Emotional concerns: the importance of GP-patient communication

In the UK, general practitioners (GPs) are the most commonly used providers of care for the emotional concerns of patients. The number of people going to GPs is very likely to increase after COVID-19 as experts are predicting a 'tsnami' of mental health problems after lockdown.

A recent systematic review of the research suggests that a positive relationship between the patient and GP facilitates effective communication around concerns the patient has about their emotional health, and its management. It also suggests that diagnosis is not strictly the domain of the GP, but rather a two way negotiated process.

A collaboration of academics from City, University of London, Plymouth University and the University of Exeter conducted the UK review as an update and expansion upon a similar review published in 2000. The current review paid particular regard to identifying barriers and facilitators to GP-patient communication, and the increasing role of the GP in managing patient's mental health problems.

Thirty research papers were included in the review, which involved 342 GPs and 720 patients across the studies.  These included studies that used both qualitative (non-numerical in nature) and quantitative (numerical in nature) methods to assess the GP-patient relationship in decision making about the patient's emotional concerns.

The term 'emotional concerns' is used in the review to capture the broad range of mental health problems commonly encountered in primary care, in the GP's surgery.  Studies included patients presenting with symptoms of anxiety and depression, 'psychiatric disorders', 'psychological problems', 'psychological distress' and 'mental health problems'. However, studies focusing on patients with more severe mental illness, such as psychosis, were excluded.

A 'thematic analysis' was performed on the study data, which is an approach for analysing qualitative data that has a focus on identifying themes (patterns of meaning) and coding the data accordingly.

Four themes relating to barriers to GP-patient communication that the analysis identified were:

• that emotional concerns are difficult to disclose for the patient. Symptoms such as low self-worth, pessimism about the future and guilt about wasting the GP's time caused patients to minimise their concerns.
• both GPs and patients reported tensions between understanding emotional concerns as a medical condition or resulting from social stressors.
• a lack of open discussion between GPs and patients about patients' preferences for control over their care, and this led to a mismatch in understandings, priorities or agendas, resulting in too little or too much patient involvement in decisions.
• the GP providing limited care driven by little time.  GPs described feeling that they needed to balance timekeeping with giving patients effective support. Another challenge for GPs was the lack of psychological services, such as talking treatment, available.

Three themes identified by the analysis that facilitated GP-patient communication were:

• that a human connection improves identification of a patient's emotional concerns. An empathetic and warm approach from the GP was particularly important to patients, as was having time to talk and being listened to. Being able to get things off their mind was a release for patients and intrinsically therapeutic.
• the GP exploring, explaining, and negotiating the nature of the patient's emotional concerns with them to reach a shared understanding. This was different to the more conventional 'diagnostic moment' in consultations where the diagnosis is delivered by the GP and involves GPs and patients varying understandings ranging from biomedical to social explanations. Simply allowing patients to talk and asking questions, such as 'how does it affect you?', helped patients to reflect on and clarify their experiences.
• upfront information provision about antidepressants and talking treatment and involvement of the patient by the GP manages the patient's expectations about recovery and improves engagement in treatment.

Professor Rose McCabe, director of the Centre for Mental Health Research, at City University of London said: "Treatment guidelines and training should further emphasise the crucial importance of the doctor-patient relationship in helping people to disclose emotional concerns which we know is very difficult for many people. If people do not trust their GP, they are less likely to disclose concerns and get the help they need. This relationship is also intrinsically therapeutic for people, many of whom do not find antidepressants or talking treatment relevant or helpful. Improving the doctor-patient relationship is not costly and has enormous untapped therapeutic potential."

The study was published in the journal, Family Practice.