Acknowledgements
 Medical students, Foundation Year doctors
 Investigators: Helen O’Sullivan, Rachel Hick, Peter Leadbetter, Gemma
Cherry

Stimulus – awareness that identification of depression and anxiety in patients by hospital consultants and GPs was poor
Primary care
• Michael Balint 1950’s in the UK began GP study groups focus the doctor-patient relationship
• Byrne & Long (1976) ‘Doctors talking to patients’
• David Goldberg 1960s to 1980s – specific skills to facilitate patient centred interviewing
Cancer
• Peter Maguire 1970s to 2005 – communication skills research and training in oncology

• Communication skills training widespread in many countries
• Communication skills are assessed in medical training throughout the UK
• Training in communication skills:
– assumes doctors help by exploring and overtly discussing fears and emotions of patients/families
– encourages doctors to do this
– talk about biomedical issues often seen as preventing emotional discussion and ignoring emotion
• Patient satisfaction, Shared decision making etc.

• John Bowlby, Mary Ainsworth 1960s to 1980s developed Attachment theory
• Focus early childhood experiences with main caregiver
• Child develops ‘internal working models’
– how to develop relationships with other people, and expected responses from others
• Assumption internal working models will become the default in times of stress, are relatively stable by late teens early 20s

• Two differing approaches towards attachment
– Developmental psychology, Social psychology
• Developmental, semi-structured interviews, focus childhood
• Social, self report, focus on romantic and/or close relationships

• Early measures typically categorised people into 1 of 4 categories
– secure, preoccupied, fearful, dismissing
• Preoccupied, fearful, dismissing usually collapsed to insecure, hence much literature refers to ‘secure’ and ‘insecure’ attachment
• Categorize and/or score on 2 dimensions ‘anxiety’ and ‘avoidance’
– Anxiety/dependency on others
– Avoidance of intimacy

The Four-Category Model of Adult Attachment
Bartholomew and Horowitz (1992)

• Internal models of interaction and inter-personal
• Model for understanding ways individuals feel, react and communicate when stressed by illness
• Attachment, has been hypothesised to play a role
• There is evidence to suggest doctors’ attachment presentations
• This series of studies focused on medical students’ clinical communication

• Liverpool Medical School – 300 medical students
• 4yrs undergraduate training, then additional 3 years
• Summative exams in each undergraduate year
• OSCEs (Observed Structured Clinical Examinations)
• Clinical communication incorporated into exams
• Typically clinical communication OSCEs 10mins
• Aware of the general topic area i.e. psychiatry, gynaecology etc.
•
All students videoed in one OSCE station, consent to view/code video

• Examiners individual ratings OSCE station
• Behaviours identified by researchers e.g. empathy, NVB
(Non-verbal behaviour), eye contact, open questions etc.
• Overall communication ratings
• summary score from 4 to 5 OSCE stations, control for examiner bias
• Clinical information
• relevant clinical information elicited from patient

• Verona Coding Definition of Emotional Sequences
To identify
1. Patient cues (hint of underlying emotion) require exploration
2. Patient concerns (explicit mention of emotion) require acknowledgement/exploration
3. Health provider responses, whether interviewer gives or reduces space for further discussion
• Data, percentage of provide vs. reduce responses from total number of responses

• Psychiatry OSCE - symptoms of depression and suicidal ideation
• N=190, 165 female (65%) 67 male (35%), mean age 22.3yrs
• Sig negative correlations attachment and OSCE scores
• Higher attachment anxiety and avoidance lower examiners OSCE scores
Assessment
Global impression communication
Clinical competency
Attachment anxiety
-0.19**
-0.19**
Attachment avoidance
-0.23**
-0.21**

• Paediatric OSCE – daughter self harming
• N=37, mean age 23yrs
• Coded with VR-CoDES
• Inter-rater (0.87) for cues/concerns
• Inter-rater (0.82) “provide space” responses
• Mean nos. cues/concerns per interview 14.6
• Mean proportion of provide space responses 63.3%
• No significant difference in provide space responses re student gender

• Sig negative correlation avoidant attachment and students provide space responses
• The more avoidant medical students attachment, more likely they will not explore patient emotional cues and concerns
• Avoidant attachment influences micro-coding assessment
Assessment Attachment avoidance
VR-CoDES proportion provide space responses r= -0.41*

• Phase 2: follow up 4 th year into 5th year Primary
Care setting
• Video cohort (n=37) of students with ‘real’ patients
(2-6 each) in GP practice
• 138 student-patient consultations
• Attachment measures repeated
• Videoed viewed and coded with the VR-CoDES

• 1255 cues/concerns across 138 consultations
• Mean number of cues/concerns per interaction 9.1
• Large variation in number of cues given varying conditions and length of consultation
• Mean proportion of provide space responses 60%
• No significant difference in provide space responses based on gender

• Sig negative correlation between attachment avoidance and attachment anxiety to proportion of provide space responses
• The more avoidant and anxious junior doctors more likely they will not explore patients’ emotional cues and concerns
Assessment
VR-CoDES proportion provide space responses
Avoidance r=-0.50*
Anxiety r=-041*

• Defined as “a type of social intelligence that involves the ability to monitor one’s own and other’s emotions, to discriminate among them, and to use this information to guide one’s own thinking and actions”
Mayer & Salovey (1997)
• Doctors make judgments about when to explicitly discuss emotion, and must also understand how patients or their relatives will perceive their
(doctor’s) emotional and instrumental behaviours
• Hypothesised that EI is associated with interpersonal competency, with doctors’ level of EI being an influence on clinical communication
• EI assessments taken into consideration for entry to
Medical Schools in USA and St George’s UK

• Mayer-Salovey-Caruso Emotional Intelligence Test
Area Scores Experiential Emotional Intelligence Ability to perceive emotional information, relate it to other sensations and use it to facilitate
Strategic Emotional Intelligence thought
Ability to understand emotional information and use it for planning and self-management
Branch
Scores
Perceiving Emotions
Facilitating Thought
Understanding Emotions
Ability to identify emotions in self and/or others
Ability to use emotions to improve thinking
Ability to understand complexities of emotional meanings/situations/transitions
Emotional Management Ability to manage emotions in own life and/or others’ lives

• N=186, 1 st yr, 4 OSCE stations, only communication
• Sig correlations EI, attachment, OSCE
EI scores
Experiential Emotional
Intelligence (Area 1)
Strategic Emotional
Intelligence (Area 2)
Total Emotional
Intelligence
Overall OSCE score
Attachment avoidance
-.26
**
-.29
-.30
**
**
-.15*
Attachment anxiety
-.17*
-.08
-.16
-.06
OSCE score
.14
.20**
.22**
-

• Research question, does EI mediate relationship between attachment and EI?
• Attachment theory, internal working models formed in early childhood
• EI, develops throughout lifetime
• Therefore, possible greater opportunity for clinical communication teaching and training

• Structural equation modelling (SEM) e 1
1
Strategic
R
2=
0.60 e 2
1
Experiential
R
2
=0.45
0.78
†
0.67
†
EI
R
2
=0.13
0.22* r 1
1
PPC
R
2
=0.07
-0.35
†
-0.08
Avoidance
1 r 2

• Attachment avoidance accounted for 13% of the variance in students’ EI
• Attachment avoidance had no direct effect on clinical communication
• EI sig predicted 7% of the variability in clinical communication
• Students with higher levels of EI are probably better able to make judgments about when to respond appropriately, regardless of their attachment style
• However, vast majority of variance in clinical communication was not explained by students’ EI

• Repeated SEM 2 nd yr students, n=296, results strengthen
Experiential EI r
2
= .64 e3
.80
***
1
Total EI r
2
= .07
Strategic EI r
2
= .67
.82
***
.33*** r1 score r
2
= .14
1
-.26
**
Attachment avoidance
1 r2
-.12

• Attachment theory is a robust conceptual model that may promote understanding of patient and health professionals individual differences in personal interactions
• Similar argument made be advanced for EI
• However, we need to know more about EI in relation to medicine
• Research in social psychology has identified high
EI scores with Machiavellianism
• i.e. “The employment of cunning and duplicity in statecraft or in general conduct” (OED)