Patients' experiences of seeking help for emotional concerns in primary care: doctor as drug, detective and collaborator

Background NICE guidelines for the management of emotional concerns in primary care emphasise the importance of communication and a trusting relationship, which is difficult to operationalise in practice. Current pressures in the NHS mean that it is important to understand care from a patient perspective. This study aimed to explore patients’ experiences of primary care consultations for emotional concerns and what patients valued when seeking care from their GP. Methods Eighteen adults with experience of consulting a GP for emotional concerns participated in 4 focus groups. Data were analysed thematically. Results (1) Doctor as Drug: Patients’ relationship with their GP was considered therapeutic with continuity particularly valued. (2) Doctor as Detective and Validator: Patients were often puzzled by their symptoms, not recognising their emotional concerns. GPs needed to play the role of detective by exploring not just symptoms, but the person and their life circumstances. GPs were crucial in helping patients understand and validate their emotional concerns. (3) Doctor as Collaborator: Patients prefer a collaborative partnership, but often need to relinquish involvement because they are too unwell, or take a more active role because they feel GPs are ill-equipped or under too much pressure to help. Patients valued: GPs booking their follow up appointments; acknowledgement of stressful life circumstances; not relying solely on medication. Conclusions Seeking help for emotional concerns is challenging due to stigma and unfamiliar symptoms. GPs can support disclosure and understanding of emotional concerns by fully exploring and validating patients’ concerns, taking into account patients’ life contexts. This process of exploration and validation forms the foundation of a curative, trusting GP-patient relationship. A trusting relationship, with an emphasis on empathy and understanding, can make patients more able to share involvement in their care with GPs. This process is cyclical, as patients feel that their GP is caring, interested, and treating them as a person, further strengthening their relationship. NICE guidance should acknowledge the importance of empathy and validation when building an effective GP-patient partnership, and the role this has in supporting patients’ involvement in their care

Barriers and facilitators to GP-patient communication about emotional concerns in UK primary care: a systematic review.

Background In the UK, general practitioners (GPs) are the most commonly used providers of care for emotional concerns. Objective To update and synthesize literature on barriers and facilitators to GP–patient communication about emotional concerns in UK primary care. Design Systematic review and qualitative synthesis. Method We conducted a systematic search on MEDLINE (OvidSP), PsycInfo and EMBASE, supplemented by citation chasing. Eligible papers focused on how GPs and adult patients in the UK communicated about emotional concerns. Results were synthesized using thematic analysis. Results Across 30 studies involving 342 GPs and 720 patients, four themes relating to barriers were: (i) emotional concerns are difficult to disclose; (ii) tension between understanding emotional concerns as a medical condition or arising from social stressors; (iii) unspoken assumptions about agency resulting in too little or too much involvement in decisions and (iv) providing limited care driven by little time. Three facilitative themes were: (v) a human connection improves identification of emotional concerns and is therapeutic; (vi) exploring, explaining and negotiating a shared understanding or guiding patients towards new understandings and (vii) upfront information provision and involvement manages expectations about recovery and improves engagement in treatment. Conclusion The findings suggest that treatment guidelines should acknowledge: the therapeutic value of a positive GP–patient relationship; that diagnosis is a two-way negotiated process rather than an activity strictly in the doctor’s domain of expertise; and the value of exploring and shaping new understandings about patients’ emotional concerns and their management

Non-verbal communication in meetings of psychiatrists and patients with schizophrenia

Objective Recent evidence found that patients with schizophrenia display non‐verbal behaviour designed to avoid social engagement during the opening moments of their meetings with psychiatrists. This study aimed to replicate, and build on, this finding, assessing the non‐verbal behaviour of patients and psychiatrists during meetings, exploring changes over time and its association with patients' symptoms and the quality of the therapeutic relationship. Method 40‐videotaped routine out‐patient consultations, involving patients with schizophrenia, were analysed. Non‐verbal behaviour of patients and psychiatrists was assessed during three fixed, 2‐min intervals using a modified Ethological Coding System for Interviews. Symptoms, satisfaction with communication and the quality of the therapeutic relationship were also measured. Results Over time, patients' non‐verbal behaviour remained stable, whilst psychiatrists' flight behaviour decreased. Patients formed two groups based on their non‐verbal profiles, one group (n = 25) displaying pro‐social behaviour, inviting interaction and a second (n = 15) displaying flight behaviour, avoiding interaction. Psychiatrists interacting with pro‐social patients displayed more pro‐social behaviours (P < 0.001). Patients' pro‐social profile was associated reduced symptom severity (P < 0.05), greater satisfaction with communication (P < 0.001) and positive therapeutic relationships (P < 0.05). Conclusion Patients' non‐verbal behaviour during routine psychiatric consultations remains unchanged, and is linked to both their psychiatrist's non‐verbal behaviour and the quality of the therapeutic relationship

Public health care resource allocation and the rule of rescue

In health care, a tension sometimes arises between the injunction to do as much good as possible with scarce resources and the injunction to rescue identifiable individuals in immediate peril, regardless of cost (the "Rule of Rescue". This tension can generate serious ethical and political difficulties for public policy makers faced with making explicit decisions about the public funding of controversial health technologies, such as costly new cancer drugs. In this paper we explore the appropriate role of the Rule of Rescue in public resource allocation decisions. We consider practical approaches to operationalising the Rule of Rescue from Australia and the UK before examining the relevance of individual moral imperatives to public policy making. We conclude that, whilst public policy makers in a humane society should facilitate exceptional departures from a cost effectiveness norm in clinical decisions about identified individuals, it is not so obvious that they should, as a matter of national public policy, except any one group of unidentified individuals within society from the rules of opportunity cost at the expense of all others

Linguistic Indicators of Severity and Progress in Online Text-based Therapy for Depression

Mental illnesses such as depression andanxiety are highly prevalent, and therapyis increasingly being offered online. Thisnew setting is a departure from face-to-face therapy, and offers both a challengeand an opportunity – it is not yet knownwhat features or approaches are likely tolead to successful outcomes in such a dif-ferent medium, but online text-based ther-apy provides large amounts of data for lin-guistic analysis. We present an initial in-vestigation into the application of compu-tational linguistic techniques, such as topicand sentiment modelling, to online ther-apy for depression and anxiety. We findthat important measures such as symptomseverity can be predicted with compara-ble accuracy to face-to-face data, usinggeneral features such as discussion topicand sentiment; however, measures of pa-tient progress are captured only by finer-grained lexical features, suggesting thataspects of style or dialogue structure mayalso be important

The relaxation of OH (v = 1) and OD (v = 1) by H2O and D2O at temperatures from 251 to 390 K

We report rate coefficients for the relaxation of OH(v = 1) and OD(v = 1) by H2O and D2O as a function of temperature between 251 and 390 K. All four rate coefficients exhibit a negative dependence on temperature. In Arrhenius form, the rate coefficients for relaxation (in units of 10–12 cm3 molecule–1 s–1) can be expressed as: for OH(v = 1) + H2O between 263 and 390 K: k = (2.4 ± 0.9) exp((460 ± 115)/T); for OH(v = 1) + D2O between 256 and 371 K: k = (0.49 ± 0.16) exp((610 ± 90)/T); for OD(v = 1) + H2O between 251 and 371 K: k = (0.92 ± 0.16) exp((485 ± 48)/T); for OD(v = 1) + D2O between 253 and 366 K: k = (2.57 ± 0.09) exp((342 ± 10)/T). Rate coefficients at (297 ± 1 K) are also reported for the relaxation of OH(v = 2) by D2O and the relaxation of OD(v = 2) by H2O and D2O. The results are discussed in terms of a mechanism involving the formation of hydrogen-bonded complexes in which intramolecular vibrational energy redistribution can occur at rates competitive with re-dissociation to the initial collision partners in their original vibrational states. New ab initio calculations on the H2O–HO system have been performed which, inter alia, yield vibrational frequencies for all four complexes: H2O–HO, D2O–HO, H2O–DO and D2O–DO. These data are then employed, adapting a formalism due to Troe (J. Troe, J. Chem. Phys., 1977, 66, 4758), in order to estimate the rates of intramolecular energy transfer from the OH (OD) vibration to other modes in the complexes in order to explain the measured relaxation rates—assuming that relaxation proceeds via the hydrogen-bonded complexes

Investigating Topic Modelling for Therapy Dialogue Analysis

Previous research shows that aspects of doctor-patient communication in therapy can predict patient symptoms, satisfaction and future adherence to treatment (a significant problem with conditions such as schizophrenia). However, automatic prediction has so far shown success only when based on low-level lexical features, and it is unclear how well these can generalise to new data, or whether their effectiveness is due to their capturing aspects of style, structure or content. Here, we examine the use of topic as a higher-level measure of content, more likely to generalise and to have more explanatory power. Investigations show that while topics predict some important factors such as patient satisfaction and ratings of therapy quality, they lack the full predictive power of lower-level features. For some factors, unsupervised methods produce models comparable to manual annotation.

Public health care resource allocation and the rule of rescue

In health care, a tension sometimes arises between the injunction to do as much good as possible with scarce resources and the injunction to rescue identifiable individuals in immediate peril, regardless of cost (the "Rule of Rescue". This tension can generate serious ethical and political difficulties for public policy makers faced with making explicit decisions about the public funding of controversial health technologies, such as costly new cancer drugs. In this paper we explore the appropriate role of the Rule of Rescue in public resource allocation decisions. We consider practical approaches to operationalising the Rule of Rescue from Australia and the UK before examining the relevance of individual moral imperatives to public policy making. We conclude that, whilst public policy makers in a humane society should facilitate exceptional departures from a cost effectiveness norm in clinical decisions about identified individuals, it is not so obvious that they should, as a matter of national public policy, except any one group of unidentified individuals within society from the rules of opportunity cost at the expense of all others