The medical consultation viewed as a value chain: a neurobehavioral approach to emotion regulation in doctor-patient interaction.

OBJECTIVE To present a model of the medical consultation as a value chain, and to apply a neurobehavioral perspective to analyze each element in the chain with relevance for emotion regulation. METHODS Current knowledge on four elements in medical consultations and neuroscientific evidence on corresponding basic processes are selectively reviewed. RESULTS The four elements of communication behaviours presented as steps in a value chain model are: (1) establishing rapport, (2) patient disclosure of emotional cues and concerns, (3) the doctor's expression of empathy, and (4) positive reappraisal of concerns. CONCLUSION The metaphor of the value chain, with emphasis on goal orientation, helps to understand the impact of each communicative element on the outcome of the consultation. Added value at each step is proposed in terms of effects on outcome indicators; in this case patients affect regulation. Neurobehavioral mechanisms are suggested to explain the association between communication behaviour and affect regulation outcome. PRACTICE IMPLICATIONS The value chain metaphor and the emphasis on behaviour-outcome-mechanisms associations may be of interest as conceptualizations for communications skills training.

[1]  B. Fredrickson.  The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions. , 2001, The American psychologist.

[2]  A. Jensen,et al.  Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease , 2003, British Journal of Cancer.

[3]  Judith A. Hall,et al.  Nonverbal behavior in clinician—patient interaction , 1995 .

[4]  David Heaney,et al.  The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure. , 2004, Family practice.

[5]  N. George,et al.  Facing the gaze of others , 2008, Neurophysiologie Clinique/Clinical Neurophysiology.

[6]  J Denollet,et al.  Personality as independent predictor of long-term mortality in patients with coronary heart disease , 1996, The Lancet.

[7]  T. Chartrand,et al.  The chameleon effect: the perception-behavior link and social interaction. , 1999, Journal of personality and social psychology.

[8]  J. Mazziotta,et al.  Modulating emotional responses: effects of a neocortical network on the limbic system , 2000, Neuroreport.

[9]  N. Christenfeld,et al.  Social support and cardiovascular reactivity. , 2000, Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie.

[10]  T. Dietrich,et al.  Placebo in Emotional Processing— Induced Expectations of Anxiety Relief Activate a Generalized Modulatory Network , 2005, Neuron.

[11]  Fabrizio Benedetti,et al.  New Insights into the Placebo and Nocebo Responses , 2008, Neuron.

[12]  Matthew D. Lieberman,et al.  An fMRI investigation of race-related amygdala activity in African-American and Caucasian-American individuals , 2005, Nature Neuroscience.

[13]  A. Finset,et al.  Frequency of GP communication addressing the patient's resources and coping strategies in medical interviews: a video-based observational study , 2009, BMC family practice.

[14]  G. Rizzolatti,et al.  The mirror neuron system. , 2009, Archives of neurology.

[15]  R. Levenson,et al.  Physiological aspects of emotional knowledge and rapport. , 1997 .

[16]  Matthew D. Lieberman,et al.  The Lasting Effect of Words on Feelings: Words May Facilitate Exposure Effects to Threatening Images , 2008 .

[17]  J. Pennebaker.  The effects of traumatic disclosure on physical and mental health: the values of writing and talking about upsetting events. , 1999, International journal of emergency mental health.

[18]  Atsushi Sato,et al.  Association of neural and physiological responses during voluntary emotion suppression , 2006, NeuroImage.

[19]  Matthew D. Lieberman,et al.  The Sunny Side of Fairness , 2008, Psychological science.

[20]  S. Scott,et al.  Positive Emotions Preferentially Engage an Auditory–Motor “Mirror” System , 2006, The Journal of Neuroscience.

[21]  Sang Hee Kim,et al.  Neural Correlates of Positive and Negative Emotion Regulation , 2007, Journal of Cognitive Neuroscience.

[22]  B. Fredrickson.  The broaden-and-build theory of positive emotions. , 2004, Philosophical transactions of the Royal Society of London. Series B, Biological sciences.

[23]  E. Knudsen.  Fundamental components of attention. , 2007, Annual review of neuroscience.

[24]  M. Csíkszentmihályi,et al.  Positive psychology. An introduction. , 2000, The American psychologist.

[25]  Peter Boesiger,et al.  Segregated neural representation of distinct emotion dimensions in the prefrontal cortex—an fMRI study , 2006, NeuroImage.

[26]  F. Benedetti,et al.  THE NEUROBIOLOGY OF PLACEBO ANALGESIA: FROM ENDOGENOUS OPIOIDS TO CHOLECYSTOKININ , 1997, Progress in Neurobiology.

[27]  STEVEN P. REIDBORD,et al.  Nonlinear Analysis of Autonomic Responses in a Therapist During Psychotherapy , 1993, The Journal of nervous and mental disease.

[28]  A. Finset,et al.  Cues and concerns by patients in medical consultations: a literature review. , 2007, Psychological bulletin.

[29]  D. Roter,et al.  The relationship of physician medical interview style to patient satisfaction. , 1991, The Journal of family practice.

[30]  J. Gross.  Emotion regulation: affective, cognitive, and social consequences. , 2002, Psychophysiology.

[31]  A. Dimascio,et al.  Physiological Correlates of Tension and Antagonism During Psychotherapy: A Study of "Interpersonal Physiology" , 1957, Psychosomatic medicine.

[32]  Matthew D. Lieberman,et al.  Putting Feelings Into Words , 2007, Psychological science.

[33]  J. Gross.  Antecedent- and response-focused emotion regulation: divergent consequences for experience, expression, and physiology. , 1998, Journal of personality and social psychology.

[34]  Ronald Epstein,et al.  Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. , 2008, Archives of internal medicine.

[35]  I. Wilkinson,et al.  Investigating the functional anatomy of empathy and forgiveness , 2001, Neuroreport.

[36]  J. Gross.  The Emerging Field of Emotion Regulation: An Integrative Review , 1998 .

[37]  Ichiro Kawachi,et al.  Positive emotion and health: going beyond the negative. , 2005, Health psychology : official journal of the Division of Health Psychology, American Psychological Association.

[38]  Yvonne M. Dolan,et al.  Steve de Shazer and the future of solution-focused therapy. , 2006, Journal of marital and family therapy.

[39]  Rebecca Elliott,et al.  Neuronal correlates of theory of mind and empathy: A functional magnetic resonance imaging study in a nonverbal task , 2006, NeuroImage.

[40]  David S. Krantz,et al.  Effects of psychological and social factors on organic disease: a critical assessment of research on coronary heart disease. , 2002, Annual review of psychology.

[41]  R. Epstein,et al.  Emotion language in primary care encounters: reliability and validity of an emotion word count coding system. , 2005, Patient education and counseling.

[42]  Steven A. Haist,et al.  House staff nonverbal communication skills and standardized patient satisfaction , 2003, Journal of General Internal Medicine.

[43]  R. Frankel,et al.  A model of empathic communication in the medical interview. , 1997, JAMA.

[44]  Keith S. Dobson,et al.  Handbook of cognitive-behavioral therapies , 2009 .

[45]  Ron D. Hays,et al.  Relationship of physicians' nonverbal communication skill to patient satisfaction, appointment noncompliance, and physician workload. , 1986, Health psychology : official journal of the Division of Health Psychology, American Psychological Association.

[46]  Sheldon Cohen,et al.  Does positive affect influence health? , 2005, Psychological bulletin.

[47]  Matthew D. Lieberman,et al.  Social cognitive neuroscience: a review of core processes. , 2007, Annual review of psychology.

[48]  Amishi P. Jha,et al.  Viewing facial expressions of pain engages cortical areas involved in the direct experience of pain , 2005, NeuroImage.

[49]  S. Feldstein,et al.  Vocal congruence in mother-infant play , 1988, Journal of psycholinguistic research.

[50]  J. Gross,et al.  Hiding feelings: the acute effects of inhibiting negative and positive emotion. , 1997, Journal of abnormal psychology.

[51]  J. Gottman,et al.  A valid procedure for obtaining self-report of affect in marital interaction. , 1985, Journal of consulting and clinical psychology.

[52]  C. Sharpley,et al.  Standard posture, postural mirroring and client-perceived rapport , 2001 .

[53]  Gereon R. Fink,et al.  Mirror Neuron and Theory of Mind Mechanisms Involved in Face-to-Face Interactions: A Functional Magnetic Resonance Imaging Approach to Empathy , 2007, Journal of Cognitive Neuroscience.

[54]  Judith A. Hall,et al.  The expression of emotion through nonverbal behavior in medical visits , 2006, Journal of General Internal Medicine.

[55]  L. Tickle-Degnen,et al.  The Nature of Rapport and Its Nonverbal Correlates , 1990 .

[56]  Judith A. Hall,et al.  Nonverbal Self-Accuracy in Interpersonal Interaction , 2007, Personality & social psychology bulletin.

[57]  J. Mcmichael,et al.  Pulmonary heart-failure. , 1947, Lancet.

[58]  J. Bargh,et al.  Automaticity of social behavior: direct effects of trait construct and stereotype-activation on action. , 1996, Journal of personality and social psychology.

[59]  H. Adler.  Toward a Biopsychosocial Understanding of the Patient–Physician Relationship: An Emerging Dialogue , 2007, Journal of General Internal Medicine.

[60]  K. Phan,et al.  Neural substrates for voluntary suppression of negative affect: A functional magnetic resonance imaging study , 2005, Biological Psychiatry.

[61]  S. Davenport,et al.  HOW PSYCHIATRIC DISORDERS ARE MISSED DURING MEDICAL CONSULTATIONS , 1987, The Lancet.

[62]  A. Finset,et al.  Communicating with Alexithymic and Non-Alexithymic Patients: An Experimental Study of the Effect of Psychosocial Communication and Empathy on Patient Satisfaction , 2004, Psychotherapy and Psychosomatics.

[63]  B. Fredrickson,et al.  Positive Emotions Speed Recovery from the Cardiovascular Sequelae of Negative Emotions. , 1998, Cognition & emotion.

[64]  S. Shazer,et al.  Clues. Investigating Solutions in Brief Therapy. New York (Norton) 1979. , 1979 .

[65]  C. Keysers,et al.  Integrating simulation and theory of mind: from self to social cognition , 2007, Trends in Cognitive Sciences.

[66]  Kevin N. Ochsner,et al.  For better or for worse: neural systems supporting the cognitive down- and up-regulation of negative emotion , 2004, NeuroImage.

[67]  Matthew D. Lieberman,et al.  Neural pathways link social support to attenuated neuroendocrine stress responses , 2007, NeuroImage.

[68]  Anthony Suchman,et al.  Making Connexions: Enhancing the Therapeutic Potential of PatientClinician Relationships , 1993, Annals of Internal Medicine.

[69]  Richard J Lilford,et al.  University of Birmingham A Systematic Review of Empathy Test in Medicine , 2022 .

[70]  P. Petrovic,et al.  Placebo and Opioid Analgesia-- Imaging a Shared Neuronal Network , 2002, Science.

[71]  Brent L. Hughes,et al.  Prefrontal-Subcortical Pathways Mediating Successful Emotion Regulation , 2008, Neuron.