Open Access

Which medical interview skills are associated with patients’ verbal indications of undisclosed feelings of anxiety and depressive feelings?

Asia Pacific Family Medicine201615:2

DOI: 10.1186/s12930-016-0027-x

Received: 6 May 2015

Accepted: 15 February 2016

Published: 28 February 2016

Abstract

Background

In medical practice, obtaining information regarding patients’ undisclosed “feelings of anxiety” or “depressive feelings” is important. The purpose of this study was to determine which interview skills are best suited for eliciting verbal indications of undisclosed feelings, for example anxiety or depressive feelings in patients.

Methods

Our group videotaped 159 medical interviews at an outpatient department of the Department of Family Medicine, Mie University Hospital (Mie, Japan). Physicians’ medical interview skills were evaluated using a Medical Interview Evaluation System and Emotional Information Check Sheet for assessing indications of “feelings of anxiety” or “depressive feelings”. We analyzed the relationship between the interview skills and patients’ consequent emotional disclosure using generalized linear model (GLIM).

Results

The usage of interview skills such as “open-ended questions” “asking the patient’s ideas about the meaning of illness” “reflection” and “legitimization” were positively associated with the number of anxiety disclosure, whereas “close-ended questions” and “focused question” were negatively associated. On the other hand, only “respect” was positively associated with the number of depressive disclosures, whereas “surveying question” was negatively associated.

Conclusions

The results revealed that there are several interview skills that are effective in eliciting verbal indication of undisclosed “feelings of anxiety” or “depressive feelings”.

Keywords

Family medicine Medical interview Depression Anxiety Communication

Background

One of the important functions of the medical interview is to understand the mental status of patients. It is important that the physician checks the mental status of the patient during the medical interview, because patients often do not come to see physicians suspecting that they might have mental disorder [1, 2]. Paying attention to the patients’ emotions could not only contribute to early detection of psychiatric disease but is said to affect the patient’s satisfaction [35]. This approach will also shorten the consultation time and reduce the extra stress of the physicians [6]. However, in many cases, patients are said to only send indirect signals with no explicit emotional expressions [7] and show only an ambiguous response [8]. The cue expressed by the patient may be overlooked due to the physician’s low awareness [9, 10] or insufficient clinical skills due to the lack of training [11, 12]. Furthermore, even when they are encouraged by the physicians, many patients would feel embarrassed, hesitated or simply feel that they do not deserve to disclose emotions [13].

In recent years, many studies have been made on the relationship between the patients’ emotional response and the physicians’ interview skills to address these needs. Many of them have discussed that physicians’ communication skills should be employed to help patients’ express their emotions [6, 8, 14, 15]. However, most of the reports on the patients’ emotional response are made in the context of cancer treatment. Sufficient studies have not been made on the physicians’ skills and the patients’ emotional response during the common medical interviews like ones at primary care facilities.

The aim of the present study is to explore the association between physicians’ interview skills and patients’ disclosure about anxiety or depression in the primary care setting.

Methods

Participants and procedures

One hundred and fifty nine different new patients (74 males and 85 females) participated in this observational, cross-sectional study. They are patients at outpatient department of the Department of Family Medicine of large-scale hospital, Japan. The patients came from both rural and urban areas and were from a wide range of socioeconomic classes. All of the patients were over 15 years of age, and most patients generally had common medical problems such as hypertension, hypercholesterolemia, and diabetes. First, we checked whether this was a first visit and asked if the prospective participant were willing to participate, and if he or she declined, no further effort was made. Second, we gave them instructions about the purpose and meaning of the study and told them that they could decline from this study anytime when they want to. Third, we obtained each participant’s signature. Parental permission was obtained for patients whose age is less than 20 years old.

Each patient was interviewed by one of 26 family physicians, 98 family medicine residents, or 35 medical students having family medicine clinical clerkship. These interviews were videotaped for evaluation.

Informed consents were obtained from patients and physicians prior to any observation of the medical interviews. The research protocol of this study was approved by the Research Ethical Committee of the Mie University School of Medicine.

Outcome measurements

The videotaped medical interview skills were reviewed by trained researchers using the Takemura Medical Interview Rating Scale (TMIRS) (Table 1) [16]. Some systems of the Roter interaction analysis system were used to build this scale [17]. “Feelings of anxiety” and “depressive feelings” were also operationally defined (Table 2). These items were all combined into a single sheet to allow us to count the skills that doctor’s used and patients’ emotional responses.
Table 1

Definition of each medical interview skill (Medical Interview Evaluation System)

Medical inter skill

Definition

Open-ended questions

An open-ended question invites the patient to use his or her own judgment in deciding what topics and problems to emphasize. These questions invite patients to describe their problems by using their own vocabulary and personal experience of their symptoms

Close-ended questions

A question which can be answered by Yes/No or a single word

Survey questions

A question after summarization (the summary) to survey the problem, and whether the patient has other problems or not

Focused questions

The question for understanding clearly the contents which a patient is going to tell and not a close-ended question but in-between open-ended questions and close-ended questions. In other words, questions which slightly limited the range of the answer. For example, “Where is the pain?”

Requests for feelings

Direct requests for the patient’s own feelings

Asking the patient’s ideas about the meaning of the illness

Directly asking the patient what he or she thinks could be causing the symptom

Asking the patient’s preferences about the examination

Directly asking the patient what kind of examination he or she would like to have or not have

Summarization

Attempts on the physician’s part to summarize the information settled to some extent that he or she has just received from the patient

Reflection

The physician’s statement of an observed feeling or emotion in the patient

Legitimization

An intervention that specifically communicates acceptance and validation of the patient’s emotional experience

Personal support

Letting the patient know that the doctor is there for the patient and wants to help

Partnership

Letting the patient feel a sense of partnership

Respect for patients

Respectful communication strategies, such as addressing the patient by name or giving affirmative comments

Table 2

Definition of feelings of anxiety and depressive feelings

Feelings of anxiety

The state of feeling nervous or worried that something bad is going to happen

Linguistic expressions: scary, sleepless, anorexic, get scared, something wrong, apprehensive about, painful, concerned about, etc.

Depressive feelings

Unhappy, disappointed, or suicidal feelings

Linguistic expressions: despair, feel like dying, boring, not fun, unhappy, not interesting in something, etc.

This scale was assessed for reliability. First, for each videotaped interview, an evaluator used the scale to evaluate the number of skills used by the physician. Second, the same evaluator did a second review a random selection of 25 interviews 2 months after the first review. The kappa value was calculated and found to be 0.93.

Interview length was considered as a confounder, because longer interview duration was presumed to positively influence our findings [18]. In addition, patients’ sex, sex matching between patient and physician, and affiliation (student, resident and family physician) were also obtained as other possible confounders.

Statistical analyses

Demographic data were obtained first. Then, we used a generalized linear model (GLM) to assess the relationship between a physician’s use of these interview skills and verbal indications of feelings of anxiety or depression. Because our observation of physicians’ interview skills and patients’ emotional disclosures were recorded as count data, we modeled the relationship using the Poisson distributions and log link function. After the generalized linear model was estimated, we verified the variance inflation factors of each independent variable and the covariates (VIF). Finally, we evaluated goodness of fit of the estimated model using Akaike Information Criteria (AIC).

Statistical significance was set as p < 0.05 for all measures. We used R version 3.1.1 [19] for statistical analyses. Generalized linear model analyses were conducted using the “glm” function. There was no missing data.

Results

Characteristics of patients and physicians are shown in Table 3. Additionally, the table shows basic statistics including mean value, standard deviations, and quartile values of each interview skill and emotional disclosure.
Table 3

Basic statistics of emotional disclosures, interview skills and covariates

Medical interview skill

Mean

SD

Quartiles

0 (%)

25 (%)

50 (%)

75 (%)

100 (%)

Demographic

 Sex of patients

Male: 74; female: 85

 Sex matching

Matched: 83; not matched 76

Interview skills

 Open-ended questions

0.6

0.5

0

0

1

1

1

 Close-ended questions

43.7

20.5

0

29

44

55

124

 Focused questions

7.7

6.2

0

4

7

10

51

 Survey questions

0.5

1.2

0

0

0

1

14

 Request for feelings

0.1

0.4

0

0

0

0

3

 Meaning of the illness

0.5

0.6

0

0

0

1

4

 Preference

0.3

0.5

0

0

0

1

2

 Summarization

0.4

0.5

0

0

0

1

2

 Reflection

0.4

0.5

0

0

1

3

23

 Legitimization

0.4

0.9

0

0

0

0

4

 Personal support

0.1

0.5

0

0

0

0

4

 Partnership

0.0

0.1

0

0

0

0

1

 Respect for patients

2.2

2.1

0

1

2

3

13

Emotional disclosures

 Anxiety

3.4

4.6

0

1

2

5

41

 Depression

0.3

0.9

0

0

0

0

32

Confounder

 Mean duration

of interview (sec)

1356.5

730.1

133

834

1205

1753

4062

The estimated model for disclosures of anxiety is shown in Table 4, and the estimated model about that of depression is shown in Table 5. For the purposes of our analyses, only modified models will be considered.
Table 4

Estimated model of physician’s interview style on number of disclosure about anxiety by patients

Item

Crudeb

Modifieda

Estimate

SE

z value

p

Estimate

SE

z value

p

Interceptc

0.389

0.154

2.529

0.011

0.234

0.329

0.712

0.477

Open-ended questions

0.189

0.096

1.975

0.048

0.282

0.100

2.821

0.005

Close-ended questions

0.004

0.003

1.317

0.188

−0.008

0.004

−2.241

0.025

Focused questions

−0.008

0.008

−0.973

0.331

−0.018

0.009

−2.053

0.040

Survey questions

−0.044

0.031

−1.414

0.157

−0.041

0.032

−1.308

0.191

Requests for feelings

0.160

0.080

2.006

0.045

−0.004

0.080

−0.050

0.960

Meaning of the illness

0.207

0.069

2.995

0.003

0.157

0.070

2.256

0.024

Preference about examination

−0.077

0.093

−0.828

0.408

−0.033

0.092

−0.361

0.718

Summarization

−0.134

0.102

−1.317

0.188

−0.175

0.104

−1.683

0.092

Reflection

0.066

0.012

5.533

<0.001

0.066

0.013

5.195

<0.001

Legitimization

0.285

0.049

5.779

<0.001

0.205

0.051

4.014

<0.001

Personal support

0.009

0.092

0.093

0.926

−0.041

0.094

−0.435

0.663

Partnership

−0.982

0.593

−1.654

0.098

−0.543

0.607

−0.895

0.371

Respect for patients

0.070

0.024

2.899

0.004

−0.002

0.028

−0.079

0.937

Model was estimated using generalized linear model. Dependent variable was number of disclosure about anxiety

SE standard error

aPatient’s sex, physician’s title, sex matching between the patient and the physician, and duration of interview were modified as covariates. AIC was 768.85

bAkaike information criteria (AIC) was 810.00. AIC is an index of goodness of fit for the estimated model by generalized linear model

cIntercept is the value of dependent variable when all the independent variables were zero

Table 5

Estimated model of physician’s interview style on number of disclosure about depression by patients

Item

Crudeb

Modifieda

Estimate

SE

z value

p

Estimate

SE

z value

p

Interceptc

−2.478

0.440

−5.630

<0.001

−4.596

0.992

−4.634

<0.001

Open-ended questions

−0.458

0.231

−1.984

0.047

−0.379

0.258

−1.469

0.142

Close-ended questions

0.014

0.008

1.793

0.073

−0.008

0.009

−0.924

0.355

Focused questions

0.029

0.012

2.379

0.017

0.004

0.013

0.325

0.745

Survey questions

−0.089

0.049

−1.825

0.068

−0.115

0.052

−2.192

0.028

Requests for feelings

0.622

0.156

3.978

<0.001

0.049

0.158

0.313

0.754

Meaning of the illness

0.129

0.174

0.742

0.458

−0.065

0.194

−0.334

0.738

Preference about examination

−0.559

0.242

−2.308

0.021

−0.085

0.230

−0.367

0.713

Summarization

−0.008

0.264

−0.031

0.975

−0.179

0.297

−0.605

0.545

Reflection

−0.010

0.030

−0.338

0.736

0.009

0.035

0.267

0.789

Legitimization

0.350

0.142

2.462

0.014

0.007

0.173

0.039

0.969

Personal support

0.068

0.150

0.454

0.650

−0.218

0.164

−1.331

0.183

Partnership

−15.362

828.283

−0.019

0.985

−15.020

982.600

−0.015

0.988

Respect for patients

0.344

0.053

6.523

<0.001

0.215

0.065

3.293

0.001

Model was estimated using generalized linear model. Dependent variable was number of disclosure about depression

SE standard error

aPatient’s sex, physician’s title, sex matching between the patient and the physician, and duration of interview were modified as covariates. AIC was 286.96

bAkaike information criteria (AIC) was 322.39. AIC is an index of goodness of fit for the estimated model by generalized linear model

cIntercept is the value of dependent variable when all the independent variables were zero

Patients’ disclosures of anxiety were positively associated with “open-ended questions” “legitimization” “reflection” and “asking the patient’s idea about the meaning of the illness (meaning of the illness)”. Conversely, they were negatively associated with “close-ended questions” and “focused questions”. As none of the interview-skills and covariates showed VIF above 10 (data not shown), multicollinearity which was found to be within acceptable norms [2023].

Patients’ disclosures of depression were positively associated with “respect for patients” and negatively associated with “survey questions”. As with the result for disclosures of anxiety, multicollinearity was found to be within acceptable limits, with no VIF above than 10 (data not shown).

We compared the respective association strengths of the various independent variables. “Open-ended questions” and “legitimization” were found to have the strongest association with respect to indications of undisclosed “feelings of anxiety”. “Close-ended questions” and “focused question” were also significant; however, their respective association strengths were close to zero. As for depression, “survey questions” and “respect for patients” were the only notable associations.

Discussion

There were differences in which skills were effective for eliciting feelings of anxiety and depression clearly.

“Open-ended questions” “meaning of the illness” “reflection” and “legitimization” had a positive association with indications of “feelings of anxiety”.

“Open-ended questions” were effective for eliciting patients’ feelings of anxiety, but “close-ended questions” or “focused questions” were not. A lot of previous studies recommended using the open-ended questions to soliciting patients’ information [2426] and the result of this study is in agreement with these investigations.

Previous study showed that “reflection” and “legitimization” were associated with patient satisfaction [16]. Another study also identified a significant positive association between the amount of information elicited from patients and patient satisfaction [27]. Furthermore, an investigation also indicated that patient satisfaction is associated with discussion of emotional distress [3, 4, 28]. This study might provide an explanation as to why “reflection” and “legitimization” have been shown to increase patient satisfaction, as enhanced disclosure has been shown to increase patients’ satisfaction.

“Meaning of the illness” was effective for eliciting patient’s feelings of anxiety, but “close-ended questions” and “focused questions” might conceal it. That results are in accordance with the previous investigation that patients are more likely talk about psychosocial issues in the atmosphere created when a physician uses less close-ended questions and less dominating [3, 4]. These results may show it is difficult for patients to express their anxieties when the patients were asked to verbalize the feeling directly by “close-ended questions” or “focused questions”.

In this study, “respect for patients” had positive association with indications of feelings of depression. Previous research showing that patients were more willing to divulge personal information; such as therapeutic, lifestyle, and psychosocial information to physicians who show respect supports the result of this study [29]. Cape and McCulloch also explored patients’ reasons for not presenting emotional problems in medical interviews and they found that 45 percent of reasons related to psychological embarrassment or hesitation to trouble the general practitioner or family physician [13]. Their result shares similarity in our result.

Strength and limitations

Strength of this study is the use of an objective method to assess medical interview skills and patients’ emotion. Conversely, there are several limitations. First, there may be other confounding factors not measured in this study; for example, other relevant patient background information, non-verbal communications, and so on. Second, it is difficult to evaluate subjective information such as mental feelings objectively.

Conclusions

This study reveals that several interview skills including “open-ended questions” “legitimization” would be effective in eliciting undisclosed “feelings of anxiety”. On the other hand, “respect for patients” was associated with undisclosed “depressive feelings”.

Declarations

Authors’ contributions

MG conceived of the study, analyzed and interpreted the videotaped data and drafted the manuscript. YT participated in the design of the study, revised it critically for important intellectual content, performed the statistical analysis and drafted the manuscript. Both authors contributed to defining the research question, participated in the coordination of the study. Both authors read and approved the final manuscript.

Acknowledgements

We would especially like to thank all the patients who participated in this study. We would also like to thank the physicians who made this study possible by inviting their patients to participate and allowing their work to be recorded. We really appreciate Shuhei Ichikawa for his assistance with the statistics processes. We wish to express our gratitude to Alberto Gayle for his assistance regarding interpretation of the results and revision to the manuscript. We would also like to thanks the technical staff that helped record and collect the video data at Mie University.This work was supported by the Sciences Research Grant of the Ministry of Health, Labour and Welfare, Japan. (No.16211701).

Competing interests

The authors declare that they have no competing interests.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Education and Research in Family and Community Medicine, Mie University Graduate School of Medicine
(2)
Department of Family Medicine, Mie University School of Medicine and Graduate School of Medicine

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Copyright

© Goto and Takemura. 2016

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