Pediatric Residents' Responses That Discourage Discussion of Psychosocial Problems in Primary Care

Abstract

Objective. Studies spanning nearly 4 decades demonstrate that doctors ignore or dismiss many patient bids for discussion of psychosocial topics. We sought to understand characteristics of doctors, patients, and visits in which this occurs. Methods. Reanalysis of 167 audiotapes from 2 studies of parent-doctor communication in a pediatric residents' continuity clinic was performed. Tapes included visits by 100 mothers or female guardians to 55 residents who were the children's primary care providers. Coders identified mentions of psychosocial topics and noted the content and the doctor's response. Responses were classified with an adaptation of a previously described, psychoanalytically derived typology of avoidant or discouraging responses. Results. Discouraging responses occurred in 34 (77%) of 44 discussions that involved corporal punishment and 51 (34%) of 64 discussions that involved other psychosocial topics. The particular topic (parent/family versus routine parenting issue) and how the topic was framed (as a problem versus simply mentioned) were associated with doctors' discouraging responses (OR: 3.07; 95% confidence interval: 1.56–6.05; and OR: 7.57; 95% confidence interval: 3.50–16.44; respectively). Discouraging responses were not related to the doctor's gender, parent's ethnicity, length of the parent-doctor relationship, or doctor's overall interview style (patient-centeredness). Discouraging responses to routine problems tended to be dismissive, but 41% of discouraging responses to parent/family problems were failed attempts to provide advice. Conclusions. Discouraging responses seem to be related less to doctor or patient characteristics than to the type and acuity of the psychosocial topic. These responses may originate with doctors' discomfort with particular subject areas and thus might be approached with training that combines communication and emotion-handling skills with clinical tools such as Bright Futures in Practice: Mental Health or the International Classification of Diseases, 10th Revision, Primary Care.