Addressing Emotion and Providing Space

The researchers used audio-recorded patient encounters collected as part of the Maximizing Respect and Improving Outcomes in HIV and Substance Abuse (MaRIPOHSA) Study, which was conducted at HIV specialty clinics in 2 urban academic medical centers.

Clinicians included physicians, nurse practitioners and physician assistants.

To code emotional communication, the researchers used the Verona Coding Definitions of Emotional Sequences (VR-CoDES), which “categorizes patients’ emotional expressions into concerns and cues according to the level of intensity.” A “concern” is defined as “a clear and unambiguous expression of an unpleasant current or recent emotion where the emotion is explicitly verbalized,” while a “cue” is defined as “a hint which suggests an underlying unpleasant emotion.”3

Dr Beach explained that each clinician response “can be coded on the basis of 2 main features: whether or not the clinician explicitly addressed the patient’s emotion—for example, repeats back the nature of the patient’s emotion or concern—and whether or not the clinician allows space for the patient to elaborate.”

If the clinician reduced rather than provided space, the researchers distinguished between giving information or advice vs trying to block further discussion of the emotional expression.

“Providing space” was divided into 5 subcategories:

  • Expressing empathy (a “verbal expression that shows clinician understanding of patient emotion”)
  • Focusing explicitly on the patient’s emotion
  • Exploring the emotional issue
  • Providing acknowledgment
  • Giving a passive response (silence, backchanneling, or non-explicit acknowledgment)

Physicians Are Pulled in Many Directions

Of the 41 clinicians included in the study, most were female (66%) and White (66%); however, most patients were male (64%) and African American (77%).

The mean length of visit was 30.4 minutes, with 67% of visits containing at least 1 emotional expression. In total, there were 1028 emotional expressions that took place over the 342 recorded encounters, with a little over a half (51%) taking place initially, and the remainder (49%) being repetitions of previously stated emotions. Although emotional expressions took place throughout the visit, the mean (SD) time at which they took place was at 10.1 (9.2) minutes (range, 0.05-40.6 minutes).

Most clinicians’ responses (81%) “broadly provided space” for the patient to elaborate on the emotion, and over half of responses (56%) were nonexplicit. When clinicians gave specific responses, most were neutral/passive, followed by asking questions that explored the patient’s emotional expression, acknowledging the emotion/circumstance, or giving information/advice.

The least common were responses categorized as empathy (only 5%) and responses blocking the patient from talking more about the emotion (6%).

The clinicians’ responses changed as the visits progressed; with each passing encounter minute, the odds of a clinician providing space for the patient to elaborate on an emotional expression significantly decreased by 4%, while the odds of the clinician being explicit significantly increased by 2%.

Patients were more likely to repeat emotions when clinicians provided space and less likely to do so when the clinicians were explicit (OR 2.33 [95% CI 1.66-3.27] and OR 0.61 [0.47-0.80], respectively). “This appears to have been largely due to the higher odds of repeating emotions after a neutral/passive response and lower odds of repeating emotions after space-reducing responses,” Dr Beach explained. Further adjustment for clinician and patient age, sex, and race/ethnicity did not alter these results.

Those visits in which clinicians provided (as opposed to reduced) space were associated with a more protracted visit (2.95 minutes longer) in unadjusted analyses, as well as in analyses that accounted for clinicians’ tendency to respond with less space as the visit continued (1.75 minutes longer), with both findings deemed “significant.” However, the finding lost its significance when the researchers further adjusted for clinician and patient age, sex, and race/ethnicity (P = 0.19).

Importantly, visits were 4.11 minutes shorter when clinicians’ responses explicitly focused on patient affect, even after the researchers adjusted for multiple factors, such as clinician and patient age, sex, and race/ethnicity and changes in clinician responses over time as the visit progressed (P < 0.05).

There were no associations found between empathetic clinician responses and visit length.

“We found that visits are indeed shorter when the clinician is explicit in their response, which suggests that there is a time-saving effect of addressing patient emotion,” Dr Beach commented.

“On the other hand, and this shouldn’t be surprising, we also found that visits are longer when the clinician allows space for the patient to talk more about this situation. And so this is probably why clinicians have the impression that addressing patient emotions takes more time,” she said.

Dr Beach emphasized that physicians want to address patients’ emotions and “take care of people holistically,” but they are “under so much time pressure that they are pulled in different directions and need to make decisions about how best to spend the limited amount of time that they have.”