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

Thus, physicians addressed psychological problems in a variety of ways—from a strictly biomedical model to a more holistic fashion. Physicians also demonstrated a wide range of skills—from very basic to quite advanced, and applied these skills differently with different patients in different situations. Although a given provider’s performance often varied among encounters, most physicians appeared to have a preferred practice philosophy and singular skill set that they regularly used during patient visits.

Discussion

As in previous studies,^10-15 we found that not all physicians appeared comfortable, trained, adept, or motivated to make sense of the emotional distress presented by patients. Parallel to the findings of Roter and colleages¹⁷ with regard to general communication patterns of primary care physicians, a typology of physician responses to emotional distress emerged from our data. The framework of encounters (recognition, triage, and management) and 4-quadrant physician typology that surfaced from this study helps clarify how physicians respond to emotional distress. Each of the approaches in this typology is likely to have pros and cons for meeting different patient needs for mental health and general medical care.

Understanding physicians’ predominant styles based on their philosophy and skill set can have 2 important uses. First, physicians can reflect and seek feedback on their own style. Patient needs that may be less well met by this style can then be identified and alternate ways of meeting these needs pursued. Second, clinicians and continuing medical education providers can use this typology to design educational approaches. This education should focus on expanding clinician flexibility and increasing insight into when to use what approach. The outcomes and tradeoffs in effectiveness, efficiency, and integration of care remain important areas for future research.²⁴

Given the constraints on time, personal energy, and apparent competition between chronic physical and mental health problems, physician behaviors can be viewed as an understandable adaptation to the realities of a busy family practice.^11-15-24-28 Although we have documented significant variation in counseling skills among family physicians, there is no data to suggest that expansion of these skills would necessarily improve patient outcomes.²⁹ The effect of a long-term relationship and its quality between patients and a family physician on patient mental health outcomes remains unexplored and is a fruitful area for further research. Also, it is important to recognize that physicians are not homogeneous in their personality, philosophy, and skills and that patients self-select the kind of physician that best fits their own personality and style. Different approaches are likely to be functional for diverse clinicians with varied patients and situations.²⁴

Limitations

Our study has important limitations, including its sampling, design, and lack of a reference standard for mental health conditions. This qualitative research, by its very nature, is not based on a random population sample and is therefore not generalizable in the traditional quantitative sense. Its generalizability lies in the resonance it generates among primary care physicians and patients who recognize these patterns from their own experiences. Also, the findings are consistent with our existing understanding of competing demands^9,28,30 and physician communication strategies.^17-19 To the extent to which midwestern physicians and patients do not reflect the ethnic and socioeconomic diversity of other parts of the country, these findings may also be limited. Future research should attempt to include diversity. Patients’ emotional distress may be communicated in other ways besides speech or may not be communicated at all, so the direct observation approach we used cannot always correctly infer patients’ unexpressed mental health needs or physicians’ assessment of the situation. Because the data were cross-sectional, it is not possible to determine what had occurred in previous visits in a longitudinal management strategy. Nevertheless, the richness of the field note data provided an excellent detailed view of a large sample of visits. Finally, the lack of a reference standard for diagnosing mental health conditions does not alter the main findings of this study—a typology of physicians’ responses to emotional distress within their practices.

In trying to understand and improve the treatment of mental health issues, many previous researchers have focused on improving physician knowledge and dissemination of guidelines; such efforts have been disappointing when used alone.^31,32 Other investigators have sought to improve the interviewing skills of physicians, and while modestly successful, these studies have been limited in scope, length of follow-up, and ability to be replicated widely.^18,19,33,34 Other approaches have included collaborative management and quality improvement efforts; while successful, such interventions may be difficult to replicate in the usual physician practice setting without substantial external resources.^35-38

Conclusions

The chasm between ideal care of mental health disorders and actual practice may be narrower than mental health professionals would have us believe, and it is certainly bridgeable. It is possible to have better outcomes for medical conditions, improved patient and provider satisfaction, and reduced costs of care.^39,40 By studying the exemplary physicians found in real world practices—as found in this study and others—we might better understand that combination of inclination, skill, and setting that promotes quality cost-effective care. We found that mental health care, while sporadically and diversely attended to in outpatient visits, is often integrated with care of the diverse medical, social, and family problems that constitute primary care. Irrespective of differences in philosophy, training, or interest, however, structural and economic issues still appear to severely limit the ability of even willing family physicians to practice coherent integrated primary care.41 It is therefore important for the field as a whole to provide feasible strategies for promoting recognition and treatment of mental health issues by diverse clinicians and patients in usual practice settings.