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Patients’ negative emotional cues and concerns in hospital consultations: A video-based observational study
Patient Education and Counseling 85 (2011) 356–362
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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Communication Study
Patients’ negative emotional cues and concerns in hospital consultations: A video-based observational study Trond Arne Mjaaland a,*, Arnstein Finset b, Ba˚rd Fossli Jensen a, Pa˚l Gulbrandsen a,c a
HØKH Research Centre, Akershus University Hospital, Lørenskog, Norway Department of Behavioural Science in Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway c Institute of Clinical Medicine, Campus Ahus, University of Oslo, Norway b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 January 2010 Received in revised form 17 December 2010 Accepted 31 December 2010
Objective: Little is known about the frequency and occurrence of patients’ negative emotional cues and concerns (NECC) across specialties in hospital departments. Methods: Ninety-six consultations were videotaped in a general hospital. The VR-CoDES (Verona Coding Definitions of Emotional Sequences) were used to code the patients’ NECC. Cohen’s kappa was used to establish reliability between coders. Results: Cohen’s kappa was above 0.60. NECC were observed in more than half of the consultations. The number of NECC in the consultations was 163, with 109 negative emotional cues and 54 concerns. The mean number of NECC in the consultations was 1.69, with a median of 1. The first NECC in consultations were stated after a median duration of 5 min 21 s. We could not find significant differences related to the gender and age of the patient or the physician, or the specialty of the physician. Conclusions: More than half of the concerns were not preceded by a negative emotional cue. Few consultations contained more than 3 NECC, and NECC tended to be expressed relatively early. Practice implications: Patients’ expressions of emotional issues are few, and most of them are subtle. Physicians should be thoroughly trained to identify and respond to them. ß 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords: Physician–patient relationship Communication Empathy Emotions Consultation Cues Concerns Hospital
1. Introduction In a number of medical consultations, patients express emotional concerns and subtle cues to such concerns. In the research literature, most attention has been given to negative cues and concerns, defined as expressions of an unpleasant current emotion, or a verbal or nonverbal hint that suggests an underlying unpleasant emotion [1,2], As opposed to positive emotions. In this paper, we therefore apply the term negative emotional cues and concerns (NECC), which is more precise than simply referring to cues and concerns. Studies have shown that the frequency of NECC expressed by patients ranges from less than one up to three NECC per consultation [3–11]. It is important for clinicians to identify and respond to NECC expressed in medical consultations for several reasons. Studies of physician–patient interaction show that NECC are correlated with
Abbreviations: NECC, negative emotional cues and concerns; ENT, ear, nose and throat; EACH, European Association for Communication in Health Care; VR-CoDES, Verona Coding Definitions of Emotional Sequences. * Corresponding author at: HØKH Research Centre, Mail drawer 95, Akershus University Hospital, N-1478 Lørenskog, Norway. Tel.: +47 2285 1019; fax: +47 2285 1300. E-mail address: [email protected] (T.A. Mjaaland). 0738-3991/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.12.031
patient distress, with higher levels of distress leading to higher numbers of negative emotional cues [12,13]. In patients with physical disease, prevalence rates of between 20% and 40% have been found for depression and anxiety [14,15]. Identification of emotional distress is important because depression is a major risk factor for noncompliance with medical treatment [16], and distressed patients report more dissatisfaction with their medical care [17]. Suppression of negative emotions by medical patients has been shown to have adverse effects, such as giving less information to doctors regarding relevant risk factors [18] and even lower survival rates among patients with coronary disease [19]. In experimental studies of emotion regulation, emotional suppression has been associated with an increased psychophysiological stress response [20]. Moreover, recent neuroimaging studies indicate that simple verbal labeling of emotions may serve to downregulate activation of the amygdala, a brain structure important for negative emotional activation [21]. Expression of negative emotional cues and concerns may therefore have important functions in the medical consultation, both by providing the doctor with information about psychological distress as a risk factor and by allowing the patient to verbalize— and thereby to regulate better—emotions. We have elsewhere proposed that expressions of concerns by patients and adequate
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provider responses may facilitate patients’ reappraisal of negative emotions and promote coping with illness [22], which is important in treatment plans for patients with chronic disease and in palliative cancer care, for instance [23,24]. Responding properly to a patient’s NECC prevents premature reassurance [25], which occurs when reassurance is given too early before a patient feels listened to and which shuts down the communication between provider and patient. Even when the focus is on reappraisal and coping, it seems important not to bypass concerns. For instance, in solution-focused therapy, the focus is on whatever is functioning well for the patient despite the illness, but only after having understood what is emotionally challenging for him or her [26]. In spite of the apparent importance of NECC in medical consultations, we know that health providers often fail to detect NECC when they appear in consultations [27–29]. Consequently, detection rates for psychological distress in consultations remain low, at around 50% in a number of studies [30–32]. Specific provider communication elements are important in order to elicit NECC statements. For instance, Eide et al. [33] found provider facilitative behavior, in particular brief moments of silence, to be associated with patients’ subsequent NECC. It has also been found that the probability of a patient emitting a cue is 10 times higher after an open question from the provider than after a closed one [34]. Most studies of NECC are from general practice and oncology. Little is known about their frequency and occurrence across specialties in a hospital setting. We therefore analyzed the occurrence of NECC in an existing data set from an intervention study about clinical communication in a 500-bed general teaching hospital in Norway [35]. The aim of the present paper is to investigate the frequency of NECC in a general hospital setting and to determine differences related to the specialties, gender, and age of physicians and patients. We also report reliability data for the method used to study NECC, the Verona Coding Definitions of Emotional Sequences (VR-CoDES). In another article [36], we report and discuss the concurrent physician responses to the NECC presented in this article. 2. Methods 2.1. Subjects The data set for the intervention study involved 71 physicians and 497 encounters from general surgery, orthopedics, ear nose and throat (ENT), internal medicine and subdisciplines, anesthesiology, neurology, pediatrics, and gynecology. The physicians were randomly drawn from the body of hospital physicians under 60 years of age. Videotapes were collected between April 2007 and June 2008. The researchers (B.F.J., P.G.) contacted the physician before planned data collection to secure the presence in an agreed time interval. Patients were included consecutively if they consented as described in a previous paper [37]. Encounters included outpatient contacts, bedside visits on rounds, and inpatient encounters as a part of diagnostic or therapeutic procedures. We drew four videos from the list of 25 physicians in the study, based on having at least two videotaped consultations available in the data set, one before and one after an intervention (not part of the current article), none of which were bedside or pediatric consultations. Bedside consultations were not included because other patients or health care personnel are often present and might affect the communication between physician and patient. Pediatric consultations were excluded because the VRCoDES were developed using adult patient interaction, and children might present emotional statements differently [38]. This gave us 100 consultations. The content of the selected consultations varies in terms of medical content and patient
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characteristics. However, the physician characteristics of age, gender, and position do not vary significantly from the nonselected consultations in the larger sample from the hospital. Six consultations were not suitable for the use of VR-CoDES and were replaced by other consultations that satisfied the inclusion criteria. Four of the replacement consultations were not suitable for the use of VR-CoDES, and no further consultations that met the inclusion criteria were available. The study thus comprised 96 consultations from the following specialties: internal medicine [27], surgery, orthopedics and ENT [46], and anesthesiology, neurology and gynecology [23]. 2.2. Interaction analysis We used VR-CoDES to code the patients’ NECC and the physicians’ responses. The patients’ NECC are reported in this paper. The Verona Network on Sequence Analysis has developed a coding scheme, VR-CoDES, to define and classify patients’ NECC and physicians’ concordant responses. The coding scheme has been under development since 2003 and in its present form is a descriptive, nonjudgmental system based on theories of emotion regulation and the theory and knowledge of sequence analysis [39]. This is the first application of the VR-CoDES to hospital consultations. The VR-CoDES manual can be obtained from the EACH (European Association for Communication in Healthcare) web site [39]. The section of the VR-CoDES covering patients’ NECC is described thoroughly in the manual, in particular definitions, expressions and examples of negative emotional cues and concerns. An overview of these is given in Table 1. A negative emotional cue in these terms is defined as a verbal or nonverbal hint to the health provider that suggests an underlying unpleasant emotion and that needs a clarification from the health provider to verify whether indeed this is the case. The power of definition obviously lies within the patient’s emotional experience, so a negative emotional cue in this sense can only be a hypothetical way for a negative emotion to be verified, if the health provider chooses to view it as such and acts accordingly during the course of the consultation. In other words, it is not expected that health providers would be able to detect cues without proper training. The situation for concerns might be slightly different because in the VR-CoDES scheme, a concern is defined as a clear verbalization of an unpleasant emotional state. This definition is very close to a commonsense definition and therefore easier to recognize. In the VR-CoDES manual, negative emotional cues are subdivided into seven categories labeled A, B, C, etc. (Table 1). The coding was performed at this level of detail, but the kappa calculations did not include negative emotional cue subcategories, because the important differentiation is between a concern and a negative emotional cue and not between different subtypes of negative emotional cues and concerns. Furthermore, the negative emotional cues that are detected remain a challenge to the calculation of reliability on a detailed level. This is also discussed in more detail in the manual [39] and by Zimmermann et al. [2]. 2.3. Units of analyses The VR-CoDES covers patients’ NECC and the corresponding physician responses; hence, the other content of consultations was not coded. We coded on turn-of-speech level [40], and the frequency of NECC is presented as NECC per consultation. Some coded examples of NECC from the consultations are displayed in Table 2.
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Table 1 Overview of emotionally negative cues and concerns from the VR-CoDES manual. Expression
Definition
Concern: clear verbalization of an unpleasant emotional state
Emotion is current or recent and issue of importance is not stated Issue of recent or current importance is stated (life event, social problems, symptoms and other issues that obviously to the observer is stressful or unpleasant)
Cue: expression in which the emotion is not clearly verbalized or might be present. The criteria of currency/recency is not applicable
A: Words or phrases in which the patient uses vague or unspecified words to describe his/her emotions B: Verbal hints to hidden possible concerns (emphasizing, unusual words, unusual description of symptoms, profanities, metaphors, ambiguous words, double negotiations, exclamations, expressions of uncertainties and of hope regarding stated problems) C: Words or phrases which emphasize (verbally or non-verbally) physiological or cognitive correlates (regarding sleep, appetite, physical energy, concentration, excitement or motor slowing down, sexual desire) of unpleasant emotional state D: Neutral words or phrases that mention issues of potential emotional importance which stand out from the narrative background and refer to stressful life events and conditions E: A patient elicited repetition of a previous neutral expression (repetition, re-verbalizations of a neutral expression within a same turn are not included) F: Non-verbal expression of emotion G: Clear expression of an unpleasant emotion, which occurred in the past (more than one month ago) or is without time frame
2.4. Reliability of the coding scheme Cohen’s kappa [41] was applied to test interrater reliability. An acceptable level was defined as above 0.60 (Table 3) [42]. Coders were trained and then practiced coding with corrective feedback until satisfactory reliability was obtained. The two coders engaged in this study participated in a 1-day training course on the theoretical and practical background of the VR-CoDES, provided by one of the authors (A.F.). The two coders and an experienced reference coder (T.M.) participated in a series of training sessions where individually coded consultations were recoded and disagreements in coding were resolved by consensus and corrective feedback from the manual. The two coders then performed four coding sessions comprising a total of 19 films, sitting in the same room and viewing the same films but coding independently. Each session was followed by a kappa calculation of the observations and corrective feedback regarding deviations from the manual by TM. The coders needed another four individual coding sessions, comprising another 14 films followed by corrective feedback to reach an acceptable kappa level. The NECC are coded by watching a video using a computer program linking the video content to a timeline. On the timeline, codes are entered into the program on a real-time basis. The Observer XT, version 6.4.1 was applied for coding [43]. When a coder observes behavior in concordance with the code book, the
coder enters a specific NECC code into the computer program. Other communication observed that is not an expression of NECC is coded as an absence of NECC and, regardless of it being one or many utterances, is coded as one absence of NECC. In other words, after and/or between NECC statements a code for the absence of NECC is entered into the computer program. Consequently, the observations consist of a series of codes starting when an NECC utterance is observed and ending with the code for the absence of NECC on the timeline of the respective consultation. It is important to note that because this is a simple seen/not seen observation of a given phenomenon, both the seen and the not seen observations should be included in the calculations. In consultations with no observed NECC, nothing was coded. 2.5. Validity of the coding scheme The VR-CoDES represent a novel approach to communication coding, and the number of published studies is limited. We have established the reliability of the observations, so we know that NECC are behaviors that different viewers agree can be observed. However, there are insufficient studies to support the validity of these observations, in the sense that they are actual representations of patients’ emotions or hints to emotions as defined by the VR-CoDES in the manual. However, in one article by Eide et al. [5], the
Table 2 Examples of emotionally negative cues and concerns from the consultations. Examples of emotionally negative cues
Examples of emotional concerns
Patient: I can absolutely not handle any stress at the moment, because, then. . . Patient: (regarding a venereal condition) . . . I haven’t done anything wrong! Patient: After that I’ll never do it again – I’ll rather die!
Patient: I get so angry at Patient: . . . but with all this I get a little anxious Patient: I do not get anxiety until I arrive, you know Physician: So you have anxiety? Patient: Yes, it is not pleasurable to be punctured Patient: I was a little nervous because of that, when I should arrive here today, that, oh, no, I hope they are here because I am very excited regarding the answer to it Patient: It did not make me any less anxious, you know, when I finally got pregnant, and then I think God! And also pain and then I started bleeding a little and then you start thinking to yourself, when you know a little about this, you get even more anxious Patient: . . . at the same time I am a little afraid to begin work again, because I do not want to have that (unlaudable) again! Patient: Well, well, but when you sit like half an hour at work and looks out in the air, it is a little unpleasant, you know, and then I get a little upset. . . I get nervous and upset by less!
Patient: Yea, but my wife is not doing well. She has osteoporosis
Patient: . . . the reason for me being a little shaken regarding the condition in my colon is that I some years ago had a polyp removed from sigmoideum Patient: It has become worse during the last years, so there is something strange there, I think, unfortunately Patient: What this might be due to, is not for anyone to tell. . . it creates a lot of thoughts, too. . .
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Table 3 Development of Cohen’s kappa to acceptable reliability. After the fourth coding sequence the coders reached a kappa above .6 on both emotionally negative cues and concerns. Consecutive order of kappa calculations
Number of films
Total number of NECC and absence codes
Number of coded absence of NECC
Number of coded negative emotional cues
Kappa for cues
Number of coded concerns
Kappa for concerns
1 2 3 4
4 3 4 3
82 36 44 24
41 18 22 12
19 8 4 9
.17 .04 .46 .82
9 3 15 3
.88 .64 .90 .63
Table 4 Incidence (%) of NECC across sub-categories in the material. Physicians were dichotomized according to the mean age of 40 years, and patients were dichotomized at the mean age of 60 years.
All Physician sex Female physician Male physician Physician age >40 years 40 years Medical specialty Internal medicine Surgical disciplines (general surgery, orthopedics and ENT) Other (anesthesiology, neurology and gynecology) Patient sex Female Male Patient age >60 years 60 years a b
All consultations in each sub-category
Consultations without NECC
Consultations with NECC
Consultations with negative emotional cues
Consultations with concerns
96(100%)
42 (44%)
54 (56%)
47 (49%)
29 (30%)
35 (37%) 61 (64%)
13 (37%) 29 (48%)
22 (63%) 32 (53%)
19 (54%) 28 (46%)
11 (31%) 18 (30%)
37 (39%) 59 (62%)
14 (38%) 28 (48%)
23 (66%) 31 (53%)
18 (49%) 29 (49%)
14 (38%) 15 (25%)
27 (28%) 46 (48%)
10 (37%) 24 (52%)
17 (63%) 22 (48%)
16 (59%) 16 (35%)a
7 (26%) 11 (24%)b
23 (24%)
8 (35%)
15 (65%)
15 (65%)
11(48%)
52 (54%) 44 (46%)
20 (39%) 22 (50%)
32 (62%) 22 (50%)
29 (56%) 18 (41%)
16 (31%) 13 (30%)
34 (35%) 62 (65%)
15 (44%) 27 (44%)
19 (56%) 35 (57%)
17 (50%) 30 (48%)
8 (24%) 21 (34%)
Significantly lower than internal medicine and other specialties (p < 0.05). Significantly lower than other specialties (p < 0.05).
authors found satisfactory validity in their study of consultations between nurses and chronic pain patients. They used the term ecological validity when the codes used were in accordance with real life phenomena as the patients reported them. To validate the VRCoDES, they asked the patients in coded films to view the films and to state to what degree the codes identified their negative emotional cues and/or concerns. This was performed using a critical incident technique framework. Patients verified all NECC (109 in 12 consultations) except for one. In addition, the patients identified six NECC that the researchers had not managed to identify. 2.6. Statistics Statistical calculations were performed using SPSS 16.0 [44]. The test of significance is the z test for comparison of proportions in two independent groups [45]. 3. Results The total number of NECC in the consultations was 163, with 109 negative emotional cues and 54 concerns. The ratio of negative emotional cues to concerns was thus 2:1. NECC were observed in 56% of the consultations (54 of the 96) (Table 4). There were NECC in at least half of the consultations in all subgroups except for surgical disciplines; however, differences were not significant. We found no significant differences in frequency related to the age or gender of the physicians or patients.
A total of 47 consultations contained at least one negative emotional cue, and 29 consultations contained at least one concern. The number of consultations containing cues was higher than the number of consultations containing concerns in all subgroups. While the total number of NECC was not significantly lower for surgical disciplines, it became significant when negative emotional cues and concerns were considered separately. This was because six of the surgical consultations contained concerns without negative emotional cues, while this applied to only one of the internal medicine consultations and none of the other consultations (Table 4). Of the 29 consultations that included at least one concern, the concern was the first NECC in 16 cases (55%), while the concern was preceded by 1–4 negative emotional cues in 13 cases (45%). There was a median of 13 s from the last negative emotional cue to the subsequent concern (range 1–863 s; in only two cases, the Table 5 N, mean, SD, median and range of NECC in all 96 consultations. Number of consultations = 96
Number of negative cues
Number of concerns
Number of negative cues and concerns
N Mean SD Median Range
109 1.14 1.97 0 0–15
54 56 1.19 0 0–8
163 1.70 2.78 1 0–19
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Table 6 Number of NECC per consultation in all 96 consultations. Number of negative cues and concerns per consultation
Number of consultations
Percent
0 1 2 3 4 5 6 15 19 Total
42 16 15 11 2 6 2 1 1 96
44 17 16 12 2 6 2 1 1 100
Table 7 Time span (min:s) from beginning to first NECC and between subsequent NECC in the 54 consultations containing NECC. Beginning to 1st NECC Number of consultations Mean SD Median Minimum Maximum
1st to 2nd NECC
2nd to 3rd NECC
3rd to 4th NECC
54
38
23
12
09:12 09:29 05:21 00:18 15:31
05:33 07:50 02:02 00:08 28:56
07:06 12:44 02:01 00:05 60:05
02:59 02:17 02:40 00:28 07:29
concern followed more than 45 s after the negative emotional cue). The patient expressed from 1 to 4 negative emotional cues after the last concern in 12 (41%) of the 29 consultations. The mean number of NECC in the consultations was 1.69, with a median of 1 and range 0–18. Among the consultations with at least one NECC, the mean number was 3.0, with a median of 2 (Table 5), while 12 consultations had more than three NECC (Table 6). The time span between the first NECC and the subsequent NECC is outlined in Table 7. The first NECC in the consultations was stated after a median duration of less than 6 min of the consultation, while the median time span between subsequent NECC was from 2 to 3 min. The time span range was from 5 s to over 60 min.
did not report cues, perhaps indicating that more cues are present in consultations with patients with severe conditions. However, even in threatening situations, NECC may not be stated. According to Floyd et al. [48], 17% of patients in a simulation in general practice stated that if they experienced chest pain, they would report only physical symptoms to the physician even when informed of the possibly fatal medical conditions associated with such pain. We would expect a large proportion of hospital consultations to include medical information of sufficient importance to raise emotional concerns. Our finding that almost one-half of the consultations did not contain NECC could lead to physician complacency and reduced attention to emotions. The absence of NECC in our study might indicate that not everyone likes to express emotions to their physician. Floyd et al. reports a wide spectrum of reasons for this [48]. In our study, both the proportion of consultations with NECC and the average frequency of NECC in each consultation correspond with the findings of Bylund and Makoul [46]. They measured the frequency of empathic opportunities in a general internal medicine clinic and found a mean of 2.49 per encounter. In the study, they define empathic opportunity ‘‘as patient statements that include an explicit (i.e., clear and direct) statement of emotions, progress or challenge by the patient.’’ The empathic opportunities were classified in terms of valence, and 22% were positive, 6% neutral and 72% negative. This figure of 1.8 negative opportunities (72% of 2.49) is close to our finding of 1.69 NECC. In our study, half of the consultations contained no NECC. The reason for this might be that specialist consultations have a narrow agenda for both patient and physician. Mutual expectations of a relatively limited scope for the consultation might give little room to raise other matters.
4.1. Discussion
4.1.1. The negative emotional cue to concern ratio As expected, patients expressed more negative emotional cues than concerns. One topic of interest is whether concerns follow a negative emotional cue in the consultation. In our sample, the concern was the first NECC in more than half of the cases where a concern was present. In surgical consultations, concerns were more frequent than cues. These findings are not in accordance with the common conception that emotions are expressed most often as subtle cues prior to the expression of an explicit emotion [4]. However, when a negative emotional cue preceded a concern, which was the case in 13 consultations, the concern tended to be expressed quite soon after the last negative emotional cue, with a median of 13 s, indicating that the concern was a direct follow-up of the negative emotional cue in those consultations.
In this study of 96 consultations in a general hospital, we found that NECC were present in just over 50% of the consultations, fairly equally distributed across consultation categories. There was a mean of 1.69 NECC per consultation. Only 12 consultations exhibited more than three NECC. The frequency of 56% corresponds well with the findings of Bylund and Makoul [46], who found empathic opportunities in 60% of the consultations they studied. A unique aspect of our study was the heterogeneity of the sample of physicians, covering most medical specialties. NECC were present in consultations in all specialties, indicating that expressions of emotion are a universal phenomenon in medical consultations. However, when counted separately, cues and concerns were significantly less frequent in consultations with surgeons than in those with internists and others. Levinson et al. [11] found clues in a larger proportion (53%) of surgery visits than we did. However, their definition of clues is not restricted to the expression of negative emotion and hence is wider than our definition of negative emotional cues. Butow et al. [47] reported that only 21% of patients in oncology consultations
4.1.2. The number of NECC per consultation and the time of occurrence The number of statements containing NECC in this study WAS 1.69 per consultation. The fact that a communicative element occurs rather infrequently in a consultation does not necessarily mean that the phenomenon is irrelevant in relation to the purpose of the consultation [49,50]. NECC tend to appear relatively early in the consultation. The median time for the first NECC statement to appear was 5 min and 21 s (range 00:18 to 51:31) into the consultation. The median duration of consultations was little more than 19 min (range 3:58 to 1:38:55), so over half of the first NECC appear in the first third of the consultation. It is important to elicit the patient’s perspective and explore his or her concerns early in the consultation [51], and hence an earlier occurrence of NECC would have been expected. There is consistency in the median time span between the first and second, second and third, and third and fourth NECC, each appearing on average about 2 min after the preceding one, although the range is wide. The large range in duration of
4. Discussion and conclusion
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encounters and the large variety of content in the consultations in our material partly account for the range in observations of NECC. If patients are willing to express emotions, they might more or less consciously perceive how early, how often, and how persistently they will need to convey the message, given the time available. Very few consultations contain more than three NECC. In fact, 78% of consultations with at least one NECC contain only 1–3 NECC. This may indicate that three NECC is the limit for patients to hint about, or state, emotions. After three NECC, they either succeed or give up conveying an emotional message. When combined with the findings that the second and third cues most often follow in a relatively quick sequence (and even more so when concerns follow cues), this finding supports the idea that a limited window of opportunity exists for the doctor to respond to cues and concerns. In the biopsychosocial model it is postulated a need for the health care provider to address a much wider scope than the biomedical one [52]. The actual content of the patients NECC easily add valuable practical, clinical contributions to the understanding and use of the biopsychosocial model. For instance, when negative emotions in cancer care are not addressed it can affect patient functioning as well as emotional well-being and may even negatively affect survival [53–55]. 4.1.3. Strengths and limitations The strength of this study is that it covers a representative sample of physicians from all but pediatric and psychiatric disciplines in a large Norwegian teaching hospital, with a fairly representative sample of patients [35]. The small total number of identified NECC in the sample made it difficult to calculate reliability on a detailed level and represents a limitation. The present study is one of the first empirical studies applying the recently developed coding system VR-CoDES. More studies are needed to confirm the validity and reliability of the system. As previously mentioned the validity of the VR-CoDES has been explored in a paper by Eide et al.; however, this used a different patient sample and had nurses rather than physicians as providers. Moreover, the way in which the VR-CoDES system determines the denominator of the kappa calculation could be a matter for further study. As the denominator rises, kappa also rises; hence, when using the VR-CoDES, kappa values will depend heavily on how those utterances that do not express negative emotional cues or concerns are counted. 4.2. Conclusion This study confirms previous findings that negative emotional cues and concerns are relatively rare phenomena in medical consultations. NECC were found 163 times in 96 consultations and occurred in slightly more than half of the consultations in this hospital consultation sample. Our analysis of the distribution of NECC throughout the consultation offered a few novel findings. More than half of the concerns were not preceded by a cue. Moreover, we found a sharp drop in the frequency of NECC after the third NECC (only 12 consultations contained more than 3 NECC). Finally, we found that NECC tended to be expressed relatively early in the consultation, with half of them expressed within the first 6 min, and the following NECC tended to occur relatively quickly, producing a crucial window of opportunity, sometimes referred to as a golden moment [56] or empathic opportunity [4], that doctors should not miss. 4.3. Practice implications Given that the recognition of NECC are important for good quality health care, and that we are able to measure them validly,
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measures should be taken to improve the communication skills of hospital physicians relevant for the handling of NECC. Competing interests None declared. Authors’ contributions Ba˚rd Fossli Jensen did the sourcing and video-recordings of the medical encounters. Trond Mjaaland, Arnstein Finset, Ba˚rd Fossli Jensen and Pa˚l Gulbrandsen have contributed equally in writing the article. Authors’ information Trond Mjaaland, PhD, is a post-doctoral research fellow at Akershus University Hospital, Arnstein Finset is professor in medical psychology at the University of Oslo, Pa˚l Gulbrandsen is senior researcher at Akershus University Hospital and associate professor at the University of Oslo, and Ba˚rd Fossli Jensen, MD, is a doctoral fellow. Ethics and privacy The Regional Committee for Medical Research Ethics of SouthEast Norway (S-07051c 2008/6205) and the Norwegian Social Science Data Services (16423/2007) approved the study. Acknowledgements The authors would like to thank Erik Holt for supreme technical support and the medical students Hanne Lise Eikeland and Knut Ørnes for coding assistance. The study was funded by the Regional Health Authorities for Southeast Norway; Grant # 2699010. References [1] Del Piccolo L, de Haes H, Heaven C, Jansen J, Verheul W, Bensing J, et al. Development of the Verona coding definitions of emotional sequences to code health providers’ responses (VR-CoDES-P) to patient cues and concerns. Patient Educ Couns )2010;(March 25). [2] Zimmermann C, Del Piccolo L, Bensing J, Bergvik S, de Haes H, Eide H, et al. Coding patient emotional cues and concerns in medical consultations: the Verona coding definitions of emotional sequences (VR-CoDES). Patient Educ Couns )2010;(April 27). [3] Zimmermann C, Del Piccolo L, Finset A. Cues and concerns by patients in medical consultations: a literature review. Psychol Bull 2007;133(May):438– 63. [4] Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. J Amer Med Assoc 1997;277(Febraury 26):678–82. [5] Eide H, Eide T, Rustøen T, Finset A. Patient’s validation of cues and concerns identified according to Verona-CoDES. A video and interview based approach, Patient Educ Couns 2011;(February): 156-62. [6] Cocksedge S, May C. The listening loop: a model of choice about cues within primary care consultations. Med Educ 2005;39(October):999–1005. [7] Brink-Muinen A, Caris-Verhallen W. Doctors’ responses to patients’ concerns: testing the use of sequential analysis. Epidemiol Psichiatr Soc 2003;12(April):92–7. [8] Epstein RM, Hadee T, Carroll J, Meldrum SC, Lardner J, Shields CG. ‘‘Could this be something serious?’’ Reassurance, uncertainty, and empathy in response to patients’ expressions of worry. J Gen Intern Med 2007;22(December):1731–9. [9] Morse DS, Edwardsen EA, Gordon HS. Missed opportunities for interval empathy in lung cancer communication. Arch Intern Med 2008;168(September 22):1853–8. [10] Repping-Wuts H, Repping T, van Riel P, van Achterberg T. Fatigue communication at the out-patient clinic of rheumatology. Patient Educ Couns 2009;76(July):57–62. [11] Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. J Amer Med Assoc 2000;284:1021–7. [12] Davenport S, Goldberg D, Millar T. How psychiatric disorders are missed during medical consultations. Lancet 1987;2(August 22):439–41.
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Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Communication Study
Patients’ negative emotional cues and concerns in hospital consultations: A video-based observational study Trond Arne Mjaaland a,*, Arnstein Finset b, Ba˚rd Fossli Jensen a, Pa˚l Gulbrandsen a,c a
HØKH Research Centre, Akershus University Hospital, Lørenskog, Norway Department of Behavioural Science in Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway c Institute of Clinical Medicine, Campus Ahus, University of Oslo, Norway b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 January 2010 Received in revised form 17 December 2010 Accepted 31 December 2010
Objective: Little is known about the frequency and occurrence of patients’ negative emotional cues and concerns (NECC) across specialties in hospital departments. Methods: Ninety-six consultations were videotaped in a general hospital. The VR-CoDES (Verona Coding Definitions of Emotional Sequences) were used to code the patients’ NECC. Cohen’s kappa was used to establish reliability between coders. Results: Cohen’s kappa was above 0.60. NECC were observed in more than half of the consultations. The number of NECC in the consultations was 163, with 109 negative emotional cues and 54 concerns. The mean number of NECC in the consultations was 1.69, with a median of 1. The first NECC in consultations were stated after a median duration of 5 min 21 s. We could not find significant differences related to the gender and age of the patient or the physician, or the specialty of the physician. Conclusions: More than half of the concerns were not preceded by a negative emotional cue. Few consultations contained more than 3 NECC, and NECC tended to be expressed relatively early. Practice implications: Patients’ expressions of emotional issues are few, and most of them are subtle. Physicians should be thoroughly trained to identify and respond to them. ß 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords: Physician–patient relationship Communication Empathy Emotions Consultation Cues Concerns Hospital
1. Introduction In a number of medical consultations, patients express emotional concerns and subtle cues to such concerns. In the research literature, most attention has been given to negative cues and concerns, defined as expressions of an unpleasant current emotion, or a verbal or nonverbal hint that suggests an underlying unpleasant emotion [1,2], As opposed to positive emotions. In this paper, we therefore apply the term negative emotional cues and concerns (NECC), which is more precise than simply referring to cues and concerns. Studies have shown that the frequency of NECC expressed by patients ranges from less than one up to three NECC per consultation [3–11]. It is important for clinicians to identify and respond to NECC expressed in medical consultations for several reasons. Studies of physician–patient interaction show that NECC are correlated with
Abbreviations: NECC, negative emotional cues and concerns; ENT, ear, nose and throat; EACH, European Association for Communication in Health Care; VR-CoDES, Verona Coding Definitions of Emotional Sequences. * Corresponding author at: HØKH Research Centre, Mail drawer 95, Akershus University Hospital, N-1478 Lørenskog, Norway. Tel.: +47 2285 1019; fax: +47 2285 1300. E-mail address: [email protected] (T.A. Mjaaland). 0738-3991/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.12.031
patient distress, with higher levels of distress leading to higher numbers of negative emotional cues [12,13]. In patients with physical disease, prevalence rates of between 20% and 40% have been found for depression and anxiety [14,15]. Identification of emotional distress is important because depression is a major risk factor for noncompliance with medical treatment [16], and distressed patients report more dissatisfaction with their medical care [17]. Suppression of negative emotions by medical patients has been shown to have adverse effects, such as giving less information to doctors regarding relevant risk factors [18] and even lower survival rates among patients with coronary disease [19]. In experimental studies of emotion regulation, emotional suppression has been associated with an increased psychophysiological stress response [20]. Moreover, recent neuroimaging studies indicate that simple verbal labeling of emotions may serve to downregulate activation of the amygdala, a brain structure important for negative emotional activation [21]. Expression of negative emotional cues and concerns may therefore have important functions in the medical consultation, both by providing the doctor with information about psychological distress as a risk factor and by allowing the patient to verbalize— and thereby to regulate better—emotions. We have elsewhere proposed that expressions of concerns by patients and adequate
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provider responses may facilitate patients’ reappraisal of negative emotions and promote coping with illness [22], which is important in treatment plans for patients with chronic disease and in palliative cancer care, for instance [23,24]. Responding properly to a patient’s NECC prevents premature reassurance [25], which occurs when reassurance is given too early before a patient feels listened to and which shuts down the communication between provider and patient. Even when the focus is on reappraisal and coping, it seems important not to bypass concerns. For instance, in solution-focused therapy, the focus is on whatever is functioning well for the patient despite the illness, but only after having understood what is emotionally challenging for him or her [26]. In spite of the apparent importance of NECC in medical consultations, we know that health providers often fail to detect NECC when they appear in consultations [27–29]. Consequently, detection rates for psychological distress in consultations remain low, at around 50% in a number of studies [30–32]. Specific provider communication elements are important in order to elicit NECC statements. For instance, Eide et al. [33] found provider facilitative behavior, in particular brief moments of silence, to be associated with patients’ subsequent NECC. It has also been found that the probability of a patient emitting a cue is 10 times higher after an open question from the provider than after a closed one [34]. Most studies of NECC are from general practice and oncology. Little is known about their frequency and occurrence across specialties in a hospital setting. We therefore analyzed the occurrence of NECC in an existing data set from an intervention study about clinical communication in a 500-bed general teaching hospital in Norway [35]. The aim of the present paper is to investigate the frequency of NECC in a general hospital setting and to determine differences related to the specialties, gender, and age of physicians and patients. We also report reliability data for the method used to study NECC, the Verona Coding Definitions of Emotional Sequences (VR-CoDES). In another article [36], we report and discuss the concurrent physician responses to the NECC presented in this article. 2. Methods 2.1. Subjects The data set for the intervention study involved 71 physicians and 497 encounters from general surgery, orthopedics, ear nose and throat (ENT), internal medicine and subdisciplines, anesthesiology, neurology, pediatrics, and gynecology. The physicians were randomly drawn from the body of hospital physicians under 60 years of age. Videotapes were collected between April 2007 and June 2008. The researchers (B.F.J., P.G.) contacted the physician before planned data collection to secure the presence in an agreed time interval. Patients were included consecutively if they consented as described in a previous paper [37]. Encounters included outpatient contacts, bedside visits on rounds, and inpatient encounters as a part of diagnostic or therapeutic procedures. We drew four videos from the list of 25 physicians in the study, based on having at least two videotaped consultations available in the data set, one before and one after an intervention (not part of the current article), none of which were bedside or pediatric consultations. Bedside consultations were not included because other patients or health care personnel are often present and might affect the communication between physician and patient. Pediatric consultations were excluded because the VRCoDES were developed using adult patient interaction, and children might present emotional statements differently [38]. This gave us 100 consultations. The content of the selected consultations varies in terms of medical content and patient
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characteristics. However, the physician characteristics of age, gender, and position do not vary significantly from the nonselected consultations in the larger sample from the hospital. Six consultations were not suitable for the use of VR-CoDES and were replaced by other consultations that satisfied the inclusion criteria. Four of the replacement consultations were not suitable for the use of VR-CoDES, and no further consultations that met the inclusion criteria were available. The study thus comprised 96 consultations from the following specialties: internal medicine [27], surgery, orthopedics and ENT [46], and anesthesiology, neurology and gynecology [23]. 2.2. Interaction analysis We used VR-CoDES to code the patients’ NECC and the physicians’ responses. The patients’ NECC are reported in this paper. The Verona Network on Sequence Analysis has developed a coding scheme, VR-CoDES, to define and classify patients’ NECC and physicians’ concordant responses. The coding scheme has been under development since 2003 and in its present form is a descriptive, nonjudgmental system based on theories of emotion regulation and the theory and knowledge of sequence analysis [39]. This is the first application of the VR-CoDES to hospital consultations. The VR-CoDES manual can be obtained from the EACH (European Association for Communication in Healthcare) web site [39]. The section of the VR-CoDES covering patients’ NECC is described thoroughly in the manual, in particular definitions, expressions and examples of negative emotional cues and concerns. An overview of these is given in Table 1. A negative emotional cue in these terms is defined as a verbal or nonverbal hint to the health provider that suggests an underlying unpleasant emotion and that needs a clarification from the health provider to verify whether indeed this is the case. The power of definition obviously lies within the patient’s emotional experience, so a negative emotional cue in this sense can only be a hypothetical way for a negative emotion to be verified, if the health provider chooses to view it as such and acts accordingly during the course of the consultation. In other words, it is not expected that health providers would be able to detect cues without proper training. The situation for concerns might be slightly different because in the VR-CoDES scheme, a concern is defined as a clear verbalization of an unpleasant emotional state. This definition is very close to a commonsense definition and therefore easier to recognize. In the VR-CoDES manual, negative emotional cues are subdivided into seven categories labeled A, B, C, etc. (Table 1). The coding was performed at this level of detail, but the kappa calculations did not include negative emotional cue subcategories, because the important differentiation is between a concern and a negative emotional cue and not between different subtypes of negative emotional cues and concerns. Furthermore, the negative emotional cues that are detected remain a challenge to the calculation of reliability on a detailed level. This is also discussed in more detail in the manual [39] and by Zimmermann et al. [2]. 2.3. Units of analyses The VR-CoDES covers patients’ NECC and the corresponding physician responses; hence, the other content of consultations was not coded. We coded on turn-of-speech level [40], and the frequency of NECC is presented as NECC per consultation. Some coded examples of NECC from the consultations are displayed in Table 2.
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Table 1 Overview of emotionally negative cues and concerns from the VR-CoDES manual. Expression
Definition
Concern: clear verbalization of an unpleasant emotional state
Emotion is current or recent and issue of importance is not stated Issue of recent or current importance is stated (life event, social problems, symptoms and other issues that obviously to the observer is stressful or unpleasant)
Cue: expression in which the emotion is not clearly verbalized or might be present. The criteria of currency/recency is not applicable
A: Words or phrases in which the patient uses vague or unspecified words to describe his/her emotions B: Verbal hints to hidden possible concerns (emphasizing, unusual words, unusual description of symptoms, profanities, metaphors, ambiguous words, double negotiations, exclamations, expressions of uncertainties and of hope regarding stated problems) C: Words or phrases which emphasize (verbally or non-verbally) physiological or cognitive correlates (regarding sleep, appetite, physical energy, concentration, excitement or motor slowing down, sexual desire) of unpleasant emotional state D: Neutral words or phrases that mention issues of potential emotional importance which stand out from the narrative background and refer to stressful life events and conditions E: A patient elicited repetition of a previous neutral expression (repetition, re-verbalizations of a neutral expression within a same turn are not included) F: Non-verbal expression of emotion G: Clear expression of an unpleasant emotion, which occurred in the past (more than one month ago) or is without time frame
2.4. Reliability of the coding scheme Cohen’s kappa [41] was applied to test interrater reliability. An acceptable level was defined as above 0.60 (Table 3) [42]. Coders were trained and then practiced coding with corrective feedback until satisfactory reliability was obtained. The two coders engaged in this study participated in a 1-day training course on the theoretical and practical background of the VR-CoDES, provided by one of the authors (A.F.). The two coders and an experienced reference coder (T.M.) participated in a series of training sessions where individually coded consultations were recoded and disagreements in coding were resolved by consensus and corrective feedback from the manual. The two coders then performed four coding sessions comprising a total of 19 films, sitting in the same room and viewing the same films but coding independently. Each session was followed by a kappa calculation of the observations and corrective feedback regarding deviations from the manual by TM. The coders needed another four individual coding sessions, comprising another 14 films followed by corrective feedback to reach an acceptable kappa level. The NECC are coded by watching a video using a computer program linking the video content to a timeline. On the timeline, codes are entered into the program on a real-time basis. The Observer XT, version 6.4.1 was applied for coding [43]. When a coder observes behavior in concordance with the code book, the
coder enters a specific NECC code into the computer program. Other communication observed that is not an expression of NECC is coded as an absence of NECC and, regardless of it being one or many utterances, is coded as one absence of NECC. In other words, after and/or between NECC statements a code for the absence of NECC is entered into the computer program. Consequently, the observations consist of a series of codes starting when an NECC utterance is observed and ending with the code for the absence of NECC on the timeline of the respective consultation. It is important to note that because this is a simple seen/not seen observation of a given phenomenon, both the seen and the not seen observations should be included in the calculations. In consultations with no observed NECC, nothing was coded. 2.5. Validity of the coding scheme The VR-CoDES represent a novel approach to communication coding, and the number of published studies is limited. We have established the reliability of the observations, so we know that NECC are behaviors that different viewers agree can be observed. However, there are insufficient studies to support the validity of these observations, in the sense that they are actual representations of patients’ emotions or hints to emotions as defined by the VR-CoDES in the manual. However, in one article by Eide et al. [5], the
Table 2 Examples of emotionally negative cues and concerns from the consultations. Examples of emotionally negative cues
Examples of emotional concerns
Patient: I can absolutely not handle any stress at the moment, because, then. . . Patient: (regarding a venereal condition) . . . I haven’t done anything wrong! Patient: After that I’ll never do it again – I’ll rather die!
Patient: I get so angry at Patient: . . . but with all this I get a little anxious Patient: I do not get anxiety until I arrive, you know Physician: So you have anxiety? Patient: Yes, it is not pleasurable to be punctured Patient: I was a little nervous because of that, when I should arrive here today, that, oh, no, I hope they are here because I am very excited regarding the answer to it Patient: It did not make me any less anxious, you know, when I finally got pregnant, and then I think God! And also pain and then I started bleeding a little and then you start thinking to yourself, when you know a little about this, you get even more anxious Patient: . . . at the same time I am a little afraid to begin work again, because I do not want to have that (unlaudable) again! Patient: Well, well, but when you sit like half an hour at work and looks out in the air, it is a little unpleasant, you know, and then I get a little upset. . . I get nervous and upset by less!
Patient: Yea, but my wife is not doing well. She has osteoporosis
Patient: . . . the reason for me being a little shaken regarding the condition in my colon is that I some years ago had a polyp removed from sigmoideum Patient: It has become worse during the last years, so there is something strange there, I think, unfortunately Patient: What this might be due to, is not for anyone to tell. . . it creates a lot of thoughts, too. . .
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Table 3 Development of Cohen’s kappa to acceptable reliability. After the fourth coding sequence the coders reached a kappa above .6 on both emotionally negative cues and concerns. Consecutive order of kappa calculations
Number of films
Total number of NECC and absence codes
Number of coded absence of NECC
Number of coded negative emotional cues
Kappa for cues
Number of coded concerns
Kappa for concerns
1 2 3 4
4 3 4 3
82 36 44 24
41 18 22 12
19 8 4 9
.17 .04 .46 .82
9 3 15 3
.88 .64 .90 .63
Table 4 Incidence (%) of NECC across sub-categories in the material. Physicians were dichotomized according to the mean age of 40 years, and patients were dichotomized at the mean age of 60 years.
All Physician sex Female physician Male physician Physician age >40 years 40 years Medical specialty Internal medicine Surgical disciplines (general surgery, orthopedics and ENT) Other (anesthesiology, neurology and gynecology) Patient sex Female Male Patient age >60 years 60 years a b
All consultations in each sub-category
Consultations without NECC
Consultations with NECC
Consultations with negative emotional cues
Consultations with concerns
96(100%)
42 (44%)
54 (56%)
47 (49%)
29 (30%)
35 (37%) 61 (64%)
13 (37%) 29 (48%)
22 (63%) 32 (53%)
19 (54%) 28 (46%)
11 (31%) 18 (30%)
37 (39%) 59 (62%)
14 (38%) 28 (48%)
23 (66%) 31 (53%)
18 (49%) 29 (49%)
14 (38%) 15 (25%)
27 (28%) 46 (48%)
10 (37%) 24 (52%)
17 (63%) 22 (48%)
16 (59%) 16 (35%)a
7 (26%) 11 (24%)b
23 (24%)
8 (35%)
15 (65%)
15 (65%)
11(48%)
52 (54%) 44 (46%)
20 (39%) 22 (50%)
32 (62%) 22 (50%)
29 (56%) 18 (41%)
16 (31%) 13 (30%)
34 (35%) 62 (65%)
15 (44%) 27 (44%)
19 (56%) 35 (57%)
17 (50%) 30 (48%)
8 (24%) 21 (34%)
Significantly lower than internal medicine and other specialties (p < 0.05). Significantly lower than other specialties (p < 0.05).
authors found satisfactory validity in their study of consultations between nurses and chronic pain patients. They used the term ecological validity when the codes used were in accordance with real life phenomena as the patients reported them. To validate the VRCoDES, they asked the patients in coded films to view the films and to state to what degree the codes identified their negative emotional cues and/or concerns. This was performed using a critical incident technique framework. Patients verified all NECC (109 in 12 consultations) except for one. In addition, the patients identified six NECC that the researchers had not managed to identify. 2.6. Statistics Statistical calculations were performed using SPSS 16.0 [44]. The test of significance is the z test for comparison of proportions in two independent groups [45]. 3. Results The total number of NECC in the consultations was 163, with 109 negative emotional cues and 54 concerns. The ratio of negative emotional cues to concerns was thus 2:1. NECC were observed in 56% of the consultations (54 of the 96) (Table 4). There were NECC in at least half of the consultations in all subgroups except for surgical disciplines; however, differences were not significant. We found no significant differences in frequency related to the age or gender of the physicians or patients.
A total of 47 consultations contained at least one negative emotional cue, and 29 consultations contained at least one concern. The number of consultations containing cues was higher than the number of consultations containing concerns in all subgroups. While the total number of NECC was not significantly lower for surgical disciplines, it became significant when negative emotional cues and concerns were considered separately. This was because six of the surgical consultations contained concerns without negative emotional cues, while this applied to only one of the internal medicine consultations and none of the other consultations (Table 4). Of the 29 consultations that included at least one concern, the concern was the first NECC in 16 cases (55%), while the concern was preceded by 1–4 negative emotional cues in 13 cases (45%). There was a median of 13 s from the last negative emotional cue to the subsequent concern (range 1–863 s; in only two cases, the Table 5 N, mean, SD, median and range of NECC in all 96 consultations. Number of consultations = 96
Number of negative cues
Number of concerns
Number of negative cues and concerns
N Mean SD Median Range
109 1.14 1.97 0 0–15
54 56 1.19 0 0–8
163 1.70 2.78 1 0–19
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Table 6 Number of NECC per consultation in all 96 consultations. Number of negative cues and concerns per consultation
Number of consultations
Percent
0 1 2 3 4 5 6 15 19 Total
42 16 15 11 2 6 2 1 1 96
44 17 16 12 2 6 2 1 1 100
Table 7 Time span (min:s) from beginning to first NECC and between subsequent NECC in the 54 consultations containing NECC. Beginning to 1st NECC Number of consultations Mean SD Median Minimum Maximum
1st to 2nd NECC
2nd to 3rd NECC
3rd to 4th NECC
54
38
23
12
09:12 09:29 05:21 00:18 15:31
05:33 07:50 02:02 00:08 28:56
07:06 12:44 02:01 00:05 60:05
02:59 02:17 02:40 00:28 07:29
concern followed more than 45 s after the negative emotional cue). The patient expressed from 1 to 4 negative emotional cues after the last concern in 12 (41%) of the 29 consultations. The mean number of NECC in the consultations was 1.69, with a median of 1 and range 0–18. Among the consultations with at least one NECC, the mean number was 3.0, with a median of 2 (Table 5), while 12 consultations had more than three NECC (Table 6). The time span between the first NECC and the subsequent NECC is outlined in Table 7. The first NECC in the consultations was stated after a median duration of less than 6 min of the consultation, while the median time span between subsequent NECC was from 2 to 3 min. The time span range was from 5 s to over 60 min.
did not report cues, perhaps indicating that more cues are present in consultations with patients with severe conditions. However, even in threatening situations, NECC may not be stated. According to Floyd et al. [48], 17% of patients in a simulation in general practice stated that if they experienced chest pain, they would report only physical symptoms to the physician even when informed of the possibly fatal medical conditions associated with such pain. We would expect a large proportion of hospital consultations to include medical information of sufficient importance to raise emotional concerns. Our finding that almost one-half of the consultations did not contain NECC could lead to physician complacency and reduced attention to emotions. The absence of NECC in our study might indicate that not everyone likes to express emotions to their physician. Floyd et al. reports a wide spectrum of reasons for this [48]. In our study, both the proportion of consultations with NECC and the average frequency of NECC in each consultation correspond with the findings of Bylund and Makoul [46]. They measured the frequency of empathic opportunities in a general internal medicine clinic and found a mean of 2.49 per encounter. In the study, they define empathic opportunity ‘‘as patient statements that include an explicit (i.e., clear and direct) statement of emotions, progress or challenge by the patient.’’ The empathic opportunities were classified in terms of valence, and 22% were positive, 6% neutral and 72% negative. This figure of 1.8 negative opportunities (72% of 2.49) is close to our finding of 1.69 NECC. In our study, half of the consultations contained no NECC. The reason for this might be that specialist consultations have a narrow agenda for both patient and physician. Mutual expectations of a relatively limited scope for the consultation might give little room to raise other matters.
4.1. Discussion
4.1.1. The negative emotional cue to concern ratio As expected, patients expressed more negative emotional cues than concerns. One topic of interest is whether concerns follow a negative emotional cue in the consultation. In our sample, the concern was the first NECC in more than half of the cases where a concern was present. In surgical consultations, concerns were more frequent than cues. These findings are not in accordance with the common conception that emotions are expressed most often as subtle cues prior to the expression of an explicit emotion [4]. However, when a negative emotional cue preceded a concern, which was the case in 13 consultations, the concern tended to be expressed quite soon after the last negative emotional cue, with a median of 13 s, indicating that the concern was a direct follow-up of the negative emotional cue in those consultations.
In this study of 96 consultations in a general hospital, we found that NECC were present in just over 50% of the consultations, fairly equally distributed across consultation categories. There was a mean of 1.69 NECC per consultation. Only 12 consultations exhibited more than three NECC. The frequency of 56% corresponds well with the findings of Bylund and Makoul [46], who found empathic opportunities in 60% of the consultations they studied. A unique aspect of our study was the heterogeneity of the sample of physicians, covering most medical specialties. NECC were present in consultations in all specialties, indicating that expressions of emotion are a universal phenomenon in medical consultations. However, when counted separately, cues and concerns were significantly less frequent in consultations with surgeons than in those with internists and others. Levinson et al. [11] found clues in a larger proportion (53%) of surgery visits than we did. However, their definition of clues is not restricted to the expression of negative emotion and hence is wider than our definition of negative emotional cues. Butow et al. [47] reported that only 21% of patients in oncology consultations
4.1.2. The number of NECC per consultation and the time of occurrence The number of statements containing NECC in this study WAS 1.69 per consultation. The fact that a communicative element occurs rather infrequently in a consultation does not necessarily mean that the phenomenon is irrelevant in relation to the purpose of the consultation [49,50]. NECC tend to appear relatively early in the consultation. The median time for the first NECC statement to appear was 5 min and 21 s (range 00:18 to 51:31) into the consultation. The median duration of consultations was little more than 19 min (range 3:58 to 1:38:55), so over half of the first NECC appear in the first third of the consultation. It is important to elicit the patient’s perspective and explore his or her concerns early in the consultation [51], and hence an earlier occurrence of NECC would have been expected. There is consistency in the median time span between the first and second, second and third, and third and fourth NECC, each appearing on average about 2 min after the preceding one, although the range is wide. The large range in duration of
4. Discussion and conclusion
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encounters and the large variety of content in the consultations in our material partly account for the range in observations of NECC. If patients are willing to express emotions, they might more or less consciously perceive how early, how often, and how persistently they will need to convey the message, given the time available. Very few consultations contain more than three NECC. In fact, 78% of consultations with at least one NECC contain only 1–3 NECC. This may indicate that three NECC is the limit for patients to hint about, or state, emotions. After three NECC, they either succeed or give up conveying an emotional message. When combined with the findings that the second and third cues most often follow in a relatively quick sequence (and even more so when concerns follow cues), this finding supports the idea that a limited window of opportunity exists for the doctor to respond to cues and concerns. In the biopsychosocial model it is postulated a need for the health care provider to address a much wider scope than the biomedical one [52]. The actual content of the patients NECC easily add valuable practical, clinical contributions to the understanding and use of the biopsychosocial model. For instance, when negative emotions in cancer care are not addressed it can affect patient functioning as well as emotional well-being and may even negatively affect survival [53–55]. 4.1.3. Strengths and limitations The strength of this study is that it covers a representative sample of physicians from all but pediatric and psychiatric disciplines in a large Norwegian teaching hospital, with a fairly representative sample of patients [35]. The small total number of identified NECC in the sample made it difficult to calculate reliability on a detailed level and represents a limitation. The present study is one of the first empirical studies applying the recently developed coding system VR-CoDES. More studies are needed to confirm the validity and reliability of the system. As previously mentioned the validity of the VR-CoDES has been explored in a paper by Eide et al.; however, this used a different patient sample and had nurses rather than physicians as providers. Moreover, the way in which the VR-CoDES system determines the denominator of the kappa calculation could be a matter for further study. As the denominator rises, kappa also rises; hence, when using the VR-CoDES, kappa values will depend heavily on how those utterances that do not express negative emotional cues or concerns are counted. 4.2. Conclusion This study confirms previous findings that negative emotional cues and concerns are relatively rare phenomena in medical consultations. NECC were found 163 times in 96 consultations and occurred in slightly more than half of the consultations in this hospital consultation sample. Our analysis of the distribution of NECC throughout the consultation offered a few novel findings. More than half of the concerns were not preceded by a cue. Moreover, we found a sharp drop in the frequency of NECC after the third NECC (only 12 consultations contained more than 3 NECC). Finally, we found that NECC tended to be expressed relatively early in the consultation, with half of them expressed within the first 6 min, and the following NECC tended to occur relatively quickly, producing a crucial window of opportunity, sometimes referred to as a golden moment [56] or empathic opportunity [4], that doctors should not miss. 4.3. Practice implications Given that the recognition of NECC are important for good quality health care, and that we are able to measure them validly,
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measures should be taken to improve the communication skills of hospital physicians relevant for the handling of NECC. Competing interests None declared. Authors’ contributions Ba˚rd Fossli Jensen did the sourcing and video-recordings of the medical encounters. Trond Mjaaland, Arnstein Finset, Ba˚rd Fossli Jensen and Pa˚l Gulbrandsen have contributed equally in writing the article. Authors’ information Trond Mjaaland, PhD, is a post-doctoral research fellow at Akershus University Hospital, Arnstein Finset is professor in medical psychology at the University of Oslo, Pa˚l Gulbrandsen is senior researcher at Akershus University Hospital and associate professor at the University of Oslo, and Ba˚rd Fossli Jensen, MD, is a doctoral fellow. Ethics and privacy The Regional Committee for Medical Research Ethics of SouthEast Norway (S-07051c 2008/6205) and the Norwegian Social Science Data Services (16423/2007) approved the study. Acknowledgements The authors would like to thank Erik Holt for supreme technical support and the medical students Hanne Lise Eikeland and Knut Ørnes for coding assistance. The study was funded by the Regional Health Authorities for Southeast Norway; Grant # 2699010. References [1] Del Piccolo L, de Haes H, Heaven C, Jansen J, Verheul W, Bensing J, et al. Development of the Verona coding definitions of emotional sequences to code health providers’ responses (VR-CoDES-P) to patient cues and concerns. Patient Educ Couns )2010;(March 25). [2] Zimmermann C, Del Piccolo L, Bensing J, Bergvik S, de Haes H, Eide H, et al. Coding patient emotional cues and concerns in medical consultations: the Verona coding definitions of emotional sequences (VR-CoDES). Patient Educ Couns )2010;(April 27). [3] Zimmermann C, Del Piccolo L, Finset A. Cues and concerns by patients in medical consultations: a literature review. Psychol Bull 2007;133(May):438– 63. [4] Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. J Amer Med Assoc 1997;277(Febraury 26):678–82. [5] Eide H, Eide T, Rustøen T, Finset A. Patient’s validation of cues and concerns identified according to Verona-CoDES. A video and interview based approach, Patient Educ Couns 2011;(February): 156-62. [6] Cocksedge S, May C. The listening loop: a model of choice about cues within primary care consultations. Med Educ 2005;39(October):999–1005. [7] Brink-Muinen A, Caris-Verhallen W. Doctors’ responses to patients’ concerns: testing the use of sequential analysis. Epidemiol Psichiatr Soc 2003;12(April):92–7. [8] Epstein RM, Hadee T, Carroll J, Meldrum SC, Lardner J, Shields CG. ‘‘Could this be something serious?’’ Reassurance, uncertainty, and empathy in response to patients’ expressions of worry. J Gen Intern Med 2007;22(December):1731–9. [9] Morse DS, Edwardsen EA, Gordon HS. Missed opportunities for interval empathy in lung cancer communication. Arch Intern Med 2008;168(September 22):1853–8. [10] Repping-Wuts H, Repping T, van Riel P, van Achterberg T. Fatigue communication at the out-patient clinic of rheumatology. Patient Educ Couns 2009;76(July):57–62. [11] Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. J Amer Med Assoc 2000;284:1021–7. [12] Davenport S, Goldberg D, Millar T. How psychiatric disorders are missed during medical consultations. Lancet 1987;2(August 22):439–41.
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