Physicians privilege responding to emotional cues in oncologic consultations: A study utilizing Verona Coding Definitions of Emotional Sequences

Abstract

The aim of this study was to describe emotional cues and concerns expressed by cancer patients and their physicians using video-recorded regular oncology consultations. The consultations were divided into units of analysis and coded according to the Verona Coding Definitions of Emotional Sequences system. The study design was mixed, descriptive, and exploratory. Twelve patients and eight oncologists participated in the study. The patients expressed 349 cues/concerns during the 12 consultations. The majority (68.8%) of the content consisted of non-explicit description of physiological and stress episodes in the disease and treatment. Physicians demonstrated that they recognized fewer underlying cues than those related to physiological complaints.

Keywords

cancer communication emotions health psychology worry

Introduction

Recognizing and dealing with patients’ emotions is a challenging task for health care providers. The main difficulty is to identify the underlying concerns and cues related to the medical condition (Eide et al., 2011) and to explore the emotional content of patients in medical consultations. There is an interest in assessing the concerns patients report and how health professionals, especially physicians, respond to these concerns (Gorawara-Bhat et al., 2017; Grimsbø et al., 2012; Kale et al., 2013; Zimmermann et al., 2007). Previous studies (Korsvold et al., 2016, 2017) show that patients constantly express cues and concerns about cancer and that these are rarely identified and responded to by health care providers. Less explicit communication of underlying concerns of patients and their families is sometimes responded to by physicians with technical information without comments on the emotional aspect indicated by the cues during consultation.

Emotional expressions consist of cues and concerns from patients’ verbal and nonverbal communication with professionals. The identification of these negative expressions and feelings communicated by patients implicitly or explicitly allows physicians to direct their actions based on empathy, favoring patient-centered communication from a biopsychosocial model (Del Piccolo, 2017; Heyn et al., 2013). In general, the expression of the patient’s emotions may change as the physician explores and develops the conversation. In addition, cues and concerns can be initiated or facilitated by health care providers to encourage patients to express their emotions (Del Piccolo et al., 2011).

In the oncologic context, a study (Humphris et al., 2019) investigated the emotional communication of breast cancer patients in review consultations during radiotherapy and explored the fear of the occurrence of relapses in up to 8 weeks of follow-up. Patients expressed many concerns about relapse, presenting physical symptoms, fear, and uncertainty about the efficacy of the treatment, and characterizing underlying emotional cues. The study provided evidence that even the patients who clearly express their concerns are not always understood and cared for by their physician. As a result, physicians, unrecognizing these concerns, may reinforce that the patient does not express psychological symptoms at the consultation (Humphris et al., 2019). Expressions such as fear, anger, and sadness are verbalized by cancer patients in medical consultations. On the other hand, physicians tend to respond more emphatically when cancer patients express intense emotions (Kennifer et al., 2009).

Emotional communication in medicine includes identifying cues and emotional concerns and how physicians respond to these emotional expressions (Clayton et al., 2014; Juslin and Persson, 2011). An international group of researchers in the field of health communication (Zimmermann et al., 2011) has developed an instrument called the Verona Coding Definitions of Emotional Sequences (VR-CoDES), which allows coding expressions of emotional distress of patients at medical consultations and interventions by health care providers regarding the expressions of emotional concerns. The literature indicates that 50 international empirical studies have already tested the VR-CoDES (Del Piccolo, 2017). These studies were conducted in different contexts and with different health care providers, such as dental surgeons, psychiatrists, pediatricians, and medical and veterinary students (Del Piccolo et al., 2012; Ortwein et al., 2017; Vatne et al., 2010; Vijfhuizen et al., 2017; Wright et al., 2012). Considering communication as a key tool in provider–patient interaction, the aim of this study was to describe cues and emotional concerns of cancer patients and physicians’ responses to their expressions using the Verona Coding Definitions for Emotional Sequences (VR-CoDES).

Methods

Study design

This is a mixed, descriptive and exploratory study of 12 video-recorded medical consultations.

Participants

The study included 12 cancer patients aged 36 to 84 years of age (M = 63.25 years; SD = 15.70 years), 8 women and 4 men, most with complete higher education (n = 7) and who were on cancer treatment for an average of 28.42 months (SD = 38.59 months). Half of the patients underwent psychological treatment and most (n = 8) used psychopharmacological medication, including 6 on antidepressants. The patients were being treated on an outpatient clinic in a private hospital in a city in southern Brazil, attended by health insurance. Only routine outpatient consultations during treatment were included, and the first consultation, when the diagnosis was disclosed, was excluded. Patients underwent at least one type of treatment (chemotherapy, radiotherapy, and surgery). The selection of participants was by convenience among those patients who were in the hospital on the day of the consultation with the oncologist. Sociodemographic and clinical data are presented in Table 1.

Table 1.

Description of the sample (12 patients).

Patient	Gender	Age	Relative present	Physician	Reason for consultation	Diagnosis
1	Male	77	–	R1\D1	Routine	Bladder
2	Male	63	Daughter	D1	Routine	Melanoma
3	Female	73	–	D2	Revision	Polycythemia vera
4	Female	84	Daughter	D2	Prevention of kidney function	Myeloma
5	Female	41	Mother	D3	Drain Retention	Sarcoma
6	Female	36	Aunt	D3	Routine	Colon/bowel
7	Male	66	–	R2\D4	Routine	Prostate
8	Female	70	–	R2\D4	Routine	Breast
9	Female	84	Daughter	D1	Routine	Straight
10	Female	62	Daughter	D1	Routine	Ovary
11	Male	51	–	D5	Pre-surgical	Stomach
12	Female	52	–	D6	Routine	Breast

Eight physicians between 33 and 59 years of age (M = 42.88 years; SD = 8.39 years) with average working time of 17.50 years (SD = 11.14 years) also participated in the study as they were the health care providers to the patients described above. Four of the physicians had received some training in the subject of doctor-patient communication during their training. There were 12 consultations with an average time of 25.46 min (SD = 4.69 min), totaling 4.63 hours of recording. This number of participants is in agreement with the literature on the subject that uses a number ranging from 9 to 12 consultations with patients and health care providers using this type of method, since their analysis is quite laborious and detailed (Eide et al., 2011; Korsvold et al., 2016; Wright et al., 2012) The physicians’ sociodemographic and labor data are presented in Table 2.

Table 2.

Description of the sample of physicians.

Demographic/labor variables	n	(%)
Sex
Female	01	(12.5%)
Male	07	(87.5%)
Specialty
Oncology	04	(50%)
Hematology	01	(12.5%)
Onco-hematology	01	(12.5%)
Oncological surgery	01	(12.5%)
Internal medicine	01	(12.5%)
Education
Specialization	04	(50%)
PhD	01	(12.5%)
Master’s degree	01	(12.5%)
Medical residency (oncology)	06	(75%)

Procedures

The invitation to the participants was made by the first author (F.B.R.), involving a previous contact with the institution and the head of the oncology service of the outpatient unit. Upon acceptance by the head of the oncology service, contact with available oncologists was made in order to participate in the real-time research study on professional–patient communication in oncology. Authorization for video-recording of consultations with patients undergoing cancer treatment was requested, according to the Informed Consent Form (ICF), and the participating physicians were invited to complete the questionnaire on sociodemographic and labor data. Contact with patients was initially made in the waiting room while they were waiting for their medical consultation. The data collection period occurred in April and May of 2018.

Interaction analysis

The Verona Coding Definitions of Emotional Sequences Coding system (VR-CoDES) was used. It consists of three manuals: one for expressions of CC-cue/concerns, another one for the answers of health care providers (P-provider), and a third one for division into units of analysis (Del Piccolo et al., 2011; Zimmermann et al., 2011). The Verona Coding (VR-CoDES) has proven to be a reliable system for identifying and coding patient emotions and corresponding health care provider responses (Barracliffe et al., 2017).

The content of the consultations was extracted and coded by two pairs of independent judges with experience in clinical research. Disagreements between judges were discussed after the evaluation. A third judge (F) was asked to analyze the content of the consultations when there was disagreement between the codifications of the two pairs. From a sample of 12 transcripts, codes (K, M, and D) coded 1680 interventions as “no cue/concern.” The number of identified cues/concerns was 349 (20.77% of all units). The degree of agreement was assessed using Cohen’s kappa coefficient between two pairs of judges 1 (K and D) and 2 (K and M), respectively, 0.785 representing excellent agreement and 0.707 representing median agreement (Perroca and Gaidzinski, 2003). The analysis of the independent judges followed the recommendations of the VR-CoDES Manual, considering the divisions of analysis units of each consultation.

Statistical analysis

Descriptive and inferential statistical analyses were performed, with frequency, percentage, means, and standard deviation using the SPSS 20.0 software. To describe the coding of the patients’ cues and emotional concerns, the VR-CoDES defined concern as a clear expression of an emotion (e.g. “feeling concerned” “feeling anxious”) and cues as less explicit expressions of underlying emotions. The cues were divided into seven subcategories: (a), (b), (c), (d), (e), (f), and (g). Cues (a), (b), (c), and (g) refer to unclearly defined emotional content. In cues (d) and (e), the verbal content indicates that some terms used by patients have a neutral meaning in the way they express themselves (Pais and Figueiredo-Braga, 2017). Table 3 presents and describes each of these cues according to the VR-CoDES-CC Manual (Del Piccolo et al., 2011; Pais and Figueiredo-Braga, 2017; Zimmermann et al., 2011).

Table 3.

Description of the patients’ cues and concerns and the PE and HPE origin (N = 349).

		Type/definition	Number of expressions	Examples of elicited and cues/concerns
Emotion describing words	Concerns		14	“(. . .) I confess I was a little anxious, but now that you are speaking I see that we will see how to treat this together, aren’t we?” (consultation #11) (PE)
	Cues	a (vague words)	12	“I feel better day after day.” (consultation #05) (HPE)
		c (physiological content)	109	“I haven’t felt . . .. I haven’t felt hungry anymore. And I have now, I don’t know if it was this other treatment or if it’s the other . . .but I have been sick, my stomach is always sick. . .” (HPE) (consultation #02)
		e (content repetition)	25	“I’m “showing off” here, as I said to him, because for the people, my family, for the general good of the family, I’m “here” doctor, bothering you. (PE) (consultation #01)
		g (past expression)	03	“I had it 16 years ago, of course it was much worse. I didn’t have that sickness medicine. The sickness killed me. But pain in the joints, I don’t know if at the time I had any leukemia pain. It gave me no pain, but now I do . . .” (consultation #10)
Expressions of underlying cues		b (metaphor/underlying concern)	90	“Bring you a gift from the tomography” [hands over the material while smiling, fiddles with her cell phone] (PE) (consultation #06)
Expressions of underlying cues		d (neutral expression. highlighted)	72	“I have been lazy. I will not deny that. I was not lazy, but now I am so lazy” (HPE) (consultation #04)
Non-verbal cues		f (nonverbal expression)	24	“Yes, completely [moves his hands suggesting he/she does not care]” (HPE)(consultation #08)
Total		349

PE: patient elicited; HPE: health provider elicited.

The physicians’ interventions were coded as Explicit (E) and Non-Explicit (N) and respectively coded with the function of providing (P) or reducing space (E), according to the VR-CoDES-P manual. The explicitation of the response (E) indicates that the professional explicitly mentions the content and/or emotion present in the cue\concern (e.g. “what made you cry?). The non-explicit response (N) indicates that the professional does not mention the content and/or emotion revealed in the cue\concern (e.g. “How difficult is it for you . . .”). In the Explicit response that Provides Space (EP), the coding system subdivides it into Explicit Providing Space in relation to Content (EPC) and Explicit Providing Space in relation to Affect (EPA). Also, for each identified patient cue/concern, a physician response was coded. According to the Verona coding system (VR-CoDES-P), the responses to the cues/emotional concerns are presented in Figure 1.

Figure 1.

VR-CoDES manual. Codification of the responses of the health care providers.

Ethics

This study was submitted to the Research Ethics Committee of Unisinos University (proposing institution) and the Ethics Committee of the co-participating hospital, located in Southern Brazil, under No. 83879318.0.3001.5328. All ethical considerations provided for in the resolution of the National Research Ethics Council—CONEP No. 510/2016 and the Humanities Resolution No. 466/2012, which regulate research with human beings, were taken into account. All participants were informed about the objectives of the study, the risks and benefits of participating, the voluntary nature of their participation, the confidentiality of information, and the possibility of withdrawal at any time, and then they signed the ICF.

Results

Cues and concerns (frequency, types, initiation)

A total of 349 cues/concerns were identified from the 12 video-recorded consultations. In response to the cues/concerns, 394 response interventions from health care providers were identified. It is important to highlight that a response from the physician was coded for each identified cue/concern. Some cues/concerns received the function “postponed,” as the physician–patient interaction is a dynamic dialogue, and the physician’s response to the patient’s cue may be given after a few conversation turns. For this reason, the number of responses exceeding the number of cues given corresponded to the coding of postponed cues. Uncoded speech turns were considered “no cue/concern,” which totaled 1680 uncoded turns from the 12 transcribed consultations. The most often underlying emotional cues verbalized by patients during consultations were cue c (F = 109; 27.7%), cue b (F = 0; 22.8%), and cue d (F = 72; 18.3%).

The origin of the cues and concerns raised by the patients (PE) indicates the patient’s initiative or effort to direct the health care provider’s attention to specific problems. The origin of the cues and concerns raised, explored, or facilitated by the physician (HPE) indicates the space given to patients to explain their concerns without their having to take initiative. The results showed that patients raised more cues and concerns (F = 219; 55.6%) than the physicians (F = 175; 44.4%). The distribution of cues and emotional concerns expressed by the patients and the description of each subcategory of verbal and nonverbal cues followed and the classification of the PE and HPE origin are shown in Table 3.

Physician’s responses from cue and concerns

The interventions most commonly used by physicians in response to patient cues/concerns were Explicit with Space Reduction (ER) (F = 135; 34.3%) and Non-Explicit with Space Reduction (NR) (F = 111; 28.2%), indicating little openness to explore the patients’ emotions. Most of the responses consisted of technical and accurate information, such as explicit advice to reduce space (ERIa) for negative emotion expressions, which often prevented the conversation from continuing. In the same consultation, the physician could respond in different ways, sometimes providing space and sometimes reducing space for the patient. Physician’s interventions in response to patient’s cues and concerns were described following the VR-CoDES-P (Professional) manual. Table 4 presents some responses from physicians in different consultation fragments.

Table 4.

Description of the types of physicians’ responses (N = 394).

Type of response	Definition	N	Examples
Non-explicit reducing space (NR)	The physician does not explicitly refer to the cue\concern and reduces space for further conversation	111	“I am going to check your weight and as we talk I am going to examine you” (M6; consultation #12)“I will write this down, I have not taken notes about this echograph, wait a minute.” (M2; consultation #03)
Non-explicit providing spaces (NP)	The physician does not explicitly refer to the cue\concern and provides space for the patient to voice his/her concern	67	“Take your decision, let’s go, cross your fingers and it’s time to . . . let’s try to eliminate this.” (M3; consultation #06)“Yeah. . . . That’s it. Right.” (M4; consultation #08)
Explicit reducing space (ER)	The physician explicitly refers to cue\concern and reduces space	135	“I do not mean to say that it is different from what is expected, but it actually is different from the usual because some things appeared there that are . . . are not compatible even with a disease progression. Ah . . . well . . . the tumor has grown . . . now we find liver metastases. It doesn’t seem like it, but at the same time those changes were not on the tomography you did the first time.” (M5; consultation #11)
Explicit reducing space (ER)			“There are some patients being accompanied, not specifically by us, but in the world we will say so, and we are not sure yet what the outcome will be. So, every time you come here [laughs] you’ll hear it from me.” (M4; consultation #07)
Explicit providing space (EPC) content	The physician explicitly refers to the cue\concern and provides space for the content	69	“And, something else, you already follow survival averages, you know that, I’ve told you several times.” (M1; consultation #02)
Explicit providing space (EPC) content			“Be more specific about what, when it started and what the symptoms are . . .” (M6; consultation #12)
Explicit providing space (EPA) affect-emotion	The physician explicitly refers to the cue/concern and provides space for the affective aspect (emotion)	12	“You never gave up. You always had a very good view of the disease. That’s true.” (M1; consultation #02)
Explicit providing space (EPA) affect-emotion			“There are some patients of mine who have enjoyed the good side wonderfully. They turned the lemon into a lemonade.” (M3; consultation #05)
Total		394

The most commonly used subdivisions, derived from these codings, were Explicit Advice with space reduction function (ERIa) (F = 104; 26.4%) and Non-Explicit Advice with Ignoring space reduction (NRIg) (F = 68; 17.3%). The response with Content Exploration with the function of providing space (EPCEx) represented 11.2% of the physicians’ interventions. The least used responses by physicians were Emotion Exploration (EPAEx) (0.3%), Active Empathy (EPAEm) (1.3%), Emotion Recognition (EPAAc) (1.5%), and Active Invitation (NPAi) (1.3%). The average total of cues/concerns per consultation was 29.25 (SD = 24.07).

Discussion

The present study allowed the exploration of doctor–patient communication using the coding of emotional sequences and physicians’ interventions, applying the VR-CoDES system to medical consultations. In general, the cues most commonly used by patients were related to physiological content (e.g. “I’m getting thinner because the disease”\“I am not feeling well, I have pain”) and content using metaphors (e.g. “The whole work is under stress”) when expressing an underlying emotion. Physicians used more directive responses focusing on clinical information, counseling, and technical provision about cancer and treatment.

The analysis of the consultations revealed that physicians missed most of the cues/concerns verbalized by patients and frequently demonstrated behaviors that discouraged patients. These data are similar to those found in medical students (Ortwein et al., 2017) who use similar responses applied to clinical case vignettes of experienced physicians, based on the VR-CoDES system. Explicit and implicit empathic responses were infrequent, as were the exploration and recognition of emotions. Nevertheless, unlike Ortwein et al. (2017), in the case of the present study, the physicians are experienced in caring for cancer patients and seem to be predominantly focused on the provision of technical information on the disease and treatment. They considered the verbalization of physiological questions, and ended up using interventions with explicit counseling responses in informative and technical manner.

Probably due to difficulties in recognizing expressions of underlying emotions, although physicians had experience in treating cancer patients, they did not use openness and empathy skills to meet the patients’ psychological demands. Responses widely used reduced the space for the patients’ emotional content. The physicians’ lack of openness and counseling interventions and subject changes could also be seen in the context of neurology, when verbal cues about concerns and references to stressful life events were verbalized by patients with Multiple Sclerosis (Del Piccolo et al., 2015). Changing the patient’s subject may be recurrent in medical consultations because professionals concentrate on relevant clinical demands making the consultation more directive and problem focused. The biomedical model reinforces this characteristic of the physician in providing the patient with all the necessary information less concerned in meeting psychological demands that may emerge in relation to the disease, directly impacting on the working alliance (Meystre et al., 2013). Many space reduction interventions have been done by physicians and, when described in their subcategories, the specifications of subject change and explicit counseling confirm that it is still difficult for physicians to migrate to a biopsychosocial model. The interpersonal social relationship between doctor and patient can impact the decision-making process. Shared decision-making is a complex process involving clinical and emotional aspects. The socio-affective dimension of the doctor must be considered. Communicating bad news can generate negative feelings like helplessness in doctors (Restivo et al., 2018).

Emotion exploration responses were scarcely employed, showing that this sensitivity still requires attentiveness from physicians. When physicians can identify the psychological aspects announced by patients, they make the patients feel understood and supported (Zimmermann et al., 2007). Limited consultation time or haste may be a factor that prevents the physician from exploring the patient’s feelings (Del Piccolo et al., 2015). Reciprocity and empathy, as the condition of putting oneself in the other’s shoes, are necessary skills for physicians and are also highly valued by patients (Finset and Ørnes, 2017). One of the hypotheses to increase the recognition of patients’ emotions and make physicians’ interventions more empathic should be training in communication skills, which, despite the wide discussion in the literature, is still under-utilized in medical schools and health programs (Barros and Otani, 2012). The data from this study indicated that there are still limitations in the establishment of an effective communication between physicians and patients. Oncologic consultations have a heavy medical agenda and frequently difficult clinical decisions have to be made. On the other hand, the effort to provide space and respond more empathically demonstrates that physicians are attempting to better understand what patients verbalize in consultations. Effective communication between physician and patient demonstrates the physician’s skill to be empathetic and understanding with compassion for the patients’ illness during their treatment. In addition, providing a welcoming environment and the physician’s good mood can help patients not to give up treatment (McCarthy, 2014) when the severity of the oncological diseases imposes adherence. Reducing space for patients’ concerns can cause patients to keep their anxieties and fears to themselves or to repeat, sometimes at the consultation, discomforts and negative feelings about the disease that could have been resolved or at least heard by the physician. Thus, training in communication skills would enable physicians to increase clinical skills in exploring patients’ emotional expressions, impacting on psychological well-being, satisfaction with interpersonal care, and greater understanding of treatment (Epstein et al., 2007). An empathic response of the physician should not use blocking behaviors, with premature advice, or use metaphors difficult to be understood by the patient, as it may appear for the patients that the physician is minimizing, devaluing, or even invalidating their concern (Del Piccolo et al., 2017). Providing space for concerns, with questions of exploration and emotional recognition, could be used more often by physicians to clarify emotional concerns, reduce uncertainties about illness and treatment, and strengthen the physician–patient relationship.

Conclusion

Physicians showed to recognize fewer underlying cues and more cues related to physiological complaints by providing information and advice on clinical demands, constraining the emotion that was implicit in the complaint. These data suggest that patients may feel discouraged to express their emotions, as physicians provide little space for the recognition and validation of emotions, with less empathic responses. In our sample, physicians showed their clinical expertise, and their ability to deliver relevant information and respond to patients’ doubts. However, continued training in emotional communication skills in this context is needed since they showed difficulties in recognizing patients’ emotions. Regarding the limitations of the study, the data are not generalizable because it adopts a qualitative mixed methodology that pursued to understand the phenomenon of physician–patient communication through the identification and coding of emotional sequences through the VR-CoDES system. Another limitation is possible cultural specificities affecting the doctor–patient relationship and communication that have to be addressed regarding the comparisons of the results of this study with studies from other countries. Future studies may deepen the theme of emotional communication in the context of oncology and identify strengths and fragilities in how health professionals (nurses, nutritionists, physiotherapists, psychologists) deal with patients’ negative emotions. In addition, further studies focusing on training in communication skills should be conducted, which may be helpful in optimizing the professionals’ sensitivity to provide patients with space to emotional disclosure using empathic responses and recognizing the content of their cues and the concerns.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Higher Education Personnel Improvement Coordination—Brazil (CAPES)—Financing Code 001.

ORCID iD

Fernanda Bittencourt Romeiro

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