Technician, Friend, Detective, and Healer: Family Physicians’ Responses to Emotional Distress

Physicians were our unit of analysis, and the authors reviewed every outpatient visit available from each of the 13 physicians selected from the larger sample. The research team members used an editing organizing style for analysis,²¹ individually highlighted text they believed to be relevant, and made interpretive notes or observations in the margins.²² The research team then engaged in detailed discussions of the encounter transcripts. Particular attention was given to the total context of the encounter, recognizing other potential competing demands within the visit. The goal of this lengthy process was to reach consensus about what was important and how it should be interpreted. After discussing every encounter of a given physician, a summary case narrative was prepared and consensus reached about key themes for that physician.

After completing this initial review, matrices (eg, variations in patient management by practice location, physician age, and sex) were constructed to visualize other emergent patterns and facilitate comparisons across cases.²³ Additional physicians were reviewed to search for confirming and disconfirming evidence (eg, did management vary by physician ethnicity?) until saturation was reached (ie, until no further novel information or themes were identified). This required the review of outpatient visits from 13 physicians. One of the primary research nurses who conducted the participant observation provided input that ensured a full diversity of physicians was considered. She also served as an additional check on interpretation of the primary data. Finally, overall theses common to all physicians were identified and important variations in management noted. Thus, we began by looking at individual physicians’ responses within each encounter, developed a coherent description of each physician’s modus operandi, and then identified overarching themes describing broad approaches to emotional distress and mental health issues.

Results

The 379 patient visits to 13 physicians represented a diverse sample of practice and encounter types (Table 1, Table 2). Although the chief complaints of many patients did not overtly appear to relate to a mental health condition or emotional distress, many patients’ emotional concerns presented within the context of an acute or chronic medical condition. All physicians had many encounters in which both overt and more covert emotional concerns and mental health issues emerged.

Physician Responses Within Encounters

The research team noted a wide range of physician reactions to patients presenting with emotional distress or potential mental health problems. During the physician-patient interaction, physicians apparently either recognized the emotional component of the encounter or did not. If emotional distress was recognized, physicians appeared to either actively ignore this problem, gloss over or triage it, or actively manage the distress. These phenomena are illustrated in Figure 1 and will be described in more detail.

Recognition
Not all emotional and mental health issues were apparently recognized. Such missed opportunities were identified with all the participant physicians, even among physicians who were consistently more attentive to addressing mental health problems. For example, during a follow-up visit with a middle-aged man with abdominal tenderness a computed tomography scan had disclosed a renal mass. The patient’s wife asked numerous questions about possible depression and anxiety in her alcohol-using husband. The physician did not pursue any of these concerns.

However, a minority of physicians actively asked about mental health problems. This “active case finding” often capitalized on the physician’s previous knowledge of the patient’s social situation or personal issues. In one encounter focusing on breast cancer follow-up, the physician asked a woman how she was interacting with her spouse after a mastectomy. In instances such as this, active case finding was part of the chatting that opened or ended an encounter, particularly among physician and patients who were familiar with each other. Physicians in this sample neither used screening instruments (eg, the Primary Care Evaluation of Mental Disorders or the Zung mental health scales) nor routinely inquired about suicidal ideation, even in their seemingly most severely depressed patients.

Gloss-Over/Triage
In some instances, the physician apparently understood the impact of a situation but seemed to gloss over the issues. During a health care maintenance visit, a woman reported that she had a miscarriage 3 months earlier. The physician asked, “Is this a good thing or a sad thing?” The patient stated that it was a sad thing, because they were looking forward to the birth. There was no further probing into how the patient and family were dealing with the miscarriage.

In other encounters, physicians clearly seemed to recognize the psychologic implications of an encounter but chose to postpone management. These physicians appeared to triage certain cases based on time, competing demands, or perhaps their own ability to weather another challenging patient. For example, in the case of a patient with arm pain seeking workers’ compensation, the patient noted, “the pain (after doing some minor chores) was simply not worth it.” The physician did not pursue this cue further, but rather concentrated on the scheduling of magnetic resonance imaging, an electromyogram, and a follow-up appointment. However, the physician later related to the nurse researcher her understanding of the impact of this problem and acknowledged the patient’s discomfort. Thus, this physician apparently “triaged” this issue to a later date.