Cerebral Imaging
Patient-centered interviewing is associated with decreased responses to painful stimuli: An initial fMRI study

https://doi.org/10.1016/j.pec.2012.10.021Get rights and content

Abstract

Objective

To identify the functional magnetic resonance imaging (fMRI) changes associated with a patient-centered interview (PCI) and a positive provider–patient relationship (PPR).

Methods

Nine female patients participated, five randomly selected to undergo a replicable, evidence-based PCI, the other four receiving standard clinician-centered interviews (CCI). To verify that PCI differed from CCI, we rated the interviews and administered a patient satisfaction with the provider–patient relationship (PPR) questionnaire. Patients were then scanned as they received painful stimulation while viewing pictures of the interviewing doctor and control images (unknown doctor).

Results

Interview ratings and questionnaire results confirmed that PCIs and CCIs were performed as planned and PCIs led to a much more positive PPR. We found significantly reduced pain-related neural activation in the left anterior insula region in the PCI group when the interviewing doctor's picture was shown.

Conclusion

This study identifies an association between a PCI that produced a positive PPR and reduced pain-related neural responses in the anterior insula. This is an initial step in understanding the neural underpinnings of a PCI.

Practice implications

If confirmed, our results indicate one neurobiological underpinning of an effective PCI, providing an additional scientific rationale for its use clinically.

Introduction

Research in healthcare communication and clinical medicine indicates that patient-centered interviewing (PCI) enhances the provider–patient relationship (PPR) and, in turn, improves health outcomes [1], [2]. This makes the PCI a critical tool for medical care, research, and education. Nevertheless, at least two related factors have impeded the full integration of PCI into mainstream medicine: (a) failure to define PCI in the replicable, behavioral terms needed to conduct interventional research and (b) the absence of an established neurobiological basis for PCI and the PPR. These criticisms have led some to eschew PCI practices, dismissing them as ‘soft science’ [3]. Our group developed an evidence-based, behaviorally defined PCI method that enabled us to study the PCI experimentally and, in this particular case, to better understand its neurobiological underpinnings [3], [4], [5], [6], [7], [8].

Finset and Mjaaland [9] recently proposed a neurobehavioral theory that identifies affect regulation as an immediate outcome of PCI, yet despite the prevalence of fMRI methods, we are aware of no actual research to explore the neurobiological basis of a PCI when it is associated with a positive PPR. However, the Finset and Mjaaland model is consistent with evidence emerging from recent fMRI studies of other dyadic relationships [10], [11]. These studies indicate that emotion regulation presents one possible benefit-conferring mechanism associated with a positive relationship. For example, Coan et al. [10] measured brain activity in women subjected to threat of electric shock while holding their husband's hand, the hand of an anonymous male, or no hand at all. The brain response in neural systems including the anterior insula showed a pervasive attenuation of activation when the women held their husband's hand. The anterior insula has been known to substantiate interoceptive awareness [12] but it is increasingly thought to subserve the broader function of integrating afferent physiological signals with higher order contextual information [13], [14].

More recently, Eisenberger et al. [11] examined pain-related brain responses when women in long-term romantic relationships viewed pictures of their partner versus a stranger. These investigators also report reductions in pain-related neural activity in the anterior insula. The findings are consistent with the notion that positive attachment relationships can modulate reactions to perceived pain (threats, more broadly), i.e., positive attachment figures act as emotion regulators in ways that strangers or negative attachments do not [10]. These findings also suggest that out of the network of regions involved in pain or threat processing, the anterior insula region is a key site of modulatory effects.

Deriving an experimental paradigm from those above, we measured brain activation during the anticipation and experience of pain stimulation in patients following a PCI or a standard clinician-centered interview (CCI). Thus, we focus on the period shortly after the interview to assess the neurobiological impact of PCI and the resultant positive PPR. Such an experimental paradigm circumvents practical and interpretive challenges of studying the actual provider–patient interaction while the patient is inside the scanner. To extend the impact of the PCI on the PPR, following the interview, we had the PCI interviewing doctor oversee preparation for scanning and showed his picture during half of the scans. We hypothesized that, compared to a CCI, patients who received a PCI would show significantly reduced pain-related activation in the anterior insula region during the anticipation and experience of painful stimulation while viewing a photograph of the interviewing doctor versus a control image (unknown doctor).

Section snippets

Overview

Following random allocation with matching for age and SES, each patient took part in a 20–25 min interview, either a PCI or CCI. Next, just prior to the fMRI session, each patient's pain threshold was determined, defined as the point at which electrical stimulation is aversive but tolerable. Perception threshold was also determined, defined as the point at which stimulation is imperceptible. As an extension of the PCI and CCI interventions, this preparation for the fMRI scans was overseen by the

Intervention delivery and impact on the PPR

As expected, shown in Table 2, PCI subjects had significantly higher scores for patient-centeredness compared to CCI subjects for Steps 3 (p < 0.01) and 4 (p < 0.03), but not for Steps 1, 2, and 5, thus confirming accurate implementation of the PCI intervention. Furthermore, shown in Table 3, PCI patients reported significantly higher satisfaction with the PPR, demonstrating that the PCI produced positive PPR changes. Significantly higher scores for the PCI group were observed for all four factors

Discussion and conclusion

These findings represent the initial step in identifying the neural underpinnings of a PCI when associated with a positive PPR.

Disclosure statement

We confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.

Acknowledgements

We would like to thank the Chairs of Radiology, James Potchen and Thomas Cooper, for their encouragement and support of this research.

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