PS2-17: What Happens When Adult Patients Cry in Primary Care Visits?

Abstract

BACKGROUND: Even if they are unfamiliar with mental health assessment tools, any physician can recognize the level of distress associated with crying by an adult. Didactic training in medical education on how to address significant emotional distress is inadequate. The literature is relatively silent on what primary care physicians should do besides show detached concern when this occurs. This study specifically seeks to understand what brings a patient to cry during a visit and how primary care physicians respond to such a sign of distress. METHODS: In-depth qualitative study of audio-recordings of 9 adult patients' primary care office visits with 5 physicians in which the patient cried. We used content analyses to explore the underlying reason(s) that led apatient to cry and the physician's response to the patient's crying. A multidisciplinary team of researchers from health services, economics, sociology, anthropology, medicine, and psychiatry performed the analyses. Population consisted of insured adult patients aged 50- 80 years of age who scheduled a routine annual check-up with their primary care physician between 2006 and 2008. RESULTS: We found that a common trigger was acute or prolonged bereavement over the death of a loved one. Suffering from emotional pain was the main precipitator for patient's crying. Physicians' responses to patient crying were mixed, ranging from immediate or delayed statements of empathy to lack of any expression of empathy, despite the obvious signal of crying. Assessment of mental health by the physicians was inconsistent, ranging from thorough investigation to dismissive comments. Among those not under any mental health treatment before the recorded visit (n=7), two patients explicitly requested treatment for their psychological distress. Both were marginally evaluated for symptoms of depression, and only one of them was given an antidepressant prescription and referral to behavioral health. The other patient was offered watchful waiting. Two additional physicians recommended behavioral health specialty care to two other patients, of which one accepted the referral while the other declined. Only four patients were briefly assessed for suicidality. Follow-up care planning was rather inadequate. Two patients were already under the care of a behavioral health specialist (n=2). Care coordination appeared lacking. CONCLUSION: Some adult patients cry during annual visits, presenting an opportunity for primary care providers to assess for and recognize the level of distress and take actions to treat or to refer to specialty mental health providers. Only a few physicians were empathic in their responses and followed guidelines for treatment of depression or other mental disorders. While some primary care physicians note that not having physical measurements to diagnose mental illness prevents them from recognizing them, a patient crying during a visit can be viewed as clear signal of patient distress and a possible need for professional help to alleviate suffering. Training on how to empathically treat a crying patient should be enhanced in undergraduate and graduate medical training or continuing medical education.