In this secondary analysis of a practice-based randomized trial, the most potent predictor of physician behavior was patient presentation (major depression versus adjustment disorder); physicians dug more deeply (and inquired about suicide more consistently) when the SPs portrayed bona fide depression than when they portrayed adjustment disorder. Requests for antidepressants affected documentation but not history-taking. Interestingly, nearly 70% of physicians were not aware that they had recently been visited by an SP. Physicians harboring such suspicions asked more questions about depression and were more likely to inquire about suicide, but were not more likely to document a depression diagnosis. These physicians might be more emotionally attuned. It is also possible that they assumed they were being “tested,” and merely performed accordingly.
Perhaps the most novel and intriguing findings concern the contributions of physician personality. Effects of physician personality on depression assessment and diagnostic documentation were independent of physician demographic and design variables. More dutiful physicians were more likely to document a depression diagnosis, and they did so by asking fewer questions. Vulnerable physicians were also more likely to document a depression diagnosis, but there was no relationship between vulnerability and depression assessment.
While preliminary, these findings may reflect individual differences in the cognitive processes involved in depression assessment and the documentation of a depression diagnosis. A personality disposition characterized by higher levels of dutifulness (an indicator of conscientiousness) may facilitate diagnosis and documentation because it entails task-adherence and behavioral routinization in the service of the reliable fulfillment of professional obligations. That dutiful physicians had lower depression assessment scores suggests that, in the context of evaluating possible depression, they are economical in their use of time. In other analyses (not reported), we found no evidence to support the idea that they use this time to inquire about physical symptoms. Vulnerable physicians appear to arrive at a correct depression diagnosis via a less economical process, albeit an effective one.
Turning to suicide inquiry, silence in the consultation room represents a modifiable barrier to suicide prevention and other public health strategies.21
Doctors must be emboldened to take the lead in these discussions, particularly when patients are habitual nonconfiders.22,23
We found scant evidence for the relationship between physician personality and suicide inquiry, though the findings for trait openness are suggestive (
.1). Yet individual differences in social-cognitive processes might account for some of the variance between physicians in suicide inquiry, as physicians were more likely to inquire about suicide when they suspected they were seeing a SP.
Doctors high in dutifulness are more likely to document a depression diagnosis but ask fewer questions about depression. They are no more (or less) likely to ask about suicide than their less dutiful peers. Concern with time-economy could explain why, despite their apparent level of vigilance, they ask fewer questions about depression and are not more likely to inquire about suicide, arguably the most important symptom of depression. Perhaps they believe that asking about suicide will extend the office visit. Perhaps, on account of their high standards for personal competence, they do not feel they could address the topic of suicide with great effectiveness. Dutiful physicians can be expected to respond appropriately to policies that reinforce more extensive depression assessments involving effective questions about suicide. Absent of such interventions, dutiful physicians will likely continue to respond to perceived organizational expectations. In this context it is worth noting that patients prefer doctors who are merely average in dutifulness,12
not higher, perhaps because the latter are seen as ignoring important patient concerns in the service of the expeditious fulfillment of professional obligations. Other findings are consistent with this interpretation.24
Numerous barriers to the detection and treatment of depression in primary care have been documented. Decreasing the burden of mood disorders requires muliti-component initiatives that address these barriers. Large-scale studies of collaborative referral and care.25–27
have proven to be reasonably effective but the ‘real-world’ feasibility and sustainability of these initiatives is questionable.28
It is probably not useful to conceptualize specific “physician personality traits” as yet another barrier that must be removed or modified. Indeed, a sociological perspective on personality suggests that the relationship between personality and organizational culture is bidirectional. Institutionalized policy initiatives that shape organizational culture could also shape and reinforce personality.29,30
Effective workplace and organizational settings are those designed to respond to the personal needs and traits of those inhabiting the setting.
What are the translational implications of research showing that physician personality traits could affect practice behaviors? This question has rarely if ever been considered. The goal is not to change physician personality. Rather, in the context of depression care, it would be useful to consider how current models of collaborative care or other treatments for depression in primary care could be engineered to accommodate variability in physician personality, which is manifest in differences in assessment and referral behavior.31,32
The health communications literature suggests that patients respond to different types of health promotion messages tailored to personality style.33
One might expect similar effects in physicians. Policies constructed to encourage screenings or assessments by “dutiful” physicians may be less effective among “open” or “vulnerable” physicians. Conceivably, educators could also make use of personality information to tailor their teaching. Messages that are persuasive to dutiful physician-trainees (“This is the standard of care here”) may not reach those who are characterized by openness (“Watch carefully how the patient connects to you when you ask forthrightly about depression”). Practicing physicians should reflect on the possibility that their personal traits and attitudes might have implications for their approach to the assessment of depression and perhaps other clinical behaviors.
Although screening for mental health concerns in primary care settings is controversial,34
the need for innovative techniques to enhance dialogue about depression and suicide is not. Physicians who are uncomfortable asking patients about depression or suicide might wish to administer brief screens. Affirmative responses could lead to appropriate referrals or provide a natural segue into deeper discussion.
Several qualifiers must be noted. The sample was limited to a single geographic location. Effect sizes were modest. The physicians were mostly white men. Finally, the SP roles were circumscribed: depressed women in their 40s. Would physicians behave differently if faced with members of demographic subgroups at higher risk for suicide and under-treated mood disorders, such as older white men or younger black men?35
Future studies should examine this issue, especially as physicians may be less likely to recognize and diagnose mood disorders in these demographic groups.36,37
This observational study used an experimental design to examine the relationship between physician personality and doctoring behavior. Research on the specific affective, cognitive and behavioral mechanisms through which personality traits influence doctoring behavior might further inform current debates concerning the most cost-effective ways of decreasing the morbidity and mortality of mood disorders. There is no single clinically correct way to ask about mood disorders or suicide. Clinicians are encouraged to adopt an effective approach that fits their personal needs and is responsive to the preferences of individual patients.