OBJECTIVE: We developed a typology of physicians’ responses to patients’ expressed mental health needs to better understand the gap between idealized practice and actual care for emotional distress and mental health problems.
STUDY DESIGN: We used a multimethod comparative case study design of 18 family practices that included detailed descriptive field notes from direct observation of 1637 outpatient visits. An immersion/crystallization approach was used to explore physicians’ responses to emotional distress and apparent mental health issues.
POPULATION: A total of 379 outpatient encounters were reviewed from a purposeful sample of 13 family physicians from the 57 clinicians observed.
OUTCOMES MEASURED: Descriptive field notes of outpatient visits were examined for emotional content and physicians’ responses to emotional distress.
RESULTS: Analyses revealed a 3-phase process by which physicians responded to emotional distress: recognition, triage, and management. The analyses also uncovered a 4-quadrant typology of management based on the physician’s philosophy (biomedical vs holistic) and skill level (basic vs more advanced).
CONCLUSIONS: Physicians appear to manage mental health issues by using 1 of 4 approaches based on their philosophy and core set of skills. Physician education and practice improvement should be tailored to build on physicians’ natural philosophical proclivity and psychosocial skills.
Primary care practices have been called America’s de facto mental health network, with more than two thirds of mental health disorders treated in the primary care sector.1 Up to 40% of primary care patients have a mental health problem,2 and 19% of outpatients report significant emotional distress during the previous 4 weeks.3 However, the detection and treatment rates of these problems are low.3-6
Thus, although the clinical philosophy of primary care professionals suggests that mental health care is an integral part of practice,7-9 there is an apparent discrepancy between these espoused ideals and usual clinical practice.3,5,10-11 Explanations of these findings include the reluctance of primary care physicians to label their patients and their use of observation and informal counseling as initial treatment efforts.11-13 The competing demands of practice, lack of resources, inadequate reimbursement, and various organizational factors such as mental health carve-outs also profoundly influence management.14-16 Using cluster analysis, Roter and colleagues17 found 5 distinct communication patterns between patients with ongoing medical problems and their physicians, ranging from narrowly biomedical to consumerist.17 Robinson and Roter18-19 found that patients are likely to respond to direct inquiry by physicians about psychosocial distress and that physicians often briefly counsel their patients in return. Callahan and coworkers3 demonstrated that recent emotional distress and mental health problems have an important impact on encounter activities (eg, more time on history taking and counseling). Despite these investigations, a robust model of physicians’ response to emotional distress remains incompletely characterized.
We sought to develop a typology of physicians’ reactions to and management of patients’ mental health problems and emotional distress. Our findings can help clinicians identify their own style and consider ways of meeting particular patient needs that may be better suited to an alternative approach.
Methods
Detailed descriptive field notes of outpatient visits were collected as part of a large multimethod comparative case study of 18 midwestern family practices. Trained field researchers spent 4 weeks or more in each practice and directly observed the practice environment and 30 outpatient visits with each clinician in the practice. While observing the outpatient visits, the field researcher took chronological notes of what was occurring during the encounters. These notes were later used to dictate detailed descriptions of each encounter. Although there were differences in the style of reporting among the observers, the quality of data was consistent. Details of the design and data collection can be found elsewhere in this issue.20
Two family physician researchers, 3 family therapists, and a medical anthropologist reviewed encounters from a purposeful sample of family physicians. Initially, encounters from 3 physicians representing diverse practice approaches (as assessed globally by a research nurse collecting the primary data) were reviewed. The goals were to understand the depth and detail of the data and to develop initial hypotheses, an organizational schema, and a crude overview of the presentation of and physician response to mental health issues. The management of mental health issues and emotional distress was then explored in a purposeful sample of physicians selected to maximize variation in sex, type, and location of practice; ethnicity; and age. By the nature of this qualitative study (without access to an independent gold standard for diagnosis of mental disorders), a broad definition of mental health problems was used, encompassing emotional distress and psychological problems. On the basis of the preliminary review of field note data, the research group identified that patients were presenting with emotional issues when they found a reported change in affect, a verbal report of an emotional issue, a somatic complaint often associated with emotional distress, or a follow-up visit for an expressed mental health issue (eg, refill of an antidepressant). This working definition was reached in the preliminary phase of the study, and through discussion a consensus was reached on the mental health aspects of each encounter.