Patient initiation of information: Exploring its role during the mental health intake visit

Abstract

Objective

Describe the role of patients’ initiation of information in patient–provider communication during mental health intake visits.

Methods

One hundred and twenty-nine mental health intake visits of diverse racial/ethnic patients were videotaped. Semi-structured interviews were conducted with patients and providers following each intake visit. We qualitatively analyzed the interviews to identify themes related to patients’ initiation of information. We quantitatively analyzed the videos of the intake visits utilizing a checklist that identified whether the patient or the provider initiated the information exchanged.

Results

Patient initiation of information affected providers’ evaluation of the credence of the information, assessment of rapport and appraisal of the success of the intake visit. Patients’ initiation of information varied with patients’ race, age and prior treatment experience; and provider's age, discipline and experience. Patients expressed a personal preference either to not be interrupted or to be asked questions by their providers.

Conclusion

Our findings illuminate the role of patient initiation of information in provider decision-making and highlight the importance of tailoring the communication style to patients’ preferences.

Practice implications

Encouraging explicit communication with patients about expectations related to information exchange styles is recommended. Improving provider awareness of assumptions regarding their decision-making is also suggested.

Introduction

The intake visit is often the first point of contact between patients seeking mental health services and providers. It usually includes a clinical interview which holds multiple aims, including but not limited to: establishing diagnosis, facilitating rapport, providing psycho-educational tools, and planning treatment [1], [2], [3]. Despite its importance for determining patient care, the intake visit has been subject to little empirical investigation [4], [5], [6]. Furthermore, there is a lack of information as to how clinicians integrate the information gathered as part of the intake visit to guide their decision-making.

Communication between patients and providers has attracted increasing attention, with research documenting its role in establishing rapport, improving information exchange, and facilitating clinical decisions [7]. Recent models of clinical interviewing such as the client centeredness model [8] emphasize an egalitarian approach in the clinical encounter, particularly in terms of how patients’ participation and sharing of information is to be encouraged.

The concept of patient participation emerged from studies on patient–provider communication and has been defined in terms of patient communication style, based on the centrality of communication in involving patients in their care [9], [10], [11], [12]. Although it received little attention, the importance of who initiates the information exchanged between patients and providers can be regarded as a key element in the concept of patient participation.

Information initiation is of particular interest in mental health encounters, where patients’ illnesses can directly affect their capacity to communicate with their providers [13]. This dilemma is of interest given the effect patients’ communication can have on providers’ decision-making. For example, when communicating with high-participation patients, clinicians volunteered more information relative to communicating with low-participation patients [12]. Similarly, other studies have found that patients who asked more questions received more information from their providers [9], [10]. Patient characteristics such as emotional distress were associated with increased initiation of new information by the patients, as well as passive, supportive listening by the provider, which was focused on the patient's emotions [14]. A time analysis of the medical encounter has documented that providers contribute about 60% of the clinical dialogue and patients the remaining 40% [15]. Typically, the contribution of patients to the dialogue consisted largely of information giving in response to providers’ questions [15].

The time spent on different topics in the medical encounter is influenced by different dimensions such as the nature and the initiator of the topic. Patients tend to speak longer if they initiate the topic [16]. Whether initiated or offered in response to provider questions, the patients’ provision of information regarding the histories of their illness, their needs, and preferences for care affords providers the data that they deem essential in making appropriate clinical decisions [17]. However, some patients report that they have not provided important information to their providers, including histories of their chief complaints [18]. Robinson and Roter [19] have found that the act of patients providing information is greatly influenced by the questions posed by providers. Patients are more likely to provide information about psychological distress to primary care physicians, if the provider asks about it.

In sum, research on patient–provider communication in the past two decades has been tied to patient care and satisfaction as well as provider decision-making during the medical encounter. However, little is known about the patient–provider communication process in mental health service delivery or the role of the initiation of information in the patient–provider encounter. In the current study we present a mixed methods investigation of the role of patient initiation of information in the patient–provider communication process during the mental health intake visit. We focus on the association between patient's initiation of information and provider's evaluation of the information and assessment of rapport. We also study patients’ preferences regarding initiation of information as well as patient and provider characteristics that are related to patient initiation of information.