Do doctors’ attachment styles and emotional intelligence influence patients’ emotional expressions in primary care consultations? An exploratory study using multilevel analysis

Highlights

• We coded 173 video-recorded primary care consultations using the VR-CoDES.

• Doctors’ attachment styles and emotional intelligence influenced patients’ cue presentation.

• The influence of doctors’ attachment and EI on patient cues varied according to patients’ presenting complaints.

• The results support a model of clinical communication proposed by the authors.

Abstract

Objective

To investigate whether and how doctors’ attachment styles and emotional intelligence (EI) might influence patients’ emotional expressions in general practice consultations.

Methods

Video recordings of 26 junior doctors consulting with 173 patients were coded using the Verona Coding Definition of Emotional Sequences (VR-CoDES). Doctors’ attachment style was scored across two dimensions, avoidance and anxiety, using the Experiences in Close Relationships: Short Form questionnaire. EI was assessed with the Mayer-Salovey-Caruso Emotional Intelligence Test. Multilevel Poisson regressions modelled the probability of patients’ expressing emotional distress, considering doctors’ attachment styles and EI and demographic and contextual factors.

Results

Both attachment styles and EI were significantly associated with frequency of patients’ cues, with patient- and doctor-level explanatory variables accounting for 42% of the variance in patients’ cues. The relative contribution of attachment styles and EI varied depending on whether patients’ presenting complaints were physical or psychosocial in nature.

Conclusion

Doctors’ attachment styles and levels of EI are associated with patients’ emotional expressions in primary care consultations. Further research is needed to investigate how these two variables interact and influence provider responses and patient outcomes.

Practice implications

Understanding how doctors’ psychological characteristics influence PPC may help to optimise undergraduate and postgraduate medical education.

Introduction

Effective patient-provider communication (PPC) is an integral part of high-quality healthcare [1], [2]. In addition to aiding effective diagnosis, treatment, referral and decision-making, effective PPC confers a number of patient benefits, including greater satisfaction with the standard of care, increased understanding of health concerns and treatment options, better recall of information and increased treatment adherence [3], [4], [5], [6], [7], [8], [9], [10]. As such, PPC is identified by regulatory bodies as a core component of clinical practice [11], [12], and is an integral part of undergraduate and postgraduate medical education curricula worldwide [1], [13], [14], [15], [16].

Effective PPC arguably plays a particularly valuable role in primary care, given that, in the United Kingdom, primary care consultations often represent patients’ first access to medical or mental health services [17], yet last, on average, only 7 to 10 min [18]. However, there remains substantial variation in primary care providers’ ability to identify and respond to patients displaying signs of emotional distress, indicating a need for targeted investigation of the factors associated with individual differences in their PPC [19]. Two related psychological theories may provide a theoretical framework for understanding why providers demonstrate different PPC behaviours when faced with the same situational stimuli: attachment theory, and the theory of emotional intelligence (EI) [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34].

Attachment theory is a theory of psychosocial development, which posits that individuals form enduring patterns of interpersonal behaviour through internalisation of interactions with their primary carer(s) in infancy [35]. These patterns are represented cognitively in the form of an internal working model (IWM) of attachment, which subsequently influences behaviour in close relationships throughout the lifespan, particularly care-giving or care-seeking relationships such as the patient-provider relationship [23], [35]. Two main dimensions of adult attachment have been proposed: attachment anxiety (characterised by habitual preoccupation and over-involvement in close relationships combined with fear of abandonment), and attachment avoidance (characterised by difficulty in trusting others, devaluation of close relationships and avoidance of intimacy) [36]. Emotional intelligence develops in childhood partly as a function of attachment style [37], and can broadly be defined as the ability to understand, perceive, use and manage their own and others’ emotions [38]. As such, EI is a multifaceted ability which encompasses skills in not only empathy (the ability to understand and share another’s emotions) but also in emotional regulation, management and self-perception [38].

Prior research indicates that both attachment style and EI are independently associated with PPC, particularly providers’ abilities to acknowledge and respond to patients’ cues of emotional distress [20], [22], [39], [40], [41], [42]. However, whilst attachment is thought to remain relatively stable throughout the lifespan [43], EI is developmental [44] and can be enhanced throughout medical education using targeted educational interventions [45], [46].

Informed by these data, we developed a theoretically-informed model of PPC in which we hypothesised that attachment would indirectly influence providers’ PPC by negatively influencing their EI. We tested this model in first- and second-year medical students, communicating in a summative Objective Structured Clinical Examinations (OSCE) [20], [22]. In both studies, support for this model was gained, but interestingly, EI had a stronger influence when more global PPC competence was considered [47]. Collectively, these data provide insight into the influence of early-year medical students’ attachment styles and EI on their PPC during early undergraduate medical education, and have important educational implications for undergraduate medical curricula. However, the generalisability of these findings to real life clinical practice is unclear, given that medical students’ PPC with patients in simulated settings may differ significantly from their PPC with real patients in a clinical setting [48], [49]. The current study aims to builds on the findings of Cherry et al. [20], [22] by investigating whether and how doctors’ attachment styles and emotional intelligence (EI) influence real patients’ emotional expressions in general practice (GP) consultations. By doing so, we will be better able to make theoretically-informed and evidence-based suggestions on how to improve undergraduate and postgraduate training and education.