How family physicians respond to unpleasant emotions of ethnic minority patients

Abstract

Objective

The diversity in our society makes patient-centered care more difficult. In this study, we aim to describe how family physicians respond to unpleasant emotions of ethnic minority patients.

Methods

One hundred ninety one consultations of family physicians with ethnic minority patients were video-recorded and analyzed using the Verona Codes for Provider Responses (VR-CoDES-P) to describe physicians’ responses to patients' expressed unpleasant emotions or cues (implicit) and concerns (explicit).

Results

42.4% (n = 81) of all the consultations contained no cues or concerns, and thus no physician responses. Of the consultations containing at least one cue or concern, a mean of 3.45 cues and a mean of 1.82 concerns per consultation were found. Physicians are significantly (p ≤ 0.001) more frequently stimulating further disclosure of patients' cues and concerns (providing space: n = 339/494 or 68.6% versus reducing space: n = 155/494 or 31.4%). However, these explorations are more often about the factual, medical content of the cue than about the emotion itself (n = 110/494 or 22.3% versus n = 79/494 or 16%). The inter-physician variation in response to patients’ cues is larger than the variation in response to the patient’s concerns.

Conclusions

Although family physicians are quite often providing room for patients' emotions, there is much room for improvement when it comes to explicitly talking about emotional issues with patients.

Practice implications

Further research should focus on a more qualitative in-depth analysis of the complex interplay between culture and language of ethnic minority patients in primary care and, consequently, create awareness among these healthcare providers about the importance of ethnic minority patients’ emotions and how to respond accordingly.

Introduction

Over the past two decades, there has been a global migration of people from and to various places in the world [1]. In 2007, Vertovec introduced the term super-diversity to emphasize the level of complexity of today’s society, a transformation that affects all Western countries [1]. According to the official numbers in 2014, 46,811 foreigners arrived in the Flemish part of Belgium for a long stay (more than three months), which means that immigration has doubled compared to numbers in 2000 [2]. In Brussels, for example, the capital of Belgium and Europe, two out of every three residents are immigrants, making it a majority minority city where the native population has become a minority [3]. Our super-diverse society exudes multiculturalism due to the interplay of various dynamic variables, such as country of origin, migration channel, and legal status, leading to new and complex social formations [1]. For the local healthcare system, and in particular primary care services, this shift has many implications and entails various challenges, of which the language barrier and its consequences is one of the most challenging obstacles [4].

Primary care in Belgium, represented by family physicians, is mostly the first contact for every patient. During these medical encounters patients often express various emotions that are intrinsic to their health and illness perceptions [5]. The way physicians respond to these explicitly or implicitly expressed emotions will have an influence on patients’ outcomes. Friendliness, warmth and empathy expressed by the physician is associated with lower levels of anxiety and uncertainty, which improves trust between both and leads to an increase in patient satisfaction and adherence [6], [7], [8].

Studies in primary care have shown that affective communication is often a challenge for physicians, in particular in encounters with ethnic minority patients [9], [10], [11]. Previous studies have revealed that, compared to encounters where physician and patient share the same culture, in encounters with ethnic minority patients both physician and patient behave differently toward each other. In the latter, there is less affective behavior, such as less social talk and empathy, and they are less emotionally engaged with each other [9], [10], [11], [12]. Furthermore, both patient and physician communicate differently about unpleasant emotions [12], [13], [14], [15]. While ethnic minority patients reveal fewer emotional cues, physicians show less positive affect and a lower degree of patient centered response with ethnic minority patients [15], [16]. Nevertheless, ethnic minority patients find a physician's display of concern, courtesy and respect very important [17]. This affectively imbalanced relationship between physicians and ethnic minority patients not only hinders further contact between both, but also decreases the chance of reaching a mutual understanding of the patient’s health complaints and delivering an adequate treatment plan based on a shared decision [10].

Previous studies already examined cues and concerns expressed by ethnic minority patients [9], [10], [11], [15], [18]. While some of these studies mainly focus on the comparison between native patients and specific ethnic minority patient groups [9], [10], [11], others focus on specialist care [18].

While Schouten & Schinkel [11] concluded that migrant patient-related factors may influence the amount of cue expression in primary care, they also stated that this study should be replicated in a more heterogeneous migrant sample. This study answers to this specific request, as well as to the underlying principle of the super-diverse society [1], making it, to our knowledge, the first that studies general practitioners’ responses to the expressed cues or concerns of ethnic minority patients of all origins in relation in family practice.

The aim of this study is to gain a deeper insight into the emotional communication of intercultural consultations in primary care in Belgium. In particular, we aim to explore the responses of family physicians to the expressed negative emotions of ethnic minority patients during medical consultations.