The challenge for doctors in practice is to correctly identify moments where an empathic response or further discussion/clarification of the cue is required. This is particularly pertinent when considering that, whilst emotion is rarely explicitly stated, cues are frequently presented in medical consultations. For example, in General Practice, patients tend to present implicit hints or cues to emotional distress four times as frequently as explicit statements (Robinson and Roter, 1999, Del Piccolo et al., 2000, Levinson et al., 2000, Del Piccolo et al., 2002), with such cues generally relating to depressive symptoms or low mood (Salmon et al., 2004) and varying according to the patient, their presenting complaint(s) and the doctor (Zimmermann et al., 2007).
It is estimated that patients present one or more cues in between 51% and 94% of consultations (Robinson and Roter, 1999, Marvel et al., 1999, Levinson et al., 2000, Salmon et al., 2004). An average of 2.40 to 6.60 cues have been found to be presented per consultation (Levinson et al., 2000, van Dulmen and van den Brink- Muinen, 2004, Street et al., 2005, Del Piccolo et al., 2007, Bensing et al., 2008, Bensing et al., 2010), with rates as high as 12 cues per consultation reported (van den Brink-Muinen and Caris-Verhallen, 2003). Rates of cue presentation in General Practice are similar to other healthcare settings; a recent review of cues and concerns in medical consultations across a variety of settings, including oncology, psychiatry and paediatrics, reported a mean frequency of 1.30 to 6.80 cues per consultation (Zimmermann et al., 2007).
Numerous reasons have been proposed for the variations in frequency of explicitly voiced emotion or cues to emotional distress in medical consultations.
Patients may feel embarrassed or afraid to voice their concerns, or may find it hard to verbally express emotion (Del Piccolo et al., 2008, Little et al., 2001a). This notion is supported by the work of Barry and colleagues, who found that, when interviewed post-consultation, patients often verbalised concerns that were not raised directly or spontaneously during their consultation (Barry et al., 2000). Personal factors such as patients’ stress levels may impact on initial and subsequent presentation of emotion (Hulsman et al., 2009, Neumann et al., 2007). Type of illness and beliefs about the value of such disclosure may also affect cue emission (Heaven and Maguire, 1997), with patients experiencing psychological distress significantly more likely to express cues than their non-distressed counterparts (Del Piccolo et al., 2000, Del Piccolo et al., 2007, Robinson and Roter, 1999, van Dulmen and van den Brink-Muinen, 2004). If patients’ cues are not listened to and responded to appropriately following initial presentation, then this too may impact on further presentation (Epstein et al., 2007, Eide et al., 2004a), either increasing frequency of cue presentation until the cue is adequately dealt with, inhibiting subsequent disclosure (Levinson et al., 2000) or resulting in the cue being ‘catastrophised’ (Dowrick et al., 2004).
3.5.1 How Do Doctors Respond to Patients’ Cues?
Studies have been conducted to assess the appropriateness of doctors’ responses to emotive cues, with ‘adequate’ responses defined as those which acknowledge and explore patients’ cues, and ‘inadequate’ responses being those which miss the cue or reduce further discussion of emotive topics. Despite recognition of the importance of effective PPC, doctors often employ communication strategies which reduce or inhibit cue presentation; cues are ‘missed’ or responded to inappropriately by doctors on as many as 50-60% of occasions (Gask et al., 1987, Gask et al., 1988).
Frequently reported responses to patients’ cues include ignoring them, changing topic or offering premature advice or reassurance (Maguire et al., 1996b, Zandbelt et al., 2007), attempting to ‘normalise’ them (Dowrick et al., 2004), interrupting or asking closed, leading or negative questions (Marvel et al., 1999, Arborelius and Österberg, 1995), especially when cues are non-explicit or indirect (Marvel et al., 1999).
On occasions where cues are responded to with facilitatory responses, these responses are more likely to be superficial (such as agreeing with the patient or paraphrasing their cue) rather than emotionally supportive (such as providing empathy, engaging in emotional discourse or providing supportive talk) (Street et al., 2005, van den Brink-Muinen and Caris-Verhallen, 2003, van Dulmen and van den Brink-Muinen, 2004, Del Piccolo et al., 2000), with return to a biomedical agenda soon after (Levinson et al., 2000, van den Brink-Muinen and Caris-Verhallen, 2003, van Dulmen and van den Brink-Muinen, 2004, Salmon et al., 2004). This can limit patient engagement with the consultation and impact on subsequent PPC.
There is a lack of consensus of opinion regarding the relationship between adequate or inadequate responses and subsequent cue presentation. PPC involving ‘active interview techniques’, such as checking information, asking for understanding or opinion and showing agreement with the patient can facilitate information giving and patient involvement and subsequently decrease cue emission (Del Piccolo et al., 2000, Del Piccolo et al., 2007, Zandbelt et al., 2007). It is argued that this occurs because patients do not need to ‘catch’ their doctor’s attention through further cue presentation, suggesting that increased cue presentation within a consultation may not be indicative of doctors’ clinical skill levels but rather may indicate a doctor who misses or ignores patients’ cues, leading to re-presentation. However, other studies have reported variable rates of doctors’ socio-emotional responding and patients’ cue presentation, both as a function of individual doctors’ consultation styles and patients’ characteristics (Street, 1991, Street, 1992). Facilitatory doctor behaviour has been linked with patients’ active participation in the consultation and subsequent increases in their cue presentation (Zimmermann et al., 2003, Del Piccolo et al., 2007, Goldberg et al., 1993, Street et al., 2005, Bensing et al., 2010). Inadequate responses such as blocking have been linked to increased presentation of cues and active participation by patients, thereby emphasising the complex and interactional nature of PPC (Salmon et al., 2004).
Sequence analysis10 allows for an understanding of chronological sequences of dialogue in medical consultations by considering speech and behaviour
10
Sequence analysis is a method derived from conversation analysis, in which the order of communicative events is analysed, providing an opportunity to study how doctors and patients react to each other.
immediately preceding and following cues. In this respect, it may offer greater insight into the relationship between cue presentation and doctor behaviour (Zimmermann et al., 2003, Bensing et al., 2010). Zimmermann (2003) studied 238 General Practice consultations and found that doctors’ open and closed questions relating to psychosocial topics or emotional support had no impact on subsequent cue presentation, but questions referring to content other than the cue content reduced cue presentation, as did medical information giving. It must be noted that the researchers did not consider cues elicited by the doctor, therefore limiting psychosocial information analysed, and used data from only six GPs. However, similar research in the area has been carried out, predominantly looking at event- based sequences (Goss et al., 2005, Rimondini et al., 2006, Zimmermann et al., 2003) and indicates that facilitative behaviour or acknowledgements are the most frequent ‘adequate’ responses to patient cues, occurring most frequently in the speech turn immediately following the cue (Rimondini et al., 2006, Zimmermann et al., 2003). Patients’ expressions of cues are less often preceded by certain doctor behaviours, including social talk, giving instructions and providing biomedical information and counselling (Bensing et al., 2010).
Quantitative research can be triangulated11 and supported with qualitative research findings and add greater depth to the study of cues and cue responses (Nolan and Behi, 1995). Arborelius and Österberg (1995) found that, in medical consultations where the patient explicitly expressed a cue, the doctor invited its discussion by using open-ended questions and an open approach and facilitated further discussion through empathic responses acknowledging the patient’s emotions. Techniques for adequately following up cues and providing resolution included clarification or checking of information, facilitation of emotive discussions and checking for psychosocial or emotional issues not previously voiced. However, non-explicitly voiced cues resulted in a tendency for doctors to ask closed, leading or negative questions, therefore preventing further disclosure and discussion of emotion by patients. Similarly, Salmon and colleagues (2004) qualitatively analysed 36 doctor-patient interactions between GPs and patients presenting with medically
11
Triangulation refers to strategies employed during the research process to reduce the risk of findings being an artefact of a single method, research bias, participant perspective or overall theoretical approach
unexplained symptoms (MUS). They found that whilst opportunities for further exploration of cues or psychosocial elements of conversation were provided in all but two consultations by patients, of which half were indirect cues to emotional or social distress, doctors responded by either facilitating further discussion or with blocking behaviours. These included disregarding the cue, normalising it, reasserting a somatic agenda or emphasising the patient’s responsibility for the symptom. In general, doctors failed to address patients’ cues or psychological needs, reaffirming findings in previous research in the field (Levinson et al., 2000, Goldberg et al., 1993, Marvel et al., 1999, Del Piccolo et al., 2000, Gask et al., 1987, Bensing et al., 2008, Del Piccolo et al., 2002). These qualitative studies (Salmon et al., 2004, Arborelius and Österberg, 1995) further support the notion that doctors’ verbal behaviours can influence the effectiveness of the PPC within the consultation, and indicate the disparity in doctors’ responses to patients’ cues.
3.5.2 Why Do Doctors Often Ignore Cues?
It is unclear whether doctors frequently choose, consciously or unconsciously, to ignore emotive cues, or whether such cues are genuinely not identified, possibly because the emotion is not directly expressed (Suchman et al., 1997). Reasons for ignoring cues may be due to the increased level of distress they elicit in doctors than more informational cues (Butow et al., 2002, Zimmermann et al., 2007, Kim et al., 2004), because doctors lack ability or confidence to successfully acknowledge and respond to them (Levinson et al., 2000, Zimmermann et al., 2007) or because of their timing within the consultation. Doctors may also wish to prioritise medical complaints (Giron et al., 1998), perhaps due to worries that responding to emotion may increase consultation length, which is a valid concern in specialties such as General Practice (Levinson et al., 2000), where consultation time is limited to between seven and twenty minutes (Deveugele et al., 2002). However, it is important to note that adequate identification of, and responding to, patients’ cues can actually shorten rather than lengthen consultation length (Levinson et al., 2000). Additionally, identifying and responding to emotion requires the doctor and patient to engage in emotive discourse, which may be challenging for doctors who employ strategies to avoid discussing psychosocial factors (Maguire and Pitceathly, 2002). As emotive cues are less frequently responded to than informational cues, it is
important to consider the role of individual characteristics influencing doctors’ PPC, including their ability to identify and respond to cues. This has been highlighted as an important research avenue (Eide et al., 2004b, Salmon et al., 2004, Epstein et al., 2007, Street et al., 2009); further understanding of influencers of PPC may improve patient care relating to psychosocial or emotional issues and impact on undergraduate and postgraduate teaching of PPC.