Technician, Friend, Detective, and Healer: Family Physicians’ Responses to Emotional Distress

Primary care practices have been called America’s de facto mental health network, with more than two thirds of mental health disorders treated in the primary care sector.¹ Up to 40% of primary care patients have a mental health problem,² and 19% of outpatients report significant emotional distress during the previous 4 weeks.³ However, the detection and treatment rates of these problems are low.^3-6

Thus, although the clinical philosophy of primary care professionals suggests that mental health care is an integral part of practice,^7-9 there is an apparent discrepancy between these espoused ideals and usual clinical practice.^3,5,10-11 Explanations of these findings include the reluctance of primary care physicians to label their patients and their use of observation and informal counseling as initial treatment efforts.^11-13 The competing demands of practice, lack of resources, inadequate reimbursement, and various organizational factors such as mental health carve-outs also profoundly influence management.^14-16 Using cluster analysis, Roter and colleagues¹⁷ found 5 distinct communication patterns between patients with ongoing medical problems and their physicians, ranging from narrowly biomedical to consumerist.¹⁷ Robinson and Roter^18-19 found that patients are likely to respond to direct inquiry by physicians about psychosocial distress and that physicians often briefly counsel their patients in return. Callahan and coworkers³ demonstrated that recent emotional distress and mental health problems have an important impact on encounter activities (eg, more time on history taking and counseling). Despite these investigations, a robust model of physicians’ response to emotional distress remains incompletely characterized.

We sought to develop a typology of physicians’ reactions to and management of patients’ mental health problems and emotional distress. Our findings can help clinicians identify their own style and consider ways of meeting particular patient needs that may be better suited to an alternative approach.

Methods

Detailed descriptive field notes of outpatient visits were collected as part of a large multimethod comparative case study of 18 midwestern family practices. Trained field researchers spent 4 weeks or more in each practice and directly observed the practice environment and 30 outpatient visits with each clinician in the practice. While observing the outpatient visits, the field researcher took chronological notes of what was occurring during the encounters. These notes were later used to dictate detailed descriptions of each encounter. Although there were differences in the style of reporting among the observers, the quality of data was consistent. Details of the design and data collection can be found elsewhere in this issue.²⁰

Two family physician researchers, 3 family therapists, and a medical anthropologist reviewed encounters from a purposeful sample of family physicians. Initially, encounters from 3 physicians representing diverse practice approaches (as assessed globally by a research nurse collecting the primary data) were reviewed. The goals were to understand the depth and detail of the data and to develop initial hypotheses, an organizational schema, and a crude overview of the presentation of and physician response to mental health issues. The management of mental health issues and emotional distress was then explored in a purposeful sample of physicians selected to maximize variation in sex, type, and location of practice; ethnicity; and age. By the nature of this qualitative study (without access to an independent gold standard for diagnosis of mental disorders), a broad definition of mental health problems was used, encompassing emotional distress and psychological problems. On the basis of the preliminary review of field note data, the research group identified that patients were presenting with emotional issues when they found a reported change in affect, a verbal report of an emotional issue, a somatic complaint often associated with emotional distress, or a follow-up visit for an expressed mental health issue (eg, refill of an antidepressant). This working definition was reached in the preliminary phase of the study, and through discussion a consensus was reached on the mental health aspects of each encounter.

Physicians were our unit of analysis, and the authors reviewed every outpatient visit available from each of the 13 physicians selected from the larger sample. The research team members used an editing organizing style for analysis,²¹ individually highlighted text they believed to be relevant, and made interpretive notes or observations in the margins.²² The research team then engaged in detailed discussions of the encounter transcripts. Particular attention was given to the total context of the encounter, recognizing other potential competing demands within the visit. The goal of this lengthy process was to reach consensus about what was important and how it should be interpreted. After discussing every encounter of a given physician, a summary case narrative was prepared and consensus reached about key themes for that physician.

After completing this initial review, matrices (eg, variations in patient management by practice location, physician age, and sex) were constructed to visualize other emergent patterns and facilitate comparisons across cases.²³ Additional physicians were reviewed to search for confirming and disconfirming evidence (eg, did management vary by physician ethnicity?) until saturation was reached (ie, until no further novel information or themes were identified). This required the review of outpatient visits from 13 physicians. One of the primary research nurses who conducted the participant observation provided input that ensured a full diversity of physicians was considered. She also served as an additional check on interpretation of the primary data. Finally, overall theses common to all physicians were identified and important variations in management noted. Thus, we began by looking at individual physicians’ responses within each encounter, developed a coherent description of each physician’s modus operandi, and then identified overarching themes describing broad approaches to emotional distress and mental health issues.

Results

The 379 patient visits to 13 physicians represented a diverse sample of practice and encounter types (Table 1, Table 2). Although the chief complaints of many patients did not overtly appear to relate to a mental health condition or emotional distress, many patients’ emotional concerns presented within the context of an acute or chronic medical condition. All physicians had many encounters in which both overt and more covert emotional concerns and mental health issues emerged.

Physician Responses Within Encounters

The research team noted a wide range of physician reactions to patients presenting with emotional distress or potential mental health problems. During the physician-patient interaction, physicians apparently either recognized the emotional component of the encounter or did not. If emotional distress was recognized, physicians appeared to either actively ignore this problem, gloss over or triage it, or actively manage the distress. These phenomena are illustrated in Figure 1 and will be described in more detail.

Recognition
Not all emotional and mental health issues were apparently recognized. Such missed opportunities were identified with all the participant physicians, even among physicians who were consistently more attentive to addressing mental health problems. For example, during a follow-up visit with a middle-aged man with abdominal tenderness a computed tomography scan had disclosed a renal mass. The patient’s wife asked numerous questions about possible depression and anxiety in her alcohol-using husband. The physician did not pursue any of these concerns.

However, a minority of physicians actively asked about mental health problems. This “active case finding” often capitalized on the physician’s previous knowledge of the patient’s social situation or personal issues. In one encounter focusing on breast cancer follow-up, the physician asked a woman how she was interacting with her spouse after a mastectomy. In instances such as this, active case finding was part of the chatting that opened or ended an encounter, particularly among physician and patients who were familiar with each other. Physicians in this sample neither used screening instruments (eg, the Primary Care Evaluation of Mental Disorders or the Zung mental health scales) nor routinely inquired about suicidal ideation, even in their seemingly most severely depressed patients.

Gloss-Over/Triage
In some instances, the physician apparently understood the impact of a situation but seemed to gloss over the issues. During a health care maintenance visit, a woman reported that she had a miscarriage 3 months earlier. The physician asked, “Is this a good thing or a sad thing?” The patient stated that it was a sad thing, because they were looking forward to the birth. There was no further probing into how the patient and family were dealing with the miscarriage.

In other encounters, physicians clearly seemed to recognize the psychologic implications of an encounter but chose to postpone management. These physicians appeared to triage certain cases based on time, competing demands, or perhaps their own ability to weather another challenging patient. For example, in the case of a patient with arm pain seeking workers’ compensation, the patient noted, “the pain (after doing some minor chores) was simply not worth it.” The physician did not pursue this cue further, but rather concentrated on the scheduling of magnetic resonance imaging, an electromyogram, and a follow-up appointment. However, the physician later related to the nurse researcher her understanding of the impact of this problem and acknowledged the patient’s discomfort. Thus, this physician apparently “triaged” this issue to a later date.

Management
Although only a minority of physicians actively sought cases of emotional distress in these encounters, most actively managed mental health problems. Prompted by the patient’s presentation, physicians followed up on “leads” to potential mental health issues, including: a mother who discussed the death of her daughter, a woman with menstrual irregularity, and marital and financial stress. Such encounters demonstrated physicians being sensitive to the underlying psychosocial issues in their patients’ lives.

The management response appeared to be predicated on the physician’s philosophy (biomedical vs holistic) and skill level (basic vs more advanced). In some instances, physicians appeared to spend considerable time on mental health issues with patients but apparently ran out of tools to deal with their problems effectively. This situation was most evident with patients who were substance abusers, who had chronic pain, those seeking workers’ compensation, and individuals with vague or multiple somatic symptoms.

A 4-Quadrant Typology of Physicians

A 4-quadrant typology of physicians emerged based on their philosophy and skill, as ascertained from the patient encounters Figure 2. Philosophically, physicians were on a continuum of being biomedically to biopsychosocially inclined, with each exhibiting a discernable dominant philosophy. Biomedically oriented physicians concentrated on the medical aspects of care and minimally explored the psychosocial milieu of the patient. Biopsychosocially oriented physicians addressed the patients’ emotional, physical, social, and sometimes spiritual wellbeing. Regardless of management approach (biomedical vs biopsychosocial), physicians demonstrated varying levels of competence in dealing with emotional distress.

Most physicians used “basic” skills—empathy, encouragement, small talk, use of silence, direct advice giving, and superficial education—to address their patients’ mental health problems. In some encounters the use of simple strategies was seemingly appropriate and effective; only occasionally were more advanced skills used. Such advanced skills ranged from effectively setting an agenda and soliciting the patient’s perspective to the use of more challenging interviewing skills, such as confrontation, implementing behavioral prescriptions, navigating referrals for skeptical patients, and mental health referrals that were part of a carefully developed treatment plan.

By combining the philosophy and skill dimensions, a 4-quadrant typology of physicians was apparent: the Technician, the Friend, the Detective, and the Healer. The Technician was medically oriented, dispensing medications and direct advice. Encounters were problem focused, and at times the physician appeared to be abrupt, ignorant of clear emotional distress, and not patient centered. In an encounter for follow-up of anxiety, one Technician told a patient complaining of neurologic symptoms that they might be stress related but still referred her to a neurologist. When she said, “This is really a frustrating way to feel,” he responded with, “Well, a neurologist deals with this,” and gave her samples of paroxetine, checked her for a sinus infection, and ended the encounter. Another patient seeing this physician for a complaint of depressive symptoms was identified without any discussion of underlying psychosocial issues; fluoxetine was dispensed in an encounter lasting less than 5 minutes.

The Friend was a biopsychosocially oriented physician with basic skills. One Friend extensively explored the patient’s background, concerns, and spiritual dimensions of illness. Encounters were long and tangential. A diverse array of topics was explored in a patient-centered fashion. However, only very basic counseling and management skills were ever observed with this physician. Direct advice was common, and conflict appeared to be avoided. A metaphor emerged of friends having coffee together.

Friends did not always appear to deliver care that optimally managed mental health issues. In some instances so many issues were discussed that the physician appeared to have difficulty setting an agenda for the visit and prioritizing problems. For example, for a patient just discharged after hospitalization for severe depression, there was no explicit discussion of depressive symptoms or suicidal ideation, despite a lengthy encounter.

The Detective was usually biomedically focused but when the occasion warranted, this type of physician demonstrated an impressive breadth of detective skills. For example, one Detective appeared most comfortable providing focused, snappy, medically oriented care. But she was alert to cues of emotional distress and demonstrated appropriate use of self-disclosure and confrontation in managing a patient with depression. In short, she was usually able to provide solutions for each case while focused on more biomedical issues.

The Healer used a full breadth of biopsychosocial skills, integrated most aspects of care seamlessly, and appeared comfortable with both strictly biomedical and psychosocial dimensions of care. One Healer regularly sought signs of emotional distress and exhibited an impressive range of skills in dealing with such problems as substance abuse and pain syndromes. For example, he astutely linked a patient’s stressful lifestyle with current somatic symptoms. In another encounter, with a woman with high blood pressure and weight gain, he assessed the possible biopsychosocial causes of the problem (etiologic stressors, sleep habits, relationship issues, diet changes, and depression, and probed about any anniversaries of a major stressor). However, even this Healer appeared to occasionally consciously temporize or triage emotional and mental health issues, such as when working with a patient with low back pain who was resistant to the treatment plan. During another encounter, he appeared to avoid the emotional implications of a diagnosis of venereal disease.

Thus, physicians addressed psychological problems in a variety of ways—from a strictly biomedical model to a more holistic fashion. Physicians also demonstrated a wide range of skills—from very basic to quite advanced, and applied these skills differently with different patients in different situations. Although a given provider’s performance often varied among encounters, most physicians appeared to have a preferred practice philosophy and singular skill set that they regularly used during patient visits.

Discussion

As in previous studies,^10-15 we found that not all physicians appeared comfortable, trained, adept, or motivated to make sense of the emotional distress presented by patients. Parallel to the findings of Roter and colleages¹⁷ with regard to general communication patterns of primary care physicians, a typology of physician responses to emotional distress emerged from our data. The framework of encounters (recognition, triage, and management) and 4-quadrant physician typology that surfaced from this study helps clarify how physicians respond to emotional distress. Each of the approaches in this typology is likely to have pros and cons for meeting different patient needs for mental health and general medical care.

Understanding physicians’ predominant styles based on their philosophy and skill set can have 2 important uses. First, physicians can reflect and seek feedback on their own style. Patient needs that may be less well met by this style can then be identified and alternate ways of meeting these needs pursued. Second, clinicians and continuing medical education providers can use this typology to design educational approaches. This education should focus on expanding clinician flexibility and increasing insight into when to use what approach. The outcomes and tradeoffs in effectiveness, efficiency, and integration of care remain important areas for future research.²⁴

Given the constraints on time, personal energy, and apparent competition between chronic physical and mental health problems, physician behaviors can be viewed as an understandable adaptation to the realities of a busy family practice.^11-15-24-28 Although we have documented significant variation in counseling skills among family physicians, there is no data to suggest that expansion of these skills would necessarily improve patient outcomes.²⁹ The effect of a long-term relationship and its quality between patients and a family physician on patient mental health outcomes remains unexplored and is a fruitful area for further research. Also, it is important to recognize that physicians are not homogeneous in their personality, philosophy, and skills and that patients self-select the kind of physician that best fits their own personality and style. Different approaches are likely to be functional for diverse clinicians with varied patients and situations.²⁴

Limitations

Our study has important limitations, including its sampling, design, and lack of a reference standard for mental health conditions. This qualitative research, by its very nature, is not based on a random population sample and is therefore not generalizable in the traditional quantitative sense. Its generalizability lies in the resonance it generates among primary care physicians and patients who recognize these patterns from their own experiences. Also, the findings are consistent with our existing understanding of competing demands^9,28,30 and physician communication strategies.^17-19 To the extent to which midwestern physicians and patients do not reflect the ethnic and socioeconomic diversity of other parts of the country, these findings may also be limited. Future research should attempt to include diversity. Patients’ emotional distress may be communicated in other ways besides speech or may not be communicated at all, so the direct observation approach we used cannot always correctly infer patients’ unexpressed mental health needs or physicians’ assessment of the situation. Because the data were cross-sectional, it is not possible to determine what had occurred in previous visits in a longitudinal management strategy. Nevertheless, the richness of the field note data provided an excellent detailed view of a large sample of visits. Finally, the lack of a reference standard for diagnosing mental health conditions does not alter the main findings of this study—a typology of physicians’ responses to emotional distress within their practices.

In trying to understand and improve the treatment of mental health issues, many previous researchers have focused on improving physician knowledge and dissemination of guidelines; such efforts have been disappointing when used alone.^31,32 Other investigators have sought to improve the interviewing skills of physicians, and while modestly successful, these studies have been limited in scope, length of follow-up, and ability to be replicated widely.^18,19,33,34 Other approaches have included collaborative management and quality improvement efforts; while successful, such interventions may be difficult to replicate in the usual physician practice setting without substantial external resources.^35-38

Conclusions

The chasm between ideal care of mental health disorders and actual practice may be narrower than mental health professionals would have us believe, and it is certainly bridgeable. It is possible to have better outcomes for medical conditions, improved patient and provider satisfaction, and reduced costs of care.^39,40 By studying the exemplary physicians found in real world practices—as found in this study and others—we might better understand that combination of inclination, skill, and setting that promotes quality cost-effective care. We found that mental health care, while sporadically and diversely attended to in outpatient visits, is often integrated with care of the diverse medical, social, and family problems that constitute primary care. Irrespective of differences in philosophy, training, or interest, however, structural and economic issues still appear to severely limit the ability of even willing family physicians to practice coherent integrated primary care.41 It is therefore important for the field as a whole to provide feasible strategies for promoting recognition and treatment of mental health issues by diverse clinicians and patients in usual practice settings.

Acknowledgments

Our study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776) and a research center grant from the American Academy of Family Physicians. The authors are grateful to the physicians, staff, and patients from the 18 practices, without whose participation this study would not have been possible. We also wish to acknowledge the dedicated work of Connie Gibbs and Jen Rouse, who spent countless hours collecting data; Diane Dodendorf and Jason Lebsack, who coordinated transcription and data management; and Mary McAndrews, who transcribed hundreds of taped interviews and dictated field notes. We would also like to thank Kurt C. Stange, MD, PhD, for reviewing earlier drafts of our manuscript.

Primary care practices have been called America’s de facto mental health network, with more than two thirds of mental health disorders treated in the primary care sector.¹ Up to 40% of primary care patients have a mental health problem,² and 19% of outpatients report significant emotional distress during the previous 4 weeks.³ However, the detection and treatment rates of these problems are low.^3-6

Thus, although the clinical philosophy of primary care professionals suggests that mental health care is an integral part of practice,^7-9 there is an apparent discrepancy between these espoused ideals and usual clinical practice.^3,5,10-11 Explanations of these findings include the reluctance of primary care physicians to label their patients and their use of observation and informal counseling as initial treatment efforts.^11-13 The competing demands of practice, lack of resources, inadequate reimbursement, and various organizational factors such as mental health carve-outs also profoundly influence management.^14-16 Using cluster analysis, Roter and colleagues¹⁷ found 5 distinct communication patterns between patients with ongoing medical problems and their physicians, ranging from narrowly biomedical to consumerist.¹⁷ Robinson and Roter^18-19 found that patients are likely to respond to direct inquiry by physicians about psychosocial distress and that physicians often briefly counsel their patients in return. Callahan and coworkers³ demonstrated that recent emotional distress and mental health problems have an important impact on encounter activities (eg, more time on history taking and counseling). Despite these investigations, a robust model of physicians’ response to emotional distress remains incompletely characterized.

We sought to develop a typology of physicians’ reactions to and management of patients’ mental health problems and emotional distress. Our findings can help clinicians identify their own style and consider ways of meeting particular patient needs that may be better suited to an alternative approach.

Methods

Detailed descriptive field notes of outpatient visits were collected as part of a large multimethod comparative case study of 18 midwestern family practices. Trained field researchers spent 4 weeks or more in each practice and directly observed the practice environment and 30 outpatient visits with each clinician in the practice. While observing the outpatient visits, the field researcher took chronological notes of what was occurring during the encounters. These notes were later used to dictate detailed descriptions of each encounter. Although there were differences in the style of reporting among the observers, the quality of data was consistent. Details of the design and data collection can be found elsewhere in this issue.²⁰

Two family physician researchers, 3 family therapists, and a medical anthropologist reviewed encounters from a purposeful sample of family physicians. Initially, encounters from 3 physicians representing diverse practice approaches (as assessed globally by a research nurse collecting the primary data) were reviewed. The goals were to understand the depth and detail of the data and to develop initial hypotheses, an organizational schema, and a crude overview of the presentation of and physician response to mental health issues. The management of mental health issues and emotional distress was then explored in a purposeful sample of physicians selected to maximize variation in sex, type, and location of practice; ethnicity; and age. By the nature of this qualitative study (without access to an independent gold standard for diagnosis of mental disorders), a broad definition of mental health problems was used, encompassing emotional distress and psychological problems. On the basis of the preliminary review of field note data, the research group identified that patients were presenting with emotional issues when they found a reported change in affect, a verbal report of an emotional issue, a somatic complaint often associated with emotional distress, or a follow-up visit for an expressed mental health issue (eg, refill of an antidepressant). This working definition was reached in the preliminary phase of the study, and through discussion a consensus was reached on the mental health aspects of each encounter.

Physicians were our unit of analysis, and the authors reviewed every outpatient visit available from each of the 13 physicians selected from the larger sample. The research team members used an editing organizing style for analysis,²¹ individually highlighted text they believed to be relevant, and made interpretive notes or observations in the margins.²² The research team then engaged in detailed discussions of the encounter transcripts. Particular attention was given to the total context of the encounter, recognizing other potential competing demands within the visit. The goal of this lengthy process was to reach consensus about what was important and how it should be interpreted. After discussing every encounter of a given physician, a summary case narrative was prepared and consensus reached about key themes for that physician.

After completing this initial review, matrices (eg, variations in patient management by practice location, physician age, and sex) were constructed to visualize other emergent patterns and facilitate comparisons across cases.²³ Additional physicians were reviewed to search for confirming and disconfirming evidence (eg, did management vary by physician ethnicity?) until saturation was reached (ie, until no further novel information or themes were identified). This required the review of outpatient visits from 13 physicians. One of the primary research nurses who conducted the participant observation provided input that ensured a full diversity of physicians was considered. She also served as an additional check on interpretation of the primary data. Finally, overall theses common to all physicians were identified and important variations in management noted. Thus, we began by looking at individual physicians’ responses within each encounter, developed a coherent description of each physician’s modus operandi, and then identified overarching themes describing broad approaches to emotional distress and mental health issues.

Results

The 379 patient visits to 13 physicians represented a diverse sample of practice and encounter types (Table 1, Table 2). Although the chief complaints of many patients did not overtly appear to relate to a mental health condition or emotional distress, many patients’ emotional concerns presented within the context of an acute or chronic medical condition. All physicians had many encounters in which both overt and more covert emotional concerns and mental health issues emerged.

Physician Responses Within Encounters

The research team noted a wide range of physician reactions to patients presenting with emotional distress or potential mental health problems. During the physician-patient interaction, physicians apparently either recognized the emotional component of the encounter or did not. If emotional distress was recognized, physicians appeared to either actively ignore this problem, gloss over or triage it, or actively manage the distress. These phenomena are illustrated in Figure 1 and will be described in more detail.

Recognition
Not all emotional and mental health issues were apparently recognized. Such missed opportunities were identified with all the participant physicians, even among physicians who were consistently more attentive to addressing mental health problems. For example, during a follow-up visit with a middle-aged man with abdominal tenderness a computed tomography scan had disclosed a renal mass. The patient’s wife asked numerous questions about possible depression and anxiety in her alcohol-using husband. The physician did not pursue any of these concerns.

However, a minority of physicians actively asked about mental health problems. This “active case finding” often capitalized on the physician’s previous knowledge of the patient’s social situation or personal issues. In one encounter focusing on breast cancer follow-up, the physician asked a woman how she was interacting with her spouse after a mastectomy. In instances such as this, active case finding was part of the chatting that opened or ended an encounter, particularly among physician and patients who were familiar with each other. Physicians in this sample neither used screening instruments (eg, the Primary Care Evaluation of Mental Disorders or the Zung mental health scales) nor routinely inquired about suicidal ideation, even in their seemingly most severely depressed patients.

Gloss-Over/Triage
In some instances, the physician apparently understood the impact of a situation but seemed to gloss over the issues. During a health care maintenance visit, a woman reported that she had a miscarriage 3 months earlier. The physician asked, “Is this a good thing or a sad thing?” The patient stated that it was a sad thing, because they were looking forward to the birth. There was no further probing into how the patient and family were dealing with the miscarriage.

In other encounters, physicians clearly seemed to recognize the psychologic implications of an encounter but chose to postpone management. These physicians appeared to triage certain cases based on time, competing demands, or perhaps their own ability to weather another challenging patient. For example, in the case of a patient with arm pain seeking workers’ compensation, the patient noted, “the pain (after doing some minor chores) was simply not worth it.” The physician did not pursue this cue further, but rather concentrated on the scheduling of magnetic resonance imaging, an electromyogram, and a follow-up appointment. However, the physician later related to the nurse researcher her understanding of the impact of this problem and acknowledged the patient’s discomfort. Thus, this physician apparently “triaged” this issue to a later date.

Management
Although only a minority of physicians actively sought cases of emotional distress in these encounters, most actively managed mental health problems. Prompted by the patient’s presentation, physicians followed up on “leads” to potential mental health issues, including: a mother who discussed the death of her daughter, a woman with menstrual irregularity, and marital and financial stress. Such encounters demonstrated physicians being sensitive to the underlying psychosocial issues in their patients’ lives.

The management response appeared to be predicated on the physician’s philosophy (biomedical vs holistic) and skill level (basic vs more advanced). In some instances, physicians appeared to spend considerable time on mental health issues with patients but apparently ran out of tools to deal with their problems effectively. This situation was most evident with patients who were substance abusers, who had chronic pain, those seeking workers’ compensation, and individuals with vague or multiple somatic symptoms.

A 4-Quadrant Typology of Physicians

A 4-quadrant typology of physicians emerged based on their philosophy and skill, as ascertained from the patient encounters Figure 2. Philosophically, physicians were on a continuum of being biomedically to biopsychosocially inclined, with each exhibiting a discernable dominant philosophy. Biomedically oriented physicians concentrated on the medical aspects of care and minimally explored the psychosocial milieu of the patient. Biopsychosocially oriented physicians addressed the patients’ emotional, physical, social, and sometimes spiritual wellbeing. Regardless of management approach (biomedical vs biopsychosocial), physicians demonstrated varying levels of competence in dealing with emotional distress.

Most physicians used “basic” skills—empathy, encouragement, small talk, use of silence, direct advice giving, and superficial education—to address their patients’ mental health problems. In some encounters the use of simple strategies was seemingly appropriate and effective; only occasionally were more advanced skills used. Such advanced skills ranged from effectively setting an agenda and soliciting the patient’s perspective to the use of more challenging interviewing skills, such as confrontation, implementing behavioral prescriptions, navigating referrals for skeptical patients, and mental health referrals that were part of a carefully developed treatment plan.

By combining the philosophy and skill dimensions, a 4-quadrant typology of physicians was apparent: the Technician, the Friend, the Detective, and the Healer. The Technician was medically oriented, dispensing medications and direct advice. Encounters were problem focused, and at times the physician appeared to be abrupt, ignorant of clear emotional distress, and not patient centered. In an encounter for follow-up of anxiety, one Technician told a patient complaining of neurologic symptoms that they might be stress related but still referred her to a neurologist. When she said, “This is really a frustrating way to feel,” he responded with, “Well, a neurologist deals with this,” and gave her samples of paroxetine, checked her for a sinus infection, and ended the encounter. Another patient seeing this physician for a complaint of depressive symptoms was identified without any discussion of underlying psychosocial issues; fluoxetine was dispensed in an encounter lasting less than 5 minutes.

The Friend was a biopsychosocially oriented physician with basic skills. One Friend extensively explored the patient’s background, concerns, and spiritual dimensions of illness. Encounters were long and tangential. A diverse array of topics was explored in a patient-centered fashion. However, only very basic counseling and management skills were ever observed with this physician. Direct advice was common, and conflict appeared to be avoided. A metaphor emerged of friends having coffee together.

Friends did not always appear to deliver care that optimally managed mental health issues. In some instances so many issues were discussed that the physician appeared to have difficulty setting an agenda for the visit and prioritizing problems. For example, for a patient just discharged after hospitalization for severe depression, there was no explicit discussion of depressive symptoms or suicidal ideation, despite a lengthy encounter.

The Detective was usually biomedically focused but when the occasion warranted, this type of physician demonstrated an impressive breadth of detective skills. For example, one Detective appeared most comfortable providing focused, snappy, medically oriented care. But she was alert to cues of emotional distress and demonstrated appropriate use of self-disclosure and confrontation in managing a patient with depression. In short, she was usually able to provide solutions for each case while focused on more biomedical issues.

The Healer used a full breadth of biopsychosocial skills, integrated most aspects of care seamlessly, and appeared comfortable with both strictly biomedical and psychosocial dimensions of care. One Healer regularly sought signs of emotional distress and exhibited an impressive range of skills in dealing with such problems as substance abuse and pain syndromes. For example, he astutely linked a patient’s stressful lifestyle with current somatic symptoms. In another encounter, with a woman with high blood pressure and weight gain, he assessed the possible biopsychosocial causes of the problem (etiologic stressors, sleep habits, relationship issues, diet changes, and depression, and probed about any anniversaries of a major stressor). However, even this Healer appeared to occasionally consciously temporize or triage emotional and mental health issues, such as when working with a patient with low back pain who was resistant to the treatment plan. During another encounter, he appeared to avoid the emotional implications of a diagnosis of venereal disease.

Thus, physicians addressed psychological problems in a variety of ways—from a strictly biomedical model to a more holistic fashion. Physicians also demonstrated a wide range of skills—from very basic to quite advanced, and applied these skills differently with different patients in different situations. Although a given provider’s performance often varied among encounters, most physicians appeared to have a preferred practice philosophy and singular skill set that they regularly used during patient visits.

Discussion

As in previous studies,^10-15 we found that not all physicians appeared comfortable, trained, adept, or motivated to make sense of the emotional distress presented by patients. Parallel to the findings of Roter and colleages¹⁷ with regard to general communication patterns of primary care physicians, a typology of physician responses to emotional distress emerged from our data. The framework of encounters (recognition, triage, and management) and 4-quadrant physician typology that surfaced from this study helps clarify how physicians respond to emotional distress. Each of the approaches in this typology is likely to have pros and cons for meeting different patient needs for mental health and general medical care.

Understanding physicians’ predominant styles based on their philosophy and skill set can have 2 important uses. First, physicians can reflect and seek feedback on their own style. Patient needs that may be less well met by this style can then be identified and alternate ways of meeting these needs pursued. Second, clinicians and continuing medical education providers can use this typology to design educational approaches. This education should focus on expanding clinician flexibility and increasing insight into when to use what approach. The outcomes and tradeoffs in effectiveness, efficiency, and integration of care remain important areas for future research.²⁴

Given the constraints on time, personal energy, and apparent competition between chronic physical and mental health problems, physician behaviors can be viewed as an understandable adaptation to the realities of a busy family practice.^11-15-24-28 Although we have documented significant variation in counseling skills among family physicians, there is no data to suggest that expansion of these skills would necessarily improve patient outcomes.²⁹ The effect of a long-term relationship and its quality between patients and a family physician on patient mental health outcomes remains unexplored and is a fruitful area for further research. Also, it is important to recognize that physicians are not homogeneous in their personality, philosophy, and skills and that patients self-select the kind of physician that best fits their own personality and style. Different approaches are likely to be functional for diverse clinicians with varied patients and situations.²⁴

Limitations

Our study has important limitations, including its sampling, design, and lack of a reference standard for mental health conditions. This qualitative research, by its very nature, is not based on a random population sample and is therefore not generalizable in the traditional quantitative sense. Its generalizability lies in the resonance it generates among primary care physicians and patients who recognize these patterns from their own experiences. Also, the findings are consistent with our existing understanding of competing demands^9,28,30 and physician communication strategies.^17-19 To the extent to which midwestern physicians and patients do not reflect the ethnic and socioeconomic diversity of other parts of the country, these findings may also be limited. Future research should attempt to include diversity. Patients’ emotional distress may be communicated in other ways besides speech or may not be communicated at all, so the direct observation approach we used cannot always correctly infer patients’ unexpressed mental health needs or physicians’ assessment of the situation. Because the data were cross-sectional, it is not possible to determine what had occurred in previous visits in a longitudinal management strategy. Nevertheless, the richness of the field note data provided an excellent detailed view of a large sample of visits. Finally, the lack of a reference standard for diagnosing mental health conditions does not alter the main findings of this study—a typology of physicians’ responses to emotional distress within their practices.

In trying to understand and improve the treatment of mental health issues, many previous researchers have focused on improving physician knowledge and dissemination of guidelines; such efforts have been disappointing when used alone.^31,32 Other investigators have sought to improve the interviewing skills of physicians, and while modestly successful, these studies have been limited in scope, length of follow-up, and ability to be replicated widely.^18,19,33,34 Other approaches have included collaborative management and quality improvement efforts; while successful, such interventions may be difficult to replicate in the usual physician practice setting without substantial external resources.^35-38

Conclusions

The chasm between ideal care of mental health disorders and actual practice may be narrower than mental health professionals would have us believe, and it is certainly bridgeable. It is possible to have better outcomes for medical conditions, improved patient and provider satisfaction, and reduced costs of care.^39,40 By studying the exemplary physicians found in real world practices—as found in this study and others—we might better understand that combination of inclination, skill, and setting that promotes quality cost-effective care. We found that mental health care, while sporadically and diversely attended to in outpatient visits, is often integrated with care of the diverse medical, social, and family problems that constitute primary care. Irrespective of differences in philosophy, training, or interest, however, structural and economic issues still appear to severely limit the ability of even willing family physicians to practice coherent integrated primary care.41 It is therefore important for the field as a whole to provide feasible strategies for promoting recognition and treatment of mental health issues by diverse clinicians and patients in usual practice settings.

Acknowledgments

Our study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776) and a research center grant from the American Academy of Family Physicians. The authors are grateful to the physicians, staff, and patients from the 18 practices, without whose participation this study would not have been possible. We also wish to acknowledge the dedicated work of Connie Gibbs and Jen Rouse, who spent countless hours collecting data; Diane Dodendorf and Jason Lebsack, who coordinated transcription and data management; and Mary McAndrews, who transcribed hundreds of taped interviews and dictated field notes. We would also like to thank Kurt C. Stange, MD, PhD, for reviewing earlier drafts of our manuscript.

Primary care practices have been called America’s de facto mental health network, with more than two thirds of mental health disorders treated in the primary care sector.¹ Up to 40% of primary care patients have a mental health problem,² and 19% of outpatients report significant emotional distress during the previous 4 weeks.³ However, the detection and treatment rates of these problems are low.^3-6

Thus, although the clinical philosophy of primary care professionals suggests that mental health care is an integral part of practice,^7-9 there is an apparent discrepancy between these espoused ideals and usual clinical practice.^3,5,10-11 Explanations of these findings include the reluctance of primary care physicians to label their patients and their use of observation and informal counseling as initial treatment efforts.^11-13 The competing demands of practice, lack of resources, inadequate reimbursement, and various organizational factors such as mental health carve-outs also profoundly influence management.^14-16 Using cluster analysis, Roter and colleagues¹⁷ found 5 distinct communication patterns between patients with ongoing medical problems and their physicians, ranging from narrowly biomedical to consumerist.¹⁷ Robinson and Roter^18-19 found that patients are likely to respond to direct inquiry by physicians about psychosocial distress and that physicians often briefly counsel their patients in return. Callahan and coworkers³ demonstrated that recent emotional distress and mental health problems have an important impact on encounter activities (eg, more time on history taking and counseling). Despite these investigations, a robust model of physicians’ response to emotional distress remains incompletely characterized.

We sought to develop a typology of physicians’ reactions to and management of patients’ mental health problems and emotional distress. Our findings can help clinicians identify their own style and consider ways of meeting particular patient needs that may be better suited to an alternative approach.

Methods

Detailed descriptive field notes of outpatient visits were collected as part of a large multimethod comparative case study of 18 midwestern family practices. Trained field researchers spent 4 weeks or more in each practice and directly observed the practice environment and 30 outpatient visits with each clinician in the practice. While observing the outpatient visits, the field researcher took chronological notes of what was occurring during the encounters. These notes were later used to dictate detailed descriptions of each encounter. Although there were differences in the style of reporting among the observers, the quality of data was consistent. Details of the design and data collection can be found elsewhere in this issue.²⁰

Two family physician researchers, 3 family therapists, and a medical anthropologist reviewed encounters from a purposeful sample of family physicians. Initially, encounters from 3 physicians representing diverse practice approaches (as assessed globally by a research nurse collecting the primary data) were reviewed. The goals were to understand the depth and detail of the data and to develop initial hypotheses, an organizational schema, and a crude overview of the presentation of and physician response to mental health issues. The management of mental health issues and emotional distress was then explored in a purposeful sample of physicians selected to maximize variation in sex, type, and location of practice; ethnicity; and age. By the nature of this qualitative study (without access to an independent gold standard for diagnosis of mental disorders), a broad definition of mental health problems was used, encompassing emotional distress and psychological problems. On the basis of the preliminary review of field note data, the research group identified that patients were presenting with emotional issues when they found a reported change in affect, a verbal report of an emotional issue, a somatic complaint often associated with emotional distress, or a follow-up visit for an expressed mental health issue (eg, refill of an antidepressant). This working definition was reached in the preliminary phase of the study, and through discussion a consensus was reached on the mental health aspects of each encounter.

Physicians were our unit of analysis, and the authors reviewed every outpatient visit available from each of the 13 physicians selected from the larger sample. The research team members used an editing organizing style for analysis,²¹ individually highlighted text they believed to be relevant, and made interpretive notes or observations in the margins.²² The research team then engaged in detailed discussions of the encounter transcripts. Particular attention was given to the total context of the encounter, recognizing other potential competing demands within the visit. The goal of this lengthy process was to reach consensus about what was important and how it should be interpreted. After discussing every encounter of a given physician, a summary case narrative was prepared and consensus reached about key themes for that physician.

After completing this initial review, matrices (eg, variations in patient management by practice location, physician age, and sex) were constructed to visualize other emergent patterns and facilitate comparisons across cases.²³ Additional physicians were reviewed to search for confirming and disconfirming evidence (eg, did management vary by physician ethnicity?) until saturation was reached (ie, until no further novel information or themes were identified). This required the review of outpatient visits from 13 physicians. One of the primary research nurses who conducted the participant observation provided input that ensured a full diversity of physicians was considered. She also served as an additional check on interpretation of the primary data. Finally, overall theses common to all physicians were identified and important variations in management noted. Thus, we began by looking at individual physicians’ responses within each encounter, developed a coherent description of each physician’s modus operandi, and then identified overarching themes describing broad approaches to emotional distress and mental health issues.

Results

The 379 patient visits to 13 physicians represented a diverse sample of practice and encounter types (Table 1, Table 2). Although the chief complaints of many patients did not overtly appear to relate to a mental health condition or emotional distress, many patients’ emotional concerns presented within the context of an acute or chronic medical condition. All physicians had many encounters in which both overt and more covert emotional concerns and mental health issues emerged.

Physician Responses Within Encounters

The research team noted a wide range of physician reactions to patients presenting with emotional distress or potential mental health problems. During the physician-patient interaction, physicians apparently either recognized the emotional component of the encounter or did not. If emotional distress was recognized, physicians appeared to either actively ignore this problem, gloss over or triage it, or actively manage the distress. These phenomena are illustrated in Figure 1 and will be described in more detail.

Recognition
Not all emotional and mental health issues were apparently recognized. Such missed opportunities were identified with all the participant physicians, even among physicians who were consistently more attentive to addressing mental health problems. For example, during a follow-up visit with a middle-aged man with abdominal tenderness a computed tomography scan had disclosed a renal mass. The patient’s wife asked numerous questions about possible depression and anxiety in her alcohol-using husband. The physician did not pursue any of these concerns.

However, a minority of physicians actively asked about mental health problems. This “active case finding” often capitalized on the physician’s previous knowledge of the patient’s social situation or personal issues. In one encounter focusing on breast cancer follow-up, the physician asked a woman how she was interacting with her spouse after a mastectomy. In instances such as this, active case finding was part of the chatting that opened or ended an encounter, particularly among physician and patients who were familiar with each other. Physicians in this sample neither used screening instruments (eg, the Primary Care Evaluation of Mental Disorders or the Zung mental health scales) nor routinely inquired about suicidal ideation, even in their seemingly most severely depressed patients.

Gloss-Over/Triage
In some instances, the physician apparently understood the impact of a situation but seemed to gloss over the issues. During a health care maintenance visit, a woman reported that she had a miscarriage 3 months earlier. The physician asked, “Is this a good thing or a sad thing?” The patient stated that it was a sad thing, because they were looking forward to the birth. There was no further probing into how the patient and family were dealing with the miscarriage.

In other encounters, physicians clearly seemed to recognize the psychologic implications of an encounter but chose to postpone management. These physicians appeared to triage certain cases based on time, competing demands, or perhaps their own ability to weather another challenging patient. For example, in the case of a patient with arm pain seeking workers’ compensation, the patient noted, “the pain (after doing some minor chores) was simply not worth it.” The physician did not pursue this cue further, but rather concentrated on the scheduling of magnetic resonance imaging, an electromyogram, and a follow-up appointment. However, the physician later related to the nurse researcher her understanding of the impact of this problem and acknowledged the patient’s discomfort. Thus, this physician apparently “triaged” this issue to a later date.

Management
Although only a minority of physicians actively sought cases of emotional distress in these encounters, most actively managed mental health problems. Prompted by the patient’s presentation, physicians followed up on “leads” to potential mental health issues, including: a mother who discussed the death of her daughter, a woman with menstrual irregularity, and marital and financial stress. Such encounters demonstrated physicians being sensitive to the underlying psychosocial issues in their patients’ lives.

The management response appeared to be predicated on the physician’s philosophy (biomedical vs holistic) and skill level (basic vs more advanced). In some instances, physicians appeared to spend considerable time on mental health issues with patients but apparently ran out of tools to deal with their problems effectively. This situation was most evident with patients who were substance abusers, who had chronic pain, those seeking workers’ compensation, and individuals with vague or multiple somatic symptoms.

A 4-Quadrant Typology of Physicians

A 4-quadrant typology of physicians emerged based on their philosophy and skill, as ascertained from the patient encounters Figure 2. Philosophically, physicians were on a continuum of being biomedically to biopsychosocially inclined, with each exhibiting a discernable dominant philosophy. Biomedically oriented physicians concentrated on the medical aspects of care and minimally explored the psychosocial milieu of the patient. Biopsychosocially oriented physicians addressed the patients’ emotional, physical, social, and sometimes spiritual wellbeing. Regardless of management approach (biomedical vs biopsychosocial), physicians demonstrated varying levels of competence in dealing with emotional distress.

Most physicians used “basic” skills—empathy, encouragement, small talk, use of silence, direct advice giving, and superficial education—to address their patients’ mental health problems. In some encounters the use of simple strategies was seemingly appropriate and effective; only occasionally were more advanced skills used. Such advanced skills ranged from effectively setting an agenda and soliciting the patient’s perspective to the use of more challenging interviewing skills, such as confrontation, implementing behavioral prescriptions, navigating referrals for skeptical patients, and mental health referrals that were part of a carefully developed treatment plan.

By combining the philosophy and skill dimensions, a 4-quadrant typology of physicians was apparent: the Technician, the Friend, the Detective, and the Healer. The Technician was medically oriented, dispensing medications and direct advice. Encounters were problem focused, and at times the physician appeared to be abrupt, ignorant of clear emotional distress, and not patient centered. In an encounter for follow-up of anxiety, one Technician told a patient complaining of neurologic symptoms that they might be stress related but still referred her to a neurologist. When she said, “This is really a frustrating way to feel,” he responded with, “Well, a neurologist deals with this,” and gave her samples of paroxetine, checked her for a sinus infection, and ended the encounter. Another patient seeing this physician for a complaint of depressive symptoms was identified without any discussion of underlying psychosocial issues; fluoxetine was dispensed in an encounter lasting less than 5 minutes.

The Friend was a biopsychosocially oriented physician with basic skills. One Friend extensively explored the patient’s background, concerns, and spiritual dimensions of illness. Encounters were long and tangential. A diverse array of topics was explored in a patient-centered fashion. However, only very basic counseling and management skills were ever observed with this physician. Direct advice was common, and conflict appeared to be avoided. A metaphor emerged of friends having coffee together.

Friends did not always appear to deliver care that optimally managed mental health issues. In some instances so many issues were discussed that the physician appeared to have difficulty setting an agenda for the visit and prioritizing problems. For example, for a patient just discharged after hospitalization for severe depression, there was no explicit discussion of depressive symptoms or suicidal ideation, despite a lengthy encounter.

The Detective was usually biomedically focused but when the occasion warranted, this type of physician demonstrated an impressive breadth of detective skills. For example, one Detective appeared most comfortable providing focused, snappy, medically oriented care. But she was alert to cues of emotional distress and demonstrated appropriate use of self-disclosure and confrontation in managing a patient with depression. In short, she was usually able to provide solutions for each case while focused on more biomedical issues.

The Healer used a full breadth of biopsychosocial skills, integrated most aspects of care seamlessly, and appeared comfortable with both strictly biomedical and psychosocial dimensions of care. One Healer regularly sought signs of emotional distress and exhibited an impressive range of skills in dealing with such problems as substance abuse and pain syndromes. For example, he astutely linked a patient’s stressful lifestyle with current somatic symptoms. In another encounter, with a woman with high blood pressure and weight gain, he assessed the possible biopsychosocial causes of the problem (etiologic stressors, sleep habits, relationship issues, diet changes, and depression, and probed about any anniversaries of a major stressor). However, even this Healer appeared to occasionally consciously temporize or triage emotional and mental health issues, such as when working with a patient with low back pain who was resistant to the treatment plan. During another encounter, he appeared to avoid the emotional implications of a diagnosis of venereal disease.

Thus, physicians addressed psychological problems in a variety of ways—from a strictly biomedical model to a more holistic fashion. Physicians also demonstrated a wide range of skills—from very basic to quite advanced, and applied these skills differently with different patients in different situations. Although a given provider’s performance often varied among encounters, most physicians appeared to have a preferred practice philosophy and singular skill set that they regularly used during patient visits.

Discussion

As in previous studies,^10-15 we found that not all physicians appeared comfortable, trained, adept, or motivated to make sense of the emotional distress presented by patients. Parallel to the findings of Roter and colleages¹⁷ with regard to general communication patterns of primary care physicians, a typology of physician responses to emotional distress emerged from our data. The framework of encounters (recognition, triage, and management) and 4-quadrant physician typology that surfaced from this study helps clarify how physicians respond to emotional distress. Each of the approaches in this typology is likely to have pros and cons for meeting different patient needs for mental health and general medical care.

Understanding physicians’ predominant styles based on their philosophy and skill set can have 2 important uses. First, physicians can reflect and seek feedback on their own style. Patient needs that may be less well met by this style can then be identified and alternate ways of meeting these needs pursued. Second, clinicians and continuing medical education providers can use this typology to design educational approaches. This education should focus on expanding clinician flexibility and increasing insight into when to use what approach. The outcomes and tradeoffs in effectiveness, efficiency, and integration of care remain important areas for future research.²⁴

Given the constraints on time, personal energy, and apparent competition between chronic physical and mental health problems, physician behaviors can be viewed as an understandable adaptation to the realities of a busy family practice.^11-15-24-28 Although we have documented significant variation in counseling skills among family physicians, there is no data to suggest that expansion of these skills would necessarily improve patient outcomes.²⁹ The effect of a long-term relationship and its quality between patients and a family physician on patient mental health outcomes remains unexplored and is a fruitful area for further research. Also, it is important to recognize that physicians are not homogeneous in their personality, philosophy, and skills and that patients self-select the kind of physician that best fits their own personality and style. Different approaches are likely to be functional for diverse clinicians with varied patients and situations.²⁴

Limitations

Our study has important limitations, including its sampling, design, and lack of a reference standard for mental health conditions. This qualitative research, by its very nature, is not based on a random population sample and is therefore not generalizable in the traditional quantitative sense. Its generalizability lies in the resonance it generates among primary care physicians and patients who recognize these patterns from their own experiences. Also, the findings are consistent with our existing understanding of competing demands^9,28,30 and physician communication strategies.^17-19 To the extent to which midwestern physicians and patients do not reflect the ethnic and socioeconomic diversity of other parts of the country, these findings may also be limited. Future research should attempt to include diversity. Patients’ emotional distress may be communicated in other ways besides speech or may not be communicated at all, so the direct observation approach we used cannot always correctly infer patients’ unexpressed mental health needs or physicians’ assessment of the situation. Because the data were cross-sectional, it is not possible to determine what had occurred in previous visits in a longitudinal management strategy. Nevertheless, the richness of the field note data provided an excellent detailed view of a large sample of visits. Finally, the lack of a reference standard for diagnosing mental health conditions does not alter the main findings of this study—a typology of physicians’ responses to emotional distress within their practices.

In trying to understand and improve the treatment of mental health issues, many previous researchers have focused on improving physician knowledge and dissemination of guidelines; such efforts have been disappointing when used alone.^31,32 Other investigators have sought to improve the interviewing skills of physicians, and while modestly successful, these studies have been limited in scope, length of follow-up, and ability to be replicated widely.^18,19,33,34 Other approaches have included collaborative management and quality improvement efforts; while successful, such interventions may be difficult to replicate in the usual physician practice setting without substantial external resources.^35-38

Conclusions

The chasm between ideal care of mental health disorders and actual practice may be narrower than mental health professionals would have us believe, and it is certainly bridgeable. It is possible to have better outcomes for medical conditions, improved patient and provider satisfaction, and reduced costs of care.^39,40 By studying the exemplary physicians found in real world practices—as found in this study and others—we might better understand that combination of inclination, skill, and setting that promotes quality cost-effective care. We found that mental health care, while sporadically and diversely attended to in outpatient visits, is often integrated with care of the diverse medical, social, and family problems that constitute primary care. Irrespective of differences in philosophy, training, or interest, however, structural and economic issues still appear to severely limit the ability of even willing family physicians to practice coherent integrated primary care.41 It is therefore important for the field as a whole to provide feasible strategies for promoting recognition and treatment of mental health issues by diverse clinicians and patients in usual practice settings.

Acknowledgments

Our study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776) and a research center grant from the American Academy of Family Physicians. The authors are grateful to the physicians, staff, and patients from the 18 practices, without whose participation this study would not have been possible. We also wish to acknowledge the dedicated work of Connie Gibbs and Jen Rouse, who spent countless hours collecting data; Diane Dodendorf and Jason Lebsack, who coordinated transcription and data management; and Mary McAndrews, who transcribed hundreds of taped interviews and dictated field notes. We would also like to thank Kurt C. Stange, MD, PhD, for reviewing earlier drafts of our manuscript.