Ian Fletcher, Division of Health Research, Lancaster University, UK Acknowledgements

1. The influence of adult attachment styles and emotional intelligence in clinical communication: data from clinicians and patients Ian Fletcher, Division of Health Research, Lancaster University, UK Acknowledgements • Medical students, Foundation Year doctors • Investigators: Helen O’Sullivan, Rachel Hick, Peter Leadbetter, Gemma Cherry

2. Background communication 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

3. Communication present day • 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.

4. Attachment origin • 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

5. Attachment approaches • 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

6. Adult attachment • 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

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

8. Attachment & communication • Internal models of interaction and inter-personal relationships across relationships in general • Model for understanding ways individuals feel, react and communicate when stressed by illness • Attachment, has been hypothesised to play a role in doctor-patient relationships • There is evidence to suggest doctors’ attachment style influences their responses to patients’ clinical presentations • This series of studies focused on medical students’ and junior doctors attachment styles and their clinical communication

9. Methods – medical students • 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

10. Outcome measures examiner • 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

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

12. Prediction • Medical students with lower attachment anxiety and/or lower attachment avoidance scores will have higher communication and clinical performance OSCE scores

13. Study 1 – medical students • 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

14. Study 2 – medical students • 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

15. Study 2 – medical students • 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

16. Study 2 - junior doctors • Phase 2: follow up 4th 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

17. Study 2 - junior doctors • 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

18. Study 2 - junior doctors • 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

19. Emotional Intelligence (EI) • 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

20. EI measure MSCEIT • Mayer-Salovey-Caruso Emotional Intelligence Test

21. EI – medical students • N=186, 1styr, 4 OSCE stations, only communication • Sig correlations EI, attachment, OSCE

22. EI – medical students • 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

23. EI – medical students • Structural equation modelling (SEM)

24. EI – medical students • 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

25. EI – medical students • Repeated SEM 2ndyr students, n=296, results strengthen

26. Conclusions • 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)