Two to 6 weeks after the intervention all physicians completed a knowledge test and saw 2 unannounced standardized patients in their offices. The actors posing as standardized patients were blind to the physicians’ intervention status. After all data were collected, the control physicians participated in the Depression Education Program. Physicians were not informed of their intervention status and did not know when they would see the standardized patients during the 6-month study period.
Intervention
The Depression Education Program consisted of 24-hour sessions given 2 weeks apart. The workshop covered 10 communication skills and 6 knowledge objectives (Table 1) based on Cohen-Cole’s 3-function model of the medical interview47 and the Agency for Health Care Policy and Research’s (AHCPR) Clinical Practice Guideline for Depression in Primary Care,17,48 respectively. We asked participants to read the workshop monograph and write down 3 personal objectives before the first session. During the workshop, participants received a syllabus and a card that listed: communication skills; strategies for office counseling and behavioral management of depression; a list of resources for educating and counseling patients; screening instruments, including a flow sheet of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria41; and the AHCPR’s Quick Reference Guide for Clinicians49 and Patient’s Guide.50
Workshops were limited to 12 participants and cofacilitated by a psychiatrist and a primary care physician. The first session consisted of the identification of personal learning objectives, a 60-minute interactive lecture, and a discussion of the strengths and weaknesses of a videotaped interview with a patient with depression. Participants identified specific communication skills they hoped to practice (Table 1) and role-played a scenario emphasizing these skills. Facilitators then gave constructive feedback, and participants repeated the role-play.
At the end of the first session, participants were asked to audiotape themselves interviewing a depressed or challenging patient in their practice. Participants selected a 5-minute segment from their tapes to review at the second session. Approximately 75% of the intervention physicians brought audiotapes to the second session.
The second session consisted of a 30-minute interactive lecture on treatment strategies and a discussion of 10 cases. The final 2 hours were used for discussion and role-play based on the participants’ audiotapes. Participants again practiced communication skills as facilitators and peers provided feedback.
Measurements
Questionnaire and knowledge test. The preintervention questionnaire included items about demographic and practice characteristics. The postintervention knowledge test was based on the workshop objectives and a previously developed test.51 The 5 workshop facilitators and 2 investigators (SAC, AJD) took a pilot version of the test. If all 7 agreed on an answer, we retained the question for the final version of the test. The final version had 54 questions, so scores could range from 0 to 54.
Standardized patients. We assessed physicians’ postintervention behaviors and communication skills using checklists and scales completed by the 2 standardized patients (actors trained to play patient roles) who were blinded to the physicians’ intervention status. Standardized patients have been used previously to assess physician performance,52-56 including physicians’ communication skills.34,38,56-58 Several studies support the accuracy and reliability of this methodology in general,52,59-61 and one study supports the reliability of actors portraying patients with major depression in particular.60
For our study, 2 standardized patients scheduled new patient office visits with the physicians. The day after the visit, the physicians received a post card asking if they detected (knew for sure), suspected (not sure, but suspicious), or did not know that patient was an actor. Because the post card named the standardized patient and was completed by the physician the following day, we anticipated that these physicians’ rate of detection would be higher than that found in other studies.53,54
The 2 standardized patients were used to assess our main outcomes: physician behaviors and communication skills under actual practice conditions. These patients were older, and presented with physical symptoms and multiple medical problems in addition to moderately severe major depression. We chose both a man and a woman who presented with different scenarios to tap into the broad domain of depression in primary care settings, recognizing that patient sex might influence the physicians’ performance.46 The woman (“Louise Williams”) was 64 years of age, well dressed, and presented with worsening lower abdominal pain. She had received a normal gynecologic examination and colonoscopy in the last year. Her past history included irritable bowel syndrome, fibrocystic breast disease, and total abdominal hysterectomy. She did not appear to be depressed because she was trying to be upbeat for her first visit with a new physician. If asked, she admitted to anhedonia, loss of appetite, insomnia, fatigue, impaired concentration, feelings of guilt, and thoughts of death for the last 3 months. The man (“Boyd Kelly”) was a 63-year-old building contractor who presented with bilateral shooting chest pains for the last 2 months, peripheral vascular disease (right common femoral endarterectomy scar and carotid bruits), hypertension, hypercholesterolemia, osteoarthritis, and dyspepsia. He had normal results on both cardiac catheterization and exercise test 1 to 2 months ago during a hospitalization for chest pain. He appeared agitated and attributed his agitation to not knowing the cause of his chest pains. If asked, he admitted to anhedonia, weight loss, insomnia, fatigue, impaired concentration, and irritability for the last 4 months.