“Could this Be Something Serious?”

Abstract

Previous work suggests that exploration and validation of patients' concerns is associated with greater patient trust, lower health care costs, improved counseling, and more guideline-concordant care. To describe physicians' responses to patients' worries, how their responses varied according to clinical context (straightforward versus medically unexplained symptoms [MUS]) and associations between their responses and patients' ratings of interpersonal aspects of care. Multimethod study. For each physician, we surveyed 50 current patients and covertly audiorecorded 2 unannounced standardized patient (SP) visits. SPs expressed worry about "something serious" in 2 scenarios: straightforward gastroesophageal reflux or poorly characterized chest pain with MUS. One hundred primary care physicians and 4,746 patients. Patient surveys measuring interpersonal aspects of care (trust, physician knowledge of the patient, satisfaction, and patient activation). Qualitative coding of 189 transcripts followed by descriptive, multivariate, and lag-sequential analyses. Physicians offered a mean of 3.1 responses to each of 613 SP prompts. Biomedical inquiry and explanations, action, nonspecific acknowledgment, and reassurance were common, whereas empathy, expressions of uncertainty, and exploration of psychosocial factors and emotions were uncommon. Empathy expressed during SP visits was associated with higher patient ratings of interpersonal aspects of care. After adjusting for demographics and comorbidities, the association was only statistically significant for the MUS role. Empathy was most likely to occur if expressed at the beginning of the conversational sequence. Empathy is associated with higher patient ratings of interpersonal care, especially when expressed in situations involving ambiguity. Empathy should be expressed early after patient expressions of worry.