Study Participants
The 77 participants represented a sample of primary care physicians serving adults in the 3 study regions. Criteria for selection of this sample included sex and specialty mix (family physicians and internists), as well as geographic accessibility. Recruitment targeted both family physicians and internists. Physicians were excluded if they had practiced at their current location for less than 1 year, their patient panel composition was less than 50% adult, they devoted less than 50% of their clinical time to primary care, they were based in a residency training site, or their practice was closed to new patients.
Case Scenarios
Four months before the first standardized patient visits, participants were assigned randomly to be visited by either a man or a woman enacting the same case scenario. The standardized patient presented with symptoms compatible with minor depression with a chief complaint of chronic headaches of 2-years’ duration, worsening during the last 3 months. The standardized patients called the practices in the study and requested an initial visit to address their presenting complaint and to establish ongoing care. They also returned as recommended for a second visit.
Medical and psychiatric faculty worked together to develop the initial case scenario. We chose this scenario because it represented a common presentation for depression in primary care: subtle mental health distress of a sufficient degree to be associated with dysfunction, as demonstrated in other studies.35 The scenario was evaluated for internal consistency and refined during guided focus groups of community physicians that were held in each study center.36
The core elements of the scenario are provided in Table 1. In the scenario, a recent move required initiation of contact with a new care provider. Insurance was described as being in transition because of a new job but was scripted not to be a barrier to care. The standarized patients paid for the encounters in cash and indicated they would submit their claims to their insurance companies on their own. No depressive symptoms were volunteered by these patients unless specifically queried. During the second visit, standardized patients reported that their symptoms were 50% better regardless of the treatment suggested at the first visit.
Instruments
An evaluation checklist (to be completed by the standardized patients) with dichotomous (yes/no) responses was developed to assess how participating physicians pursued the presenting complaints and the criteria for a depressive disorder as listed in the Diagnostic and Statistical Manual of Mental Disroders, Third Edition, Revised (DSM-III-R).37 We pilot-tested the checklist in each study center to ensure that each item was readily observable and accurately scored by the standardized patients. The actors also used audiotape recorders with high-fidelity microphones to record the physician-patient interactions. These machines were concealed in briefcases or book bags specially adapted for this purpose. After each encounter, the standardized patient completed the checklist, reviewing the audiotape when necessary.
At the end of the study, audiotapes were sent to Allegheny Medical College for interview coding using the Interaction System for Interview Evaluation (ISIE-81) originally developed by the National Board of Medical Examiners to specifically evaluate physician-patient communication when medical or surgical and psychological problems were present.38 Using ISIE-81, specially trained persons coded the audiotapes at 2-second intervals, classifying the segments into 35 subgroups of 7 major categories. Each code indicated what was occurring at that time. Interrater reliability of the ISIE-81 averages 0.84.39 The ISIE-81 categories include both physician and patient behaviors. Because ISIE-81 was developed to code videotapes rather than audiotapes, not all categories were codeable. The ISIE-81 categories we used in these analyses and their definitions are outlined in Table 2. Narrow psychosocial questions could be answered with yes, no, or another short direct answer. Broad psychosocial questions encouraged more than a short direct answer.
Implementation
Twelve actors were recruited from medical education programs that use standardized patients for teaching and evaluation. All standardized patients were within 120% of their ideal body weight, and the clothing they wore to the visits was consistent with the cases being enacted. The specifics of standardized patient training and testing are described elsewhere.34 Three weeks after the final standardized patient visit, physicians were informed that the visits had taken place. They were asked to either describe or name the patient. If the standardized patient was detected, physicians were asked when during the encounter the detection occurred. Detection occurred in 22.8% of cases. The majority of the detections occurred at the end of the second visit or in retrospect after the second visit had occurred, which likely did not influence the physicians’ performance to a significant degree. Therefore all of the detected cases were included in the analysis. All physicians forwarded standardized patient medical records for abstraction and participated in a debriefing telephone call about their interactions with their assigned patient after both visits were completed.