ReviewThe influence of medical students’ and doctors’ attachment style and emotional intelligence on their patient–provider communication
Introduction
Effective patient–provider communication (PPC) is important for patients’ health and well-being and for the delivery of high quality medical care [1], [2]. As such, it is outlined by regulatory bodies as a core component of clinical practice [3], [4], [5] and its principles are taught and assessed during UK undergraduate and postgraduate medical education [6], [7]. One aspect of effective PPC is the ability to identify patients’ emotional distress and respond in an appropriate manner, congruent with patients’ needs [8]. Patients rarely explicitly vocalise emotional distress and rather hint to it during consultations [9]. Detection and appropriate management of such distress may therefore be difficult [10], [11], [12] and require both parties to engage in emotive discourse. Lack of identification of, or inadequate responding to, patients’ emotional distress can lead to a number of negative iatrogenic outcomes, including incorrect diagnoses or treatment and unnecessary referrals. In addition, patient satisfaction and trust in the doctor may be negatively affected [13], [14], [15]. It is therefore important to identify individual characteristics of doctors that may influence their PPC, such as their attachment style and emotional intelligence (EI).
Attachment style develops in early childhood and consists of thoughts, feelings and expectations regarding close relationships [16], [17]. Two dimensions of adult attachment have been identified: attachment anxiety (in which high scorers display over-involvement in emotive situations or feelings) and attachment avoidance (in which high scorers display avoidance of intimacy and emotional expression, and suppression of feelings) [18]. Individuals can also be classed into one of four attachment categories based on their dimensional scores. Securely attached individuals are able to seek support from others, communicate their needs and find others accessible and responsive during times of need [16], [17]. Adults with preoccupied attachment display strong dependency on others to maintain positive self-regard, desire for social contact that is inhibited by fear of rejection and tendency to seek close relationships to meet security needs [16], [17]. Dismissing-avoidant individuals display avoidance of closeness with others due to negative expectations, denial of the value of close relationships, discomfort in trusting others and detachment from emotion and need for others when distressed [16], [17]. Finally, fearful-avoidant individuals display mistrust of themselves and others, dependence on others for self-worth and avoidance of relationships due to negative expectations of others [19], [20]. Adults with preoccupied, dismissing-avoidant or fearful-avoidant attachment style are often referred to collectively as ‘insecurely attached’ [16], [17].
Most research into the influence of healthcare providers’ attachment style on their PPC has been conducted in psychotherapy or mental health settings [20], [21], concluding that securely attached care providers may be better able to respond appropriately to patients exhibiting emotional or psychosocial cues of emotional distress than their insecurely attached counterparts [20], [22]. Securely attached providers can respond to and explore patients’ hints and cues to underlying health worries and are more likely to communicate in a flexible, problem-based, patient-centred way [20]. Attachment theory may therefore provide a theoretical framework for explaining differences in emotional regulation and the likelihood of recognising and engaging appropriately with patients’ emotions across a wide range of situations. Medical students’ and doctors’ attachment style may therefore aid or impede their PPC depending on where they score on the two attachment dimensions [23].
Given the relatively fixed and enduring nature of attachment style [24], [25], educational implications arising from such research might be limited to raising medical students’ and doctors’ awareness about its possible influence. However, a developmental and malleable individual factor linked to PPC is EI [26], [27], [28], [29], “a type of social intelligence that involves the ability to monitor one's own and other's emotions, to discriminate among them, and to use this information to guide one's own thinking and actions” [30]. Research into the role of EI in medicine suggests that EI may foster patient–provider relationships due to its links with interpersonal skills and empathy, compassion, sensitivity, impulse management and stress management [31], [32], [33]; EI may therefore also form a theoretical framework for the study of individual differences in PPC.
Attachment style and EI are not independent of each other; rather, emotional management and regulation develop in childhood partly as a function of an individual's attachment style [34] and this relationship continues into adulthood, with securely attachment positively related to emotional regulation strategies that minimise stress and emphasise positive emotions [35]. Attachment style is related to branches of EI and related communication, including ability to manage emotions [36], interpersonal skills [37], expressivity and disclosure [37], conversational regulation [38], conflict resolution [39] and interpersonal sensitivity [40]. However, whilst attachment is perceived as resistant to revision and change through life [41], EI is developmental, increasing with age and experience [42].
Whilst considering the role of attachment in medical education, it is therefore important to bear in mind the complex interplay between attachment and emotional management and regulation, particularly from an educational standpoint. No published reviews have, as yet, considered the interplay between these concepts. The purpose of this systematic review was therefore to examine the published evidence regarding medical students’ and doctors’ attachment style, EI and their PPC, identify gaps in the current literature and to propose practice implications. Based on the empirical and theoretical literature outlined above, the following review questions were explored:
- 1.
What is the relationship between medical students’ or doctors’ attachment style and their PPC?
- 2.
What is the relationship between medical students’ or doctors’ EI and their PPC?
- 3.
What are the combined influences of medical students’ or doctors’ attachment style and EI on their PPC?
Section snippets
Methods
The systematic review was guided by the general principles recommended by the Centre for Reviews and Dissemination (CRD) [43] to ensure rigour and transparency. After several scoping searches, a comprehensive search strategy was employed to identify relevant literature. Medline, psycINFO, CINAHL and Embase were searched for relevant published literature from their inception through to January 2013. These databases were chosen to be as comprehensive as possible. The search combined index terms
Number of studies identified and included
A total of 1597 non-duplicate records were identified by the search strategy and subsequently screened for inclusion in the review. Fourteen studies filled the inclusion criteria and were included [28], [29], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55]. Twelve were published in peer-reviewed journals [28], [29], [44], [45], [46], [48], [49], [50], [51], [52], [53], [54]; the remaining two were doctoral theses [47], [55] (see Fig. 1 for flow diagram of inclusion). Data
Discussion
The purpose of this review was to systematically identify and synthesise the findings of studies reporting associations between attachment style and/or EI and PPC.
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