communication shorten the consultation time and reduce the extra stress Background of the physicians [6]. However, in many cases, patients One of the important functions of the medical interview are said to only send indirect signals with no explicit is to understand the mental status of patients. It is impor- emotional expressions [7] and show only an ambiguous tant that the physician checks the mental status of the response [8]. The cue expressed by the patient may be patient during the medical interview, because patients overlooked due to the physician’s low awareness [9, 10] or often do not come to see physicians suspecting that they might have mental disorder [1, 2]. Paying attention insufficient clinical skills due to the lack of training [ 11, to the patients’ emotions could not only contribute to 12]. Furthermore, even when they are encouraged by the early detection of psychiatric disease but is said to affect physicians, many patients would feel embarrassed, hesi- the patient’s satisfaction [3–5]. This approach will also tated or simply feel that they do not deserve to disclose emotions [13]. In recent years, many studies have been made on the *Correspondence: yousuke@clin.medic.mie-u.ac.jp relationship between the patients’ emotional response Department of Family Medicine, Mie University School of Medicine and Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, and the physicians’ interview skills to address these Japan needs. Many of them have discussed that physicians’ Full list of author information is available at the end of the article © 2016 Goto and Takemura. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons. org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Goto and Takemura Asia Pac Fam Med (2016) 15:2 Page 2 of 6 communication skills should be employed to help This scale was assessed for reliability. First, for each patients’ express their emotions [6, 8, 14, 15]. However, videotaped interview, an evaluator used the scale to eval- most of the reports on the patients’ emotional response uate the number of skills used by the physician. Second, are made in the context of cancer treatment. Suffi - the same evaluator did a second review a random selec- cient studies have not been made on the physicians’ tion of 25 interviews 2 months after the first review. The skills and the patients’ emotional response during the kappa value was calculated and found to be 0.93. common medical interviews like ones at primary care Interview length was considered as a confounder, facilities. because longer interview duration was presumed to posi- The aim of the present study is to explore the associa - tively influence our findings [18]. In addition, patients’ tion between physicians’ interview skills and patients’ sex, sex matching between patient and physician, and disclosure about anxiety or depression in the primary affiliation (student, resident and family physician) were care setting. also obtained as other possible confounders. Methods Statistical analyses Participants and procedures Demographic data were obtained first. Then, we used a One hundred and fifty nine different new patients (74 generalized linear model (GLM) to assess the relation- males and 85 females) participated in this observational, ship between a physician’s use of these interview skills cross-sectional study. They are patients at outpatient and verbal indications of feelings of anxiety or depres- department of the Department of Family Medicine of sion. Because our observation of physicians’ interview large-scale hospital, Japan. The patients came from both skills and patients’ emotional disclosures were recorded rural and urban areas and were from a wide range of soci- as count data, we modeled the relationship using the oeconomic classes. All of the patients were over 15 years Poisson distributions and log link function. After the of age, and most patients generally had common medical generalized linear model was estimated, we verified the problems such as hypertension, hypercholesterolemia, variance inflation factors of each independent variable and diabetes. First, we checked whether this was a first and the covariates (VIF). Finally, we evaluated goodness visit and asked if the prospective participant were willing of fit of the estimated model using Akaike Information to participate, and if he or she declined, no further effort Criteria (AIC). was made. Second, we gave them instructions about the Statistical significance was set as p < 0.05 for all meas - purpose and meaning of the study and told them that ures. We used R version 3.1.1 [19] for statistical analyses. they could decline from this study anytime when they Generalized linear model analyses were conducted using want to. Third, we obtained each participant’s signature. the “glm” function. There was no missing data. Parental permission was obtained for patients whose age is less than 20 years old. Results Each patient was interviewed by one of 26 family phy- Characteristics of patients and physicians are shown sicians, 98 family medicine residents, or 35 medical stu- in Table  3. Additionally, the table shows basic statistics dents having family medicine clinical clerkship. These including mean value, standard deviations, and quartile interviews were videotaped for evaluation. values of each interview skill and emotional disclosure. Informed consents were obtained from patients and The estimated model for disclosures of anxiety is physicians prior to any observation of the medical inter- shown in Table 4, and the estimated model about that of views. The research protocol of this study was approved depression is shown in Table  5. For the purposes of our by the Research Ethical Committee of the Mie University analyses, only modified models will be considered. School of Medicine. Patients’ disclosures of anxiety were positively asso- ciated with “open-ended questions” “legitimization” Outcome measurements “reflection” and “asking the patient’s idea about the The videotaped medical interview skills were reviewed by meaning of the illness (meaning of the illness)”. Con- trained researchers using the Takemura Medical Inter- versely, they were negatively associated with “close-ended view Rating Scale (TMIRS) (Table  1) [16]. Some systems questions” and “focused questions”. As none of the inter- of the Roter interaction analysis system were used to view-skills and covariates showed VIF above 10 (data not build this scale [17]. “Feelings of anxiety” and “depressive shown), multicollinearity which was found to be within feelings” were also operationally defined (Table  2). These acceptable norms [20–23]. items were all combined into a single sheet to allow us to Patients’ disclosures of depression were positively asso- count the skills that doctor’s used and patients’ emotional ciated with “respect for patients” and negatively asso- responses. ciated with “survey questions”. As with the result for Goto and Takemura Asia Pac Fam Med (2016) 15:2 Page 3 of 6 Table 1 Definition of each medical interview skill (Medical Interview Evaluation System) Medical inter skill Definition Open-ended questions An open-ended question invites the patient to use his or her own judgment in deciding what topics and problems to emphasize. These questions invite patients to describe their problems by using their own vocabulary and personal experience of their symp- toms Close-ended questions A question which can be answered by Yes/No or a single word Survey questions A question after summarization (the summary) to survey the problem, and whether the patient has other problems or not Focused questions The question for understanding clearly the contents which a patient is going to tell and not a close-ended question but in-between open-ended questions and close-ended questions. In other words, questions which slightly limited the range of the answer. For example, “Where is the pain?” Requests for feelings Direct requests for the patient’s own feelings Asking the patient’s ideas about the Directly asking the patient what he or she thinks could be causing the symptom meaning of the illness Asking the patient’s preferences about Directly asking the patient what kind of examination he or she would like to have or not the examination have Summarization Attempts on the physician’s part to summarize the information settled to some extent that he or she has just received from the patient Reflection The physician’s statement of an observed feeling or emotion in the patient Legitimization An intervention that specifically communicates acceptance and validation of the patient’s emotional experience Personal support Letting the patient know that the doctor is there for the patient and wants to help Partnership Letting the patient feel a sense of partnership Respect for patients Respectful communication strategies, such as addressing the patient by name or giving affirmative comments Table 2 Definition of feelings of anxiety and depressive feelings Feelings of anxiety The state of feeling nervous or worried that something bad is going to happen Linguistic expressions: scary, sleepless, anorexic, get scared, something wrong, apprehensive about, painful, concerned about, etc. Depressive feelings Unhappy, disappointed, or suicidal feelings Linguistic expressions: despair, feel like dying, boring, not fun, unhappy, not interesting in something, etc. disclosures of anxiety, multicollinearity was found to be “Open-ended questions” “meaning of the illness” within acceptable limits, with no VIF above than 10 (data “reflection” and “legitimization” had a positive associa - not shown). tion with indications of “feelings of anxiety”. We compared the respective association strengths of “Open-ended questions” were effective for eliciting the various independent variables. “Open-ended ques- patients’ feelings of anxiety, but “close-ended questions” tions” and “legitimization” were found to have the strong- or “focused questions” were not. A lot of previous studies est association with respect to indications of undisclosed recommended using the open-ended questions to solic- “feelings of anxiety”. “Close-ended questions” and iting patients’ information [24–26] and the result of this “focused question” were also significant; however, their study is in agreement with these investigations. respective association strengths were close to zero. As for Previous study showed that “reflection” and “legiti - depression, “survey questions” and “respect for patients” mization” were associated with patient satisfaction were the only notable associations. [16]. Another study also identified a significant posi - tive association between the amount of information Discussion elicited from patients and patient satisfaction [27]. There were differences in which skills were effective for Furthermore, an investigation also indicated that eliciting feelings of anxiety and depression clearly. patient satisfaction is associated with discussion of Goto and Takemura Asia Pac Fam Med (2016) 15:2 Page 4 of 6 Table 3 Basic statistics of emotional disclosures, interview skills and covariates Medical interview skill Mean SD Quartiles 0 (%) 25 (%) 50 (%) 75 (%) 100 (%) Demographic Sex of patients Male: 74; female: 85 Sex matching Matched: 83; not matched 76 Interview skills Open-ended questions 0.6 0.5 0 0 1 1 1 Close-ended questions 43.7 20.5 0 29 44 55 124 Focused questions 7.7 6.2 0 4 7 10 51 Survey questions 0.5 1.2 0 0 0 1 14 Request for feelings 0.1 0.4 0 0 0 0 3 Meaning of the illness 0.5 0.6 0 0 0 1 4 Preference 0.3 0.5 0 0 0 1 2 Summarization 0.4 0.5 0 0 0 1 2 Reflection 0.4 0.5 0 0 1 3 23 Legitimization 0.4 0.9 0 0 0 0 4 Personal support 0.1 0.5 0 0 0 0 4 Partnership 0.0 0.1 0 0 0 0 1 Respect for patients 2.2 2.1 0 1 2 3 13 Emotional disclosures Anxiety 3.4 4.6 0 1 2 5 41 Depression 0.3 0.9 0 0 0 0 32 Confounder Mean duration 1356.5 730.1 133 834 1205 1753 4062 of interview (sec) Table 4 Estimated model of physician’s interview style on number of disclosure about anxiety by patients b a Item Crude Modified Estimate SE z value p Estimate SE z value p Intercept 0.389 0.154 2.529 0.011 0.234 0.329 0.712 0.477 Open-ended questions 0.189 0.096 1.975 0.048 0.282 0.100 2.821 0.005 Close-ended questions 0.004 0.003 1.317 0.188 −0.008 0.004 −2.241 0.025 Focused questions −0.008 0.008 −0.973 0.331 −0.018 0.009 −2.053 0.040 Survey questions −0.044 0.031 −1.414 0.157 −0.041 0.032 −1.308 0.191 Requests for feelings 0.160 0.080 2.006 0.045 −0.004 0.080 −0.050 0.960 Meaning of the illness 0.207 0.069 2.995 0.003 0.157 0.070 2.256 0.024 Preference about examination −0.077 0.093 −0.828 0.408 −0.033 0.092 −0.361 0.718 Summarization −0.134 0.102 −1.317 0.188 −0.175 0.104 −1.683 0.092 Reflection 0.066 0.012 5.533 <0.001 0.066 0.013 5.195 <0.001 Legitimization 0.285 0.049 5.779 <0.001 0.205 0.051 4.014 <0.001 Personal support 0.009 0.092 0.093 0.926 −0.041 0.094 −0.435 0.663 Partnership −0.982 0.593 −1.654 0.098 −0.543 0.607 −0.895 0.371 Respect for patients 0.070 0.024 2.899 0.004 −0.002 0.028 −0.079 0.937 Model was estimated using generalized linear model. Dependent variable was number of disclosure about anxiety SE standard error Patient’s sex, physician’s title, sex matching between the patient and the physician, and duration of interview were modified as covariates. AIC was 768.85 Akaike information criteria (AIC) was 810.00. AIC is an index of goodness of fit for the estimated model by generalized linear model Intercept is the value of dependent variable when all the independent variables were zero Goto and Takemura Asia Pac Fam Med (2016) 15:2 Page 5 of 6 Table 5 Estimated model of physician’s interview style on number of disclosure about depression by patients b a Item Crude Modified Estimate SE z value p Estimate SE z value p Intercept −2.478 0.440 −5.630 <0.001 −4.596 0.992 −4.634 <0.001 Open-ended questions −0.458 0.231 −1.984 0.047 −0.379 0.258 −1.469 0.142 Close-ended questions 0.014 0.008 1.793 0.073 −0.008 0.009 −0.924 0.355 Focused questions 0.029 0.012 2.379 0.017 0.004 0.013 0.325 0.745 Survey questions −0.089 0.049 −1.825 0.068 −0.115 0.052 −2.192 0.028 Requests for feelings 0.622 0.156 3.978 <0.001 0.049 0.158 0.313 0.754 Meaning of the illness 0.129 0.174 0.742 0.458 −0.065 0.194 −0.334 0.738 Preference about examination −0.559 0.242 −2.308 0.021 −0.085 0.230 −0.367 0.713 Summarization −0.008 0.264 −0.031 0.975 −0.179 0.297 −0.605 0.545 Reflection −0.010 0.030 −0.338 0.736 0.009 0.035 0.267 0.789 Legitimization 0.350 0.142 2.462 0.014 0.007 0.173 0.039 0.969 Personal support 0.068 0.150 0.454 0.650 −0.218 0.164 −1.331 0.183 Partnership −15.362 828.283 −0.019 0.985 −15.020 982.600 −0.015 0.988 Respect for patients 0.344 0.053 6.523 <0.001 0.215 0.065 3.293 0.001 Model was estimated using generalized linear model. Dependent variable was number of disclosure about depression SE standard error Patient’s sex, physician’s title, sex matching between the patient and the physician, and duration of interview were modified as covariates. AIC was 286.96 Akaike information criteria (AIC) was 322.39. AIC is an index of goodness of fit for the estimated model by generalized linear model Intercept is the value of dependent variable when all the independent variables were zero emotional distress [3, 4, 28]. This study might provide Strength and limitations an explanation as to why “reflection” and “legitimiza - Strength of this study is the use of an objective method tion” have been shown to increase patient satisfaction, to assess medical interview skills and patients’ emotion. as enhanced disclosure has been shown to increase Conversely, there are several limitations. First, there may patients’ satisfaction. be other confounding factors not measured in this study; “Meaning of the illness” was effective for eliciting for example, other relevant patient background informa- patient’s feelings of anxiety, but “close-ended questions” tion, non-verbal communications, and so on. Second, it is and “focused questions” might conceal it. That results difficult to evaluate subjective information such as men - are in accordance with the previous investigation that tal feelings objectively. patients are more likely talk about psychosocial issues in the atmosphere created when a physician uses less Conclusions close-ended questions and less dominating [3, 4]. These This study reveals that several interview skills including results may show it is difficult for patients to express their “open-ended questions” “legitimization” would be effec - anxieties when the patients were asked to verbalize the tive in eliciting undisclosed “feelings of anxiety”. On the feeling directly by “close-ended questions” or “focused other hand, “respect for patients” was associated with questions”. undisclosed “depressive feelings”. In this study, “respect for patients” had positive asso- Authors’ contributions ciation with indications of feelings of depression. Previ- MG conceived of the study, analyzed and interpreted the videotaped data and ous research showing that patients were more willing to drafted the manuscript. Y T participated in the design of the study, revised it critically for important intellectual content, performed the statistical analysis divulge personal information; such as therapeutic, life- and drafted the manuscript. Both authors contributed to defining the research style, and psychosocial information to physicians who question, participated in the coordination of the study. Both authors read and show respect supports the result of this study [29]. Cape approved the final manuscript. and McCulloch also explored patients’ reasons for not Author details presenting emotional problems in medical interviews 1 Department of Education and Research in Family and Community Medi- and they found that 45 percent of reasons related to psy- cine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan. Department of Family Medicine, Mie University School chological embarrassment or hesitation to trouble the of Medicine and Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie general practitioner or family physician [13]. Their result 514-8507, Japan. shares similarity in our result. Goto and Takemura Asia Pac Fam Med (2016) 15:2 Page 6 of 6 Acknowledgements 12. Gask L, Goldberg D, Lesser AL, Millar T. Improving the psychiatric skills of We would especially like to thank all the patients who participated in this the general practice trainee: an evaluation of a group training course. study. We would also like to thank the physicians who made this study Med Educ. 1988;2:132–8. possible by inviting their patients to participate and allowing their work to 13. Cape J, McCulloch Y. Patients’ reasons for not presenting emotional prob- be recorded. We really appreciate Shuhei Ichikawa for his assistance with lems in general practice consultations. Br J Gen Pract. 1999;49:875–9. the statistics processes. We wish to express our gratitude to Alberto Gayle 14. Hsu I, Saha S, Korthuis PT, Sharp V, Cohn J, Moore RD, Beach MC. Provid- for his assistance regarding interpretation of the results and revision to the ing support to patients in emotional encounters: a new perspective on manuscript. We would also like to thanks the technical staff that helped record missed empathic opportunities. Patient Educ Couns. 2012;3:436–42. and collect the video data at Mie University.This work was supported by the 15. Adams K, Cimino JE, Arnold RM, Anderson WG. 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Journal

Asia Pacific Family MedicineSpringer Journals

Published: Feb 28, 2016

References