Abstract Listing

Beckman H, Markakis K, Suchman A, Frankel R. “Getting the most from a 20-minute visit” American Journal of Gastroenterology 89(5): 662-664, May 1994.

“The four core skills - active listening, soliciting attribution, providing support and establishing agreement - are at the heart of the model of co-participation between physician and patient. Used effectively, they provide a mutually satisfying environment in which psychosocial as well as biologic aspects of a problem can be explored in a humane, caring and surprisingly efficient way.

Bernzweig J, Takayama JI, Phibbs C, Lewis C, Pantell RH. “Gender differences in physician-patient communication. Evidence from pediatric visits” Archives of Pediatric and Adolescent Medicine 151(6): 586-591, June 1997. 

“Research was conducted to determine whether physician gender and patient gender influence the process of communication and parent and child satisfaction during pediatric office visits. The data showed that female physician visits were 29% longer than those of male physicians and included more social exchange, encouragement and reassurance, communication during the physical examination, and more information gathering with children. Male and female physicians engaged in similar amounts of discussions regarding illness management. Children were more satisfied with physicians of the same gender, while parents were more satisfied with female physicians.”

Cavanaugh RM. “Obtaining a personal and confidential history from adolescents. An opportunity for prevention” Journal of Adolescent Health Care 7(2): 118-122, March 1986.

“Fifty adolescent girls ages 12-18 years were asked to complete a confidential questionnaire exploring many important issues of adolescence. The responses included the following: 23 (46%) had used alcoholic beverages (10 at age less than or equal to 13 years), 17 (34%) had experience with marijuana, four (8%) had used other psychoactive drugs, and 14 (28%) were having sexual intercourse, while only eight were using contraception. This study suggests the usefulness of a questionnaire to identify individual health care needs for which preventive counseling may be offered.”

Cavanaugh RM, Henneberger PK. “Talking to teens about family problems: an opportunity for prevention” Clinical Pediatrics 35(2): 67-71, February 1996.

“Most pediatricians do not screen for family problems as part of routine adolescent health care. This study documents fears, worries, and concerns about family issues expressed by 147 teenagers on a confidential questionnaire during consecutive initial visits to an adolescent medicine clinic in a university hospital setting. The data demonstrate a high frequency of stressful and anxiety-provoking family situations as reported by adolescents on a confidential questionnaire.”

Cassata DM, Kirkman-Liff BL. “Mental health activities of family physicians” Journal of Family Practice 12(4): 683-692, April 1981.

“A questionnaire survey of residency trained graduates and nonresidency trained family physicians showed both groups reporting relatively infrequent practice of behavioral medicine. Referrals and counseling sessions/visits produce a combined total of 20 activities per month, or two to four percent of all patient encounters, even though the physicians in the sample reported that 33 percent of their diagnoses were behavioral/psychological. More than 85 percent of the physicians reported access to more than one mental health provider. The six most common health problems encountered in the office were depression, anxiety, obesity, marital discord, alcohol abuse, and sexual problems.”

Cole WM, Baker RM, Twersky RK “Classification and coding of psychosocial problems in family medicine” Journal of Family Practice 4(1): 85-89, January 1977.

“Disease and problem classification systems for primary care have recognized that psychosocial problems are integrally related to more traditional medical problems which patients present to physicians. This paper presents a classification and coding system of psychosocial problems gleaned from a number of existing coding systems. The purpose of presenting it here is to contribute to a dialogue which will result in the establishment of a common psychosocial language for all health professionals.”

Coleman WL, Howard BJ. “Family-focused behavioral pediatrics: clinical techniques for primary care” Pediatrics in Review 16(12): 448-455, December, 1995.

“Whenever a behavioral or psychosocial problem presents in a child, all members of the family are affected. Conversely, when the problem lies within the family, the child is affected and often presents as the symptomatic patient. The goals of family-focused pediatrics are to: 1) determine the need for a family intervention; 2) conduct a family interview-assessment; 3) clarify the issues; 4) teach healthy communication skills and interactions; and 5) facilitate generation of family goals and solutions. Family-focused strategies provide an effective, brief, and timely approach that can aid the pediatrician in helping children and their families function in more healthy and satisfying ways.”

Epstein RM, Campbell TL, Cohen-Cole SA, McWhinney IR, Smilkstein G. “Perspectives on patient-doctor communication” Journal of Family Practice 37(4): 377-388, October 1993.

“Until recently, the content, structure, and function of communication between doctors and patients has received little attention and has been excluded from the realm of scientific inquiry; as a result, most clinicians have had little formal training in communication skills. In this paper leaders in doctor-patient communication present four approaches that are currently used as the basis for clinical training and research, summarize the progress made in forming a consensus, and outline the implications of these perceptions for practicing physicians.”

Erzinger S. “Communication between Spanish-speaking patients and their doctors in medical encounters” Culture, Medicine and Psychiatry 15(1): 91-110, March 1991.

“Little research in patient-doctor communication addresses the profound difficulties that emerge as Spanish-speaking patients seek medical services in the U.S. This study examines the interaction of language and culture in medical encounters between Spanish-speaking Latino patients and their doctors who have a range of Spanish language ability and a variety of cultural backgrounds. Initial ethnographic fieldwork investigated Spanish-speaking patients’ perceptions of doctors’ Spanish language skill as it relates to their medical service. To elaborate on these fieldwork findings, medical encounters were audiotaped for detailed conversational analysis. Data from the two methods illustrate how language and culture interact in accomplishing communicative tasks as doctors attend Spanish-speaking patients.”

Flaitz CM, Vojir CP, Bradley KA, Casamassimo PS, Kaplan DW. “A comparison of parent and adolescent responses from independent health histories” Pediatric Dentistry 13(1): 27-31, January 1991. 

“This study compared agreement of written responses between parent and adolescent concerning medical and psychosocial information from independent health histories during an initial medical visit. Records with two health histories completed separately by 268 parent/adolescent pairs were studied. The following medical questions were coded and compared: chief complaint, infectious diseases, review of systems, hospitalizations, accidents, allergies, and medications. Psychosocial questions included recreational drug use, sexual behavior, body image, home life, and mental health. Using three-factor repeated measures ANOVA, significant differences were found primarily in the psychosocial category and chief complaint question. Findings suggest that many adolescents are reliable informants about their medical histories, but private interviewing of the teenager may be necessary to determine high-risk behaviors.”

Garrison WT, Bailey EN, Garb J, Ecker B, Spencer P, Sigelman D. “Interactions between parents and pediatric primary care physicians about children’s mental health” Hospital and Community Psychiatry 43(5): 489-493, May 1992.

“Interaction patterns between parents and pediatricians were examined during 1,378 well-child visits to four public and private pediatric clinics. During 327 visits, parents listed at least one psychosocial concern related to their child’s mental health. At 37% of these visits, parents said they did not wish to discuss the concern with the physician. Physicians failed to address concerns during approximately 35% of visits at which parents were willing to discuss them. Successful parent-physician interactions were three times more frequent in private practices than in a public clinic; they were more likely when fewer concerns were stated and less likely when behavior problems were the concern. Parents concerned about the parent-infant relationship were four times more likely to be referred to outside mental health services, although these cases were relatively rare. Older children and families receiving Medicaid were also more likely to be referred to such services.”

Holden P, Serrano AC. “Language barriers in pediatric care” Clinical Pediatrics 28(4): 193-194, April 1989.

“Language differences between pediatrician and parents can create a barrier in the doctor-patient relationship. Use of a translator to overcome that barrier introduces other potential problems such as a diminished sense of privacy, inadequate data collection, and misinterpretation of medical or family history due to translator distortions. Physicians should carefully choose the translator, avoiding persons who are linguistically incompetent, culturally insensitive, and medically unsophisticated. Physicians also should avoid assuming that parents who “speak English” are fluent. A determination of their language preference and their degree of English proficiency may lead the pediatrician to use a translator even with partially fluent families.”

Horwitz SM, Leaf PJ, Leventhal JM, Forsyth B, Speechley KN. “Identification and management of psychosocial and developmental problems in community-based, primary care pediatric practices” Pediatrics 89(3): 480-485, March 1992.

“The goal of this research was to refocus interest on the problems of the new morbidity. This study examined the rates and predictors of psychological problems in 19 of 23 randomly chosen pediatric practices in the greater New Haven area. Families of all 4- to 8-year-old children were invited to participate and to complete the Child Behavior Checklist prior to seeing a clinician. Clinicians completed a 13-category checklist of psychosocial and developmental problems based on a World Health Organization-sponsored primary care, child-oriented classification system. Of the 2006 eligible families, 1886 (94%) participated. Clinicians identified at least one psychosocial or developmental problem in 515 children (27.3%). Thirty-one percent of the children with problems received no active intervention, 40% received intervention by the clinician, and 16% were referred to specialty services. Not surprisingly, children whose problems were rated as moderate or severe were twice as likely to be referred compared with children with mild problems. Recognition of a problem was related to four characteristics: if the visit was for well child rather than acute care; if the clinician felt he or she knew a child well; if the child was male; and if the child had unmarried parents.”

Howard BJ. “The referral role of pediatricians" Pediatric Clinics of North America 42(1): 103-118, February, 1995.

“Pediatricians have a vital role in making effective mental health referrals for many children and their families. After selecting families who are appropriate for referral, for which type of resource, and the severity of their problems, the clinician should carry out a careful process to ensure the success of the referral. Special attention should be paid to finding the pain in individual family members, locating appropriate resources, and following up once a referral has been made.”

Jellinek M, Little M, Murphy JM, Pagano M. “The pediatric symptom checklist. Support for a role in a managed care environment” Archives of Pediatric and Adolescent Medicine 149(7): 740-746, July 1995.

“The purpose of this study was to gather data based on studies of the Pediatric Symptom Checklist, identify risk factors associated with high levels of dysfunction in primary care pediatric settings, and explore the relationship between common risk factors and psychosocial problems identified by pediatricians. Children with a single parent and/or those who were economically disadvantaged were significantly more likely to show psychosocial impairment. The specificity of the Pediatric Symptom Checklist was 100% in samples with a lower socioeconomic status compared with 68% in middle-class samples, and sensitivity was 95% in middle-class samples compared with 80% in lower-class samples. Pediatricians identified psychosocial problems in eight of 15 children with a history of familial mental illness or substance abuse and seven of eight children with a history of physical or sexual abuse, but only six of 17 cases from single-parent families and four of 11 cases from poor families.”

Levinson W, Stiles WB, Inui TS, Engle R “Physician frustration in communication with patients” Medical Care 31(4): 285-295, April 1993.

“In this study, the nature of practicing physicians’ 'frustrating' visits was explored and a guide to help physicians identify problems in communicating with patients was developed. The study included 1,076 practicing physicians who attended a voluntary workshop on physician-patient communication. The method included development of a preliminary item pool (descriptions of frustrating patients and occasions) by experienced physicians and teachers of medical communication, additions/deletions/revisions of items within the pool, empirical analyses to reduce redundancy and group-like items, and construct validation of the final 25-item questionnaire. Factor analysis was used to identify subscales. Physicians most often attributed communication problems to the patient rather than to their own limitations. Seven types of communication problems (subscales) were identified, including: 1) lack of trust/agreement, 2) too many problems, 3) feeling distressed, 4) lack of understanding, 5) lack of adherence, 6) demanding/controlling patient, and 7) special problems. Primary care physicians reported greater problems than specialists on four subscales. Physicians practicing in health maintenance organizations reported greater problems than physicians in fee-for-service practice on five subscales. Seven sources of frustration physicians experience in their work with patients were identified.”

Levinson W, Roter D. “Physicians’ psychosocial beliefs correlate with their patient communication skills” Journal of General Internal Medicine 10(7): 375-379, July 1995.

“The purpose of this research was to assess the relationship between physicians’ beliefs about the psychosocial aspects of patient care and their routine communication with patients. The data showed that physicians’ attitudes toward psychosocial aspects of care were associated with both physician and patient dialogue in visits. The physicians who had positive attitudes used more statements of emotion (ie, empathy, reassurance) and fewer closed-ended questions than did their colleagues who had less positive attitudes. The patients of the physicians who had positive attitudes more actively participated in care (ie, expressing opinions, asking questions), and these physicians provided relatively more psychosocial and less biomedical information.”

Levy DR. “White doctors and black patients: influence of race on the doctor-patient relationship” Pediatrics 75(4): 639-643, April 1985.

“Effective communication between doctor and patient, a skill not emphasized in medical education programs, is essential for patient satisfaction and optimal patient care. In many teaching hospitals, the doctor is commonly white and middle class and the patient black and indigent. Racial differences, even in the absence of social class differences, may have a negative impact on the quality of the doctor-patient relationship. The impact of racism is reviewed and recommendations to enhance the relationship between white doctors and black patients are made.”

Lynch TR, Wildman BG, Smucker WD. “Parental disclosure of child psychosocial concerns: relationship to physician identification and management” Journal of Family Practice 44(3): 273-280, March 1997.

“The purpose of this research was to evaluate a method of prompting parental disclosure of such problems and to determine the impact of parental disclosure on family physicians’ identification of and intervention for childhood psychosocial problems. Participants were parents and physicians of 60 children between the ages of 3 and 10 years attending an ambulatory care clinic of a community-based, university-affiliated family medicine training program. Parents completed the Child Behavior Checklist and also indicated whether psychosocial problems were discussed or managed. Physicians completed a checklist about the psychosocial status of the child and potential interventions for identified problems. One half of the participating parents formed the experimental group and were also asked to note their concerns on a Psychosocial Checklist for Children and to discuss these concerns with their child’s physician; the other half of parents received no such checklist and acted as the control group. All interactions between parents and physicians were videotaped. The data showed that the number of parental psychosocial disclosures, but not the number of parents who disclosed them, was significantly higher for the experimental group. Physicians were three times as likely to identify a psychosocial problem and 10 times as likely to intervene when parents discussed psychosocial concerns.”

Merrill JM, Laux L, Thornby JI. “Troublesome aspects of the patient-physician relationship: a study of human factors” Southern Medical Journal 80(10): 1211-1215, October 1987.  

“We investigated three onerous aspects of the patient-physician relationship using contemporary psychosocial research methods. A “hassle index” identified three dimensions of vexation in practice: problems with running a practice, medical conditions of patients, and social characteristics of patients. In general, hassle was found to be dependent on the type of practice, but physicians were equally annoyed by unlikeable patients irrespective of their practice site. Diagnostic errors made by resident physicians from various clinics were more related to an unlikeable medical disorder than to differences in the clinics. To clarify doctors’ negative feelings toward patients, a questionnaire measuring antipathy toward specific patient types was administered to physicians. Responses indicated that physicians’ antipathy was unrelated to the doctors’ ethical beliefs and their medicopolitical orientation. Personality variables indicative of “extremeness” of opinion about patients included high needs for dominance, low needs for nurturance and “intraception” (the ability to analyze the behavior and motives of others), and low self-esteem. Personality profiles of physicians least vexed by medical practice reflected less psychopathology—less self-derogation, less need for emotional support, and more extroversion. Medical College Aptitude Test scores revealed that high science scores were associated with extremeness of opinion, and low scores on general information were indicative of increased susceptibility to the daily irritations of medical practice.”

Metz JR, Allen CM, Barr G, Shinefield H. “A pediatric screening examination for psychosocial problems” Pediatrics 58(4): 595-606, October 1976. 

“In an effort to avert the cumulative effects of unresolved emotional problems on children’s social and school adjustment, a psychosocial phase was added to a pediatric multiphasic examination. Based upon a cumulative stress concept, the screening procedures included child behavior and family stress questionnaires for parents, and abbreviated standard psychological tests for children, administered by specially trained aides. Computerized results were reported to the child’s pediatrician. Follow-up by mental health counselors attached to the pediatric clinic was provided for patients identified as being at high risk of serious psychosocial problems. Evidence of validity of the screen, factors affecting the scores, and effectiveness of clinical follow-up of high-risk patients are discussed. Valid semicomputerized screening of school-age children for serious psychosocial problems can be carried out routinely and at relatively low cost by paraprofessional personnel in a pediatric setting. Impediments to effective use of the screening results on the part of both health care provider and patient are discussed.”

Ong LM, de Haes JC, Hoos AM, Lammes FB. “Doctor-patient communication: a review of the literature” Social Science and Medicine 149(7): 903-918, April 1995.

“Communication can be seen as the main ingredient in medical care. In reviewing doctor-patient communication, the following topics are addressed: different purposes of medical communication; analysis of doctor-patient communication; specific communicative behaviors; the influence of communicative behaviors on patient outcomes; and concluding remarks. Three different purposes of communication are identified, namely: creating a good interpersonal relationship; exchanging information; and making treatment-related decisions. Communication during medical encounters can be analyzed by using different interaction analysis systems (IAS). These systems differ with regard to their clinical relevance, observational strategy, reliability/validity and channels of communicative behavior. Several communicative behaviors that occur in consultations are discussed: instrumental (cure oriented) vs affective (care oriented) behavior, verbal vs non-verbal behavior, privacy behavior, high vs low controlling behavior, and medical vs everyday language vocabularies. Consequences of specific physician behaviors on certain patient outcomes, namely: satisfaction, compliance/adherence to treatment, recall and understanding of information, and health status/psychiatric morbidity are described. Finally, a framework relating background, process and outcome variables is presented.”

Pantell RH, Stewart TJ, Dias JK, Wells P, Ross AW. “Physician communication with children and parents” Pediatrics 70(3): 396-402, September 1982.

“The purpose of this study was to document the content of medical interviews in routine pediatric visits and to identify demographic and situational characteristics that influenced the extent of communication between doctor and child. One hundred fifteen office visits to 49 physicians were videotaped and analyzed. Children studied were 4 to 14 years old with a mean age of 8.5 years. Verbal transactions were coded according to direction of communication, transaction type, and content category. Coder reliability for this system was 0.84. A considerable amount of the total communication, 45.5%, was between doctor and child. Doctors interacted differently with parents and children. More information about the current problem was obtained from children; physicians provided feedback primarily to parents. Parents received 4.4. times as much information as children about the nature and prognosis of a condition. The extent to which doctors talked to children in “substantive” areas was primarily associated with a child’s age but was partly influenced by family size and family utilization. Race, socioeconomic status, type of problem, and previous encounter with the examining physician did not alter communication patterns. Boys were given more information than girls. We suggest a theoretical framework for future investigation and teaching that identifies the child as an active participant in the medical process.”

Patterson JM. “Promoting resilience in families experiencing stress” Pediatric Clinics of  North America 42(1): 47-63, February 1995.

“All families experience many different life events, strains, and hassles over their life spans. Stress emerges in the family when demands exceed capabilities. When this imbalance persists and becomes larger, children and other family members often show signs and symptoms of distress, including health-related problems. Pediatricians are increasingly called on to evaluate this situation and to be helpful to stressed families and their children. A family assessment model is presented to aid pediatricians in helping families to identify the sources and degree of stress they are experiencing, and even more importantly, to facilitate their ability to discover and use their own strengths and resources. The goal for the pediatrician is to promote balance and resilience in families, which, in turn, will contribute to better health and functioning in children.”

Sharp L, Pantell RH, Murphy LO, Lewis CC. “Psychosocial problems during child health supervision visits: eliciting, then what?” Pediatrics 89(4   Pt. 1): 619-623, April 1992.

“The purpose of this study was to determine the extent to which parents had opportunities to express psychosocial concerns and the nature of physicians’ responses to these concerns during health supervision visits. Analyzing videotapes of child health supervision visits by 34 children aged 5-12, the authors assessed (1) the nature of opportunities provided to express concerns, (2) categories of psychosocial problems expressed by parents and children, and (3) the nature of physicians’ responses. In 88% of the child health supervision visits, opportunities were created by the physician to discuss psychosocial concerns or were spontaneously raised by the parent or child. In half of the visits, parents or children expressed a total of 30 psychosocial concerns, such as conduct/behavior problems (47%), insecurity (13%), family, sibling, or social problems (13%), learning difficulties (10%), somatization (7%), and other (10%). Physicians’ responses to these psychosocial concerns were as follows: 17% ignored the concern; 43% asked further exploratory questions but provided no information, reassurance, or guidance; 3% reassured the parent; 27% responded with psychosocial information and/or action; 3% responded with medical information and/or action; and 7% responded with a combination of these latter two modes of actions.”

Stewart TJ, Pantell RH, Dias JK, Wells PA, Ross AW. “Children as patients: a communications process study in family practice” Journal of Family Practice 13(6): 827-835, November 1981.

“To determine how family physicians divide their attention between children and parents, 115 videotaped pediatric encounters of children (aged 4 to 14 years) and parents with family physicians in a family medicine center were analyzed. It was learned that physicians tended to involve children actively in the diagnostic stages of interviews but much less so in discussions of treating or dealing with their problems. Physicians did not alter this pattern as they advanced in training. Older children were more likely to receive direct communication from physicians in all phases of office encounters. Though the family physicians in this sample had more direct communication with children than reported in previous research, it is argued that greater involvement of children in all phases of pediatric visits is warranted.”

Street RL. “Communicative styles and adaptations in physician-parent consultations” Social Science and Medicine 34(10): 1155-1163, May 1992.

“This investigation compares the degree to which personal and interactive factors respectively account for variation in patterns of physician-parent communicative exchange. The analysis of audiorecordings of 115 pediatric consultations revealed several notable findings: (a) individual physicians differed in the degree to which each provided information, issued directives, exhibited positive socioemotional behavior, and engaged in partnership-building, (b) parents who asked more questions and expressed more negative affect (eg, concerns, frustrations) received more information and directives from physicians, (c) parents who were more affectively expressive elicited a greater number of positive socioemotional comments from doctors, and (d) parents’ question-asking and opinion-giving were related to the parents’ level of education and the degree to which physicians’ engaged in partnership-building.”

Sunde ER, Mabe PA, Josephson A. “Difficult parents. From adversaries to partners” Clinical Pediatrics 32(4): 213-219, April 1993.

“The pediatrician’s job becomes frustrating when it is necessary to deal with difficult parents. Some physicians may not have the training or inclination to engage such parents in a therapeutic partnership. This paper discusses tools available to physicians which will help them develop an effective partnership that includes uncovering the hidden meaning behind a child’s illness; understanding the reciprocal nature of partnerships; and the importance of determining each party’s goals, roles, and expectations. Negotiating these steps enables physicians to develop a productive relationship with difficult parents of sick children. This strategy can facilitate the child’s medical care and improve the parents’ and physician’s satisfaction with the services rendered. This paper also discusses steps to take when these attempts are not sufficient to handle the situation.”

Tellerman K, Medio F. “Pediatrician’s opinions of mothers” Pediatrics 81(2): 186-189, February 1988.

“The purpose of this study was to determine factors that influence pediatricians’ opinions of mothers. The degree to which mother-physician interactions, mother-child interactions, and maternal demographic variables influence pediatricians’ opinions of mothers was assessed with a 54-item questionnaire. A majority of the 230 pediatricians who responded reported that their opinions were 'greatly' positively influenced by mothers who communicate clearly (60%), understand recommendations (56%), follow recommendations (68%), and keep appointments (58%). In comparison, significantly fewer pediatricians’ opinions were 'greatly' influenced by mothers who are friendly to them (38%) or who like them (34%). Pediatricians were also 'greatly' influenced by mothers who seem safety conscious (67%), use car restraints (57%), and keep immunizations updated (61%). Female pediatricians, in contrast to men, were significantly more influenced by mothers who 'respond to their crying infants' and who 'try to calm an anxious child.'”

Triggs EG, Perrin EC. “Listening carefully. Improving communication about behavior and development. Recognizing parental concerns.” Clinical Pediatrics 28(4): 185-192, April 1989.

“A simple checklist was developed for completion by parents prior to their regular meetings with their pediatricians for health supervision. Its efficacy in improving communication between pediatricians and parents about behavioral and developmental concerns was evaluated. Without the checklist, 30% of parents’ concerns were discussed. More items overall, and more items that were concerns of the parent, were discussed with the use of the checklist than without it. An intermediate but statistically significant effect was observed even when the pediatrician did not see the completed checklist; this effect was increased when he did (53% of concerns discussed). There were marked differences among pediatricians in the number of concerns that were discussed both with and without use of the checklist. Items regarding patterns of family life and child care, death or illness, siblings, and other stresses of modern families were frequently indicated as concerns on the checklist but were less frequently discussed. The data demonstrate the effectiveness of a simple and efficient method to improve communication about children’s behavior and development between their parents and their pediatricians.”

White J, Levinson W, Roter D. “Oh, by the way...” The closing moments of the medical visit” Journal of General Internal Medicine 9(1): 24-28, January 1994.

“The purpose of this research was to define and describe the communication between physicians and patients in the closing phase of the medical visit, and to identify types of communication throughout the visit that are associated with the introduction of a new problem during the closing moments of the visit or with longer closures. Using audiotaped office visits, the authors found that physicians initiated the closing in 86% of the visits. The physicians clarified the plan of care in 75% of the visits and asked whether the patients had more questions in 25% of the cases. The patients introduced new problems not previously discussed in 21% of the closures. New problems in closure were associated with less information exchanged previously by physicians and patients about therapy, fewer orientation statements by physicians, and higher patient affect scores. Long closures (>2 minutes) correlated with physicians’ asking open-ended questions, laughing, showing responsiveness to patients, being self-disclosing, and engaging in psychosocial discussion with patients.”

Williamson P, Beitman BD, Katon W. “Beliefs that foster physician avoidance of psychosocial aspects of health care” Journal of Family Practice 13(7): 999-1003, July 1981.

“Although training in family medicine emphasizes a biopsychosocial approach to patients, many residents experience difficulties in carrying out the appropriate psychosocial part of their diagnosis and treatment. There are a set of core tacit beliefs which inhibit physicians from thinking psychosocially about their patients. These beliefs appear to be rigidly held but not examined or challenged. This paper presents the major of these beliefs and for each a more realistic therapeutic reply. They are grouped into three categories: (1) beliefs concerning physician’s role (eg, 'I must rule out organic disease; only then can I focus on psychosocial problems'), (2) beliefs concerning what the patient supposedly wants or does not want (eg, 'My patients want me to rule out organic problems'), and (3) physicians’ fears about approaching patients as people (eg, 'If the patient has the same problem I do, how can I help if I have not helped myself'). By making overt these tacit assumptions, this paper attempts to highlight core barriers to the implementation of biopsychosocial care, increase understanding of effective alternatives, and challenge physicians to examine their hidden beliefs about patient care and their approach to patients.”

Wissow LS, Roter DL, Wilson ME. “Pediatrician interview style and mothers’ disclosure of psychosocial issues” Pediatrics 93(2): 289-295, February 1994.

“Primary care pediatricians play an important role in the detection, diagnosis, treatment, and referral of children with mental health problems. Some parents, however, are reluctant to discuss behavioral and emotional symptoms with their child’s pediatrician. Studies of patient-physician communication suggest that specific aspects of pediatrician interview style (asking questions about psychosocial issues, making supportive statements, and listening attentively) increase disclosure of sensitive information. The authors hypothesized that disclosures of parent and child psychosocial problems would be more likely to occur during visits when pediatricians used these techniques. Study results found that the use of psychosocially oriented interviewing techniques was associated with a greater likelihood of disclosure for all four of the topic areas studied. Odds ratios for disclosure, adjusted for parental concerns and child age, ranged from 1.09 to 1.22 depending on the interview technique and outcome involved. Positive associations were observed both for topics raised primarily in response to pediatrician questions (family and parent problems) and for topics raised primarily by mothers (behavior and punishment).”

Worchel FF, Prevatt BC, Miner J, Allen M, Wagner L, Nation P. “Pediatrician’s communication style: relationship to parent’s perceptions and behaviors” Journal of Pediatric Psychology 20(5): 633-644, October 1995.

“Investigated physician-parent communication styles and the effects of concordance between parent’s desired communication styles and the communication style exhibited by physicians. Subjects were 107 parents of children scheduled for an appointment with a pediatrician at a general medical clinic. Parents and physicians completed rating forms indicating the degree to which parents desired each of four communication styles (information giving, interpersonal sensitivity, partnership, and directing one’s own treatment). Parents and physicians also rated the degree to which they believed the physician exhibited each of these four styles. Follow-up interviews with parents assessed the level of satisfaction with the visit, perception that parent’s concerns had been addressed, and subsequent telephone calls to the physician. Results indicated that physicians underestimated the degree of interaction desired by the parents. Parent desires for particular communication styles were not predicted by characteristics of the parents. Interaction variables predicted parent perceptions and subsequent need for contact with the physician.”