Management
Although only a minority of physicians actively sought cases of emotional distress in these encounters, most actively managed mental health problems. Prompted by the patient’s presentation, physicians followed up on “leads” to potential mental health issues, including: a mother who discussed the death of her daughter, a woman with menstrual irregularity, and marital and financial stress. Such encounters demonstrated physicians being sensitive to the underlying psychosocial issues in their patients’ lives.
The management response appeared to be predicated on the physician’s philosophy (biomedical vs holistic) and skill level (basic vs more advanced). In some instances, physicians appeared to spend considerable time on mental health issues with patients but apparently ran out of tools to deal with their problems effectively. This situation was most evident with patients who were substance abusers, who had chronic pain, those seeking workers’ compensation, and individuals with vague or multiple somatic symptoms.
A 4-Quadrant Typology of Physicians
A 4-quadrant typology of physicians emerged based on their philosophy and skill, as ascertained from the patient encounters Figure 2. Philosophically, physicians were on a continuum of being biomedically to biopsychosocially inclined, with each exhibiting a discernable dominant philosophy. Biomedically oriented physicians concentrated on the medical aspects of care and minimally explored the psychosocial milieu of the patient. Biopsychosocially oriented physicians addressed the patients’ emotional, physical, social, and sometimes spiritual wellbeing. Regardless of management approach (biomedical vs biopsychosocial), physicians demonstrated varying levels of competence in dealing with emotional distress.
Most physicians used “basic” skills—empathy, encouragement, small talk, use of silence, direct advice giving, and superficial education—to address their patients’ mental health problems. In some encounters the use of simple strategies was seemingly appropriate and effective; only occasionally were more advanced skills used. Such advanced skills ranged from effectively setting an agenda and soliciting the patient’s perspective to the use of more challenging interviewing skills, such as confrontation, implementing behavioral prescriptions, navigating referrals for skeptical patients, and mental health referrals that were part of a carefully developed treatment plan.
By combining the philosophy and skill dimensions, a 4-quadrant typology of physicians was apparent: the Technician, the Friend, the Detective, and the Healer. The Technician was medically oriented, dispensing medications and direct advice. Encounters were problem focused, and at times the physician appeared to be abrupt, ignorant of clear emotional distress, and not patient centered. In an encounter for follow-up of anxiety, one Technician told a patient complaining of neurologic symptoms that they might be stress related but still referred her to a neurologist. When she said, “This is really a frustrating way to feel,” he responded with, “Well, a neurologist deals with this,” and gave her samples of paroxetine, checked her for a sinus infection, and ended the encounter. Another patient seeing this physician for a complaint of depressive symptoms was identified without any discussion of underlying psychosocial issues; fluoxetine was dispensed in an encounter lasting less than 5 minutes.
The Friend was a biopsychosocially oriented physician with basic skills. One Friend extensively explored the patient’s background, concerns, and spiritual dimensions of illness. Encounters were long and tangential. A diverse array of topics was explored in a patient-centered fashion. However, only very basic counseling and management skills were ever observed with this physician. Direct advice was common, and conflict appeared to be avoided. A metaphor emerged of friends having coffee together.
Friends did not always appear to deliver care that optimally managed mental health issues. In some instances so many issues were discussed that the physician appeared to have difficulty setting an agenda for the visit and prioritizing problems. For example, for a patient just discharged after hospitalization for severe depression, there was no explicit discussion of depressive symptoms or suicidal ideation, despite a lengthy encounter.
The Detective was usually biomedically focused but when the occasion warranted, this type of physician demonstrated an impressive breadth of detective skills. For example, one Detective appeared most comfortable providing focused, snappy, medically oriented care. But she was alert to cues of emotional distress and demonstrated appropriate use of self-disclosure and confrontation in managing a patient with depression. In short, she was usually able to provide solutions for each case while focused on more biomedical issues.
The Healer used a full breadth of biopsychosocial skills, integrated most aspects of care seamlessly, and appeared comfortable with both strictly biomedical and psychosocial dimensions of care. One Healer regularly sought signs of emotional distress and exhibited an impressive range of skills in dealing with such problems as substance abuse and pain syndromes. For example, he astutely linked a patient’s stressful lifestyle with current somatic symptoms. In another encounter, with a woman with high blood pressure and weight gain, he assessed the possible biopsychosocial causes of the problem (etiologic stressors, sleep habits, relationship issues, diet changes, and depression, and probed about any anniversaries of a major stressor). However, even this Healer appeared to occasionally consciously temporize or triage emotional and mental health issues, such as when working with a patient with low back pain who was resistant to the treatment plan. During another encounter, he appeared to avoid the emotional implications of a diagnosis of venereal disease.