Communication Study
Why should I talk about emotion? Communication patterns associated with physician discussion of patient expressions of negative emotion in hospital admission encounters

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Abstract

Objective

To describe hospital-based physicians’ responses to patients’ verbal expressions of negative emotion and identify patterns of further communication associated with different responses.

Methods

Qualitative analysis of physician–patient admission encounters audio-recorded between August 2008 and March 2009 at two hospitals within a university system. A codebook was iteratively developed to identify patients’ verbal expressions of negative emotion. We categorized physicians’ responses by their immediate effect on further discussion of emotion – focused away (away), focused neither toward nor away (neutral), and focused toward (toward) – and examined further communication patterns following each response type.

Results

In 79 patients’ encounters with 27 physicians, the median expression of negative emotion was 1, range 0–14. Physician responses were 25% away, 43% neutral, and 32% toward. Neutral and toward responses elicited patient perspectives, concerns, social and spiritual issues, and goals for care. Toward responses demonstrated physicians’ support, contributing to physician–patient alignment and agreement about treatment.

Conclusion

Responding to expressions of negative emotion neutrally or with statements that focus toward emotion elicits clinically relevant information and is associated with positive physician–patient relationship and care outcomes.

Practice implications

Providers should respond to expressions of negative emotion with statements that allow for or explicitly encourage further discussion of emotion.

Introduction

Research in outpatient settings demonstrates that empathy is a key element in physician–patient communication [1], [2], [3], [4]. It encourages discussion of patients’ distress [1], [5] and is associated with decreased anxiety, increased satisfaction, and improved medical outcomes [6], [7], [8], [9], [10], [11]. Despite these benefits, outpatient studies have shown that physicians infrequently respond with empathy to patient expressions of negative emotion [1], [2], [3], [5], [12], [13], [14], [15].

Physician–patient communication is an increasingly important quality measure of inpatient care [16]. Hospitalization may be a source of increased emotional distress for patients, and physician empathy may be a key factor in communication in the hospital. The hospitalist model – in which hospitalized patients are cared for not by their outpatient physicians, but by physicians who specialize in inpatient care – now provides care to most hospitalized medical patients in the US, and a rapidly growing number worldwide [17], [18]. This model has shown benefits in patient outcomes, quality of care, and education [19], [20]; yet, concerns remain about its effects on the physician–patient relationship [21]. The goals of this study were to understand how hospitalists respond to patients’ expressions of negative emotion and to identify how different types of responses influence further communication in the encounter.

Section snippets

Design and setting

We qualitatively analyzed attending physician–patient admission encounters which were audio-recorded between August 2008 and March 2009 on the general medical services at two hospitals within a university system [22].

Participants

All attending hospitalist physicians at the two hospitals were eligible. Eligible patients were admitted under the care of – but had not yet met – a participating physician and were able to communicate verbally in English and provide informed consent.

Recruitment and data collection

Physicians were recruited

Patient expressions of negative emotion

We analyzed 79 patients’ admission encounters with 27 physicians (Table 2). Consent rates were 91% for physicians and 66% for patients [22]. We identified 190 instances of patient emotional expression, 58% indirect and 42% direct. The median number of expressions per encounter was 1, range 0–14; 71% of encounters contained at least one expression.

Physician responses

Table 1 provides examples of physician responses by category: away, neutral, and toward. Percentages of physician responses within each category are

Discussion

In our qualitative analysis of physician–patient hospital admission encounters, we found that patients verbally expressed negative emotion in most encounters, and that physicians most often responded with statements that allowed or explicitly encouraged continued discussion of emotion. Physician responses that focused discussion away, toward, or neither toward nor away from emotion were each associated with distinct patterns of further communication within the encounters.

We found a higher

Acknowledgments

We would like to thank the patients and physicians who generously donated their time to participate in this study. Dr. Anderson was funded by the National Palliative Care Research Center and the University of California San Francisco Clinical and Translational Science Institute Career Development Program, which is supported by NIH grant number 5 KL2 RR024130-04. The University of California San Francisco Academic Senate funded study expenses.

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