Tai-Seale Ming, Hatfield Laura A, Wilson Caroline J, Stults Cheryl D, McGuire Thomas G, Diamond Lisa C, Frankel Richard M, MacLean Lisa, Stone Ashley, Elston Lafata Jennifer
2350 W El Camino Real, Rm 446, Mountain View, CA 94301. E-mail:
Am J Manag Care. 2016 Oct 1;22(10):e350-e357.
Periodic health examinations (PHEs) are the most common reason adults see primary care providers. It is unknown if PHEs serve as a "safe portal" for patients with mental health needs to initiate care. We examined how physician communication styles impact mental health service delivery in PHEs.
Retrospective observational study using audio-recordings of 255 PHEs with patients likely to need mental health care.
Mixed-methods examined the timing of a mental health discussion (MHD), its quality, and the relationship between MHD quality and physician practice styles. MHD quality was measured against evidence-based practices as a 3-level variable (evidence-based, perfunctory, or absent). Physician practice styles were measured by: visit length, verbal dominance, and elicitation of a patient's agenda. A generalized ordered logit model was used.
Many patients came with mental health concerns, as over 50% of the MHDs occurred in the first 5 minutes of the visit. One-third of the 255 patients had an evidence-based MHD, another third had a perfunctory MHD, and the remaining had no MHD. MHD quality was significantly associated with physician communication styles. Visits with physicians who tend to spend more time with patients, fully elicit patients' agendas, and let patients talk (instead of being verbally dominant) were more likely to deliver evidence-based MHD.
If done well, PHEs could be a safe portal for patients to seek mental health care, but most PHEs fell short. Improving PHE quality may require reimbursement for longer visits and coaching for physicians to more fully elicit patients' agendas and to listen more attentively.
定期健康检查（PHEs）是成年人就诊初级保健提供者的最常见原因。尚不清楚PHEs是否能作为有心理健康需求的患者开始接受治疗的“安全入口”。我们研究了医生的沟通方式如何影响PHEs中的心理健康服务提供。
采用回顾性观察研究，对255次与可能需要心理健康护理的患者进行的PHEs录音。
采用混合方法研究心理健康讨论（MHD）的时机、质量以及MHD质量与医生执业风格之间的关系。MHD质量根据循证实践作为一个三级变量进行衡量（循证、敷衍或无）。医生的执业风格通过以下指标衡量：就诊时长、言语主导性以及对患者议程的引出。使用广义有序logit模型。
许多患者带着心理健康问题前来就诊，因为超过50%的MHD发生在就诊的前5分钟内。在255名患者中，三分之一接受了循证MHD，另外三分之一接受了敷衍的MHD，其余患者没有MHD。MHD质量与医生的沟通方式显著相关。与那些倾向于花更多时间与患者交流、充分引出患者议程并让患者发言（而不是言语主导）的医生进行的就诊更有可能提供循证MHD。
如果做得好，PHEs可以成为患者寻求心理健康护理的安全入口，但大多数PHEs未达标准。提高PHE质量可能需要为更长时间的就诊提供报销，并对医生进行培训，以更充分地引出患者议程并更专注地倾听。
